HospitalInspections.org

K 18

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through
observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

SOUTH PAVILION

1. Cath Lab Clean Storage door (S-1E93) fails to latch.
2. Radiology Techs ' Computer Room (T-1E78) fails to latch.

FRANCISCAN MEDICAL PAVILION

1. The door to the Administrative area from the ASC failed to latch.

During the survey tour on 1/13/2014, between the hours of 0845 to 1645 it while accompanied by the lead Engineer, through observation and interview, it was discovered that the facility failed to maintain the vertical openings in the building, this has the potential for the passage of smoke throughout the building in the event of a fire. These findings were acknowledged at the time of the survey by the lead engineer.

The findings include but are not limited to:

1. The laundry chute in 10-D failed to close and latch.
2. The laundry chute in 9-D failed to close and latch.
3. The laundry chute in 7-D failed to close and latch.
4. The laundry chute in 6-D failed to close and latch.

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through observation and staff interview, it was discovered that the facility has failed to maintain the smoke barrier doors so that they close and latch as to resist the passage of smoke upon release from the approved hold open device. The failure of the doors to close in a position that would resist the passage of smoke would allow smoke to travel from one smoke compartment to another. These findings were acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

SOUTH PAVILLION

1. 4th Floor East Corridor (S-4F51): Cross-corridor fire doors failed to latch when tested.
2. Emergency Department West Corridor (S-1WF51): Cross-corridor fire doors failed to latch when tested.
3. Emergency Department West Corridor (S-1WF80): Cross-corridor fire doors failed to latch when tested (binding).

MAIN HOSPITAL TOWER

1. The double fire doors into 12-B failed to close and latch.
2. The double fire doors into 10-A failed to close and latch.
3. The double fire doors into 9-D failed to close and latch.
4. The double fire doors into 8-D failed to close and latch.
5. The double fire doors into 5-B failed to close and latch.

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through observation and staff interview, it was discovered that the facility has failed to maintain the doors to hazardous areas so that they self-close and latch as to resist the passage of smoke. The failure of the doors to close in a position that would resist the passage of smoke would allow smoke to travel from the hazardous area into the exit corridor placing residents, staff and visitors at risk. This finding was acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

1. Surgery Admit/Discharge (T-1W06) - Soiled Utility Room:
door failed to latch when tested.

During the survey tour of 01/13/2014, between the hours of 1000 and 1330, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility is lacking battery-operated emergency lights in surgical procedure rooms. This could result in loss of lighting in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during surgical procedures. This finding was acknowledged by the Chief Safety Officer.

The findings are as follows:

1. South Pavilion Cath Labs are lacking battery back-up emergency lighting in the rooms.
2. Tower OR Heart Room 9 is lacking battery back-up emergency lighting.

3. In the old generator room there is no battery back-up task lighting to illuminate the area in the event the emergency generator should fail.

4. During the survey of the ASC in the Franciscan Medical Pavillion it was observed that there is no battery back-up task lighting in the generator building to provide lighting in the event the emergency generator should fail.

5. In the ASC OR's there are no battery back-up lighting to provide immediate lighting in the event of a power outage.

During the survey tour of 01/13/2014, between the hours of 1330 and 1430, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility is lacking battery-operated emergency lights in surgical procedure rooms. This could result in loss of lighting in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during surgical procedures. This finding was acknowledged by the Chief Safety Officer.

The findings are as follows:
1. OR 1 is lacking battery back-up emergency lighting.
2. OR 6 is lacking battery back-up emergency lighting.
3. Note: all of the other ORs were in use and the lighting could not be checked.

During the survey tour of 01/13/2014, between the hours of 1430 and 1600, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility has failed to install and maintain the fire alarm system in accordance with the requirements of NFPA 72. Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire. This finding was acknowledged by the Chief Safety Officer.

The findings include but are not limited to: There is no smoke detector installed in the south pavilion doctors' sleep room (S-GW47).

FRANCISCAN MEDICAL PAVILLION

During the survey of the ASC in the Franciscan Medical Pavillion on 1/14/2014 between the hours of 0845 to 1015 and review of the facility fire alarm confidence test report it was observed that the following deficiencies were noted, these deficiencies have not been corrected at this time. These findings were acknowledged at the time of the survey by the facility engineer.

The findings include but are not limited to:

1. The smoke detector in OR#1 is to close to the HVAC vent.
2. The smoke detector in the 1st floor Pediatrics is to close to the HVAC vent.
3. The elevator pit and machine room shut off valves are not equipt with tamper switches.

During the survey tour of 1/14/2014 between the hours of 0830 to 1015, while accompanied by the lead engineer, through observation and staff interviews , it was discovered that the facility failed to maintain the sprinkler system in the building free of obstructions. This has the potential for the delay of the sprinkler heads to extinguish a fire. These findings were acknowledged at the time of the survey by the facility lead engineer.

The findings include but are not limited to:

1. In OR #1 there are sprinkler heads that have been painted.
2. In OR #2 there are sprinkler heads that have been painted.

During the survey tour of 01/13/2014, between the hours of 1000 and 12300, while accompanied by the Chief Safety Officer and Lead Engineer, through
observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Chief Safety Officer.

This standard is not being met as evidenced by:

1. On the roof of the South Pavilion, at the Heliport Lobby, there is one FE 36 Clean Agent 13.25# portable fire extinguisher. Outside the lobby, mounted in cases on either side of the pad are 2 Class 20A 120 BC portable fire extinguishers.

NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy this requirement.

During the survey tour on 1/14/2014 between the hours of 0830 to 1015, while accompanied by the lead engineer, through observation and interview, it was discovered that the facility has failed to maintain the use of Alchol based hand sanitizer in the building, this has the potential for a fire in the event of a spark. This finding was acknowledged at the time of the survey by the facility lead engineer.

The finding includes but is not limited to:

1. In the Franciscan Medical Pavillion ASC there is a Alchol hand sanitizer located above a light switch in the Clean utility.

K 18

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through
observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

SOUTH PAVILION

1. Cath Lab Clean Storage door (S-1E93) fails to latch.
2. Radiology Techs ' Computer Room (T-1E78) fails to latch.

FRANCISCAN MEDICAL PAVILION

1. The door to the Administrative area from the ASC failed to latch.

During the survey tour on 1/13/2014, between the hours of 0845 to 1645 it while accompanied by the lead Engineer, through observation and interview, it was discovered that the facility failed to maintain the vertical openings in the building, this has the potential for the passage of smoke throughout the building in the event of a fire. These findings were acknowledged at the time of the survey by the lead engineer.

The findings include but are not limited to:

1. The laundry chute in 10-D failed to close and latch.
2. The laundry chute in 9-D failed to close and latch.
3. The laundry chute in 7-D failed to close and latch.
4. The laundry chute in 6-D failed to close and latch.

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through observation and staff interview, it was discovered that the facility has failed to maintain the smoke barrier doors so that they close and latch as to resist the passage of smoke upon release from the approved hold open device. The failure of the doors to close in a position that would resist the passage of smoke would allow smoke to travel from one smoke compartment to another. These findings were acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

SOUTH PAVILLION

1. 4th Floor East Corridor (S-4F51): Cross-corridor fire doors failed to latch when tested.
2. Emergency Department West Corridor (S-1WF51): Cross-corridor fire doors failed to latch when tested.
3. Emergency Department West Corridor (S-1WF80): Cross-corridor fire doors failed to latch when tested (binding).

MAIN HOSPITAL TOWER

1. The double fire doors into 12-B failed to close and latch.
2. The double fire doors into 10-A failed to close and latch.
3. The double fire doors into 9-D failed to close and latch.
4. The double fire doors into 8-D failed to close and latch.
5. The double fire doors into 5-B failed to close and latch.

During the survey tour of 01/13/2014, between the hours of 1000 and 1230, while accompanied by the Chief Safety Officer and Lead Engineer, through observation and staff interview, it was discovered that the facility has failed to maintain the doors to hazardous areas so that they self-close and latch as to resist the passage of smoke. The failure of the doors to close in a position that would resist the passage of smoke would allow smoke to travel from the hazardous area into the exit corridor placing residents, staff and visitors at risk. This finding was acknowledged by the Chief Safety Officer and Lead Engineer.

The findings include but are not limited to:

1. Surgery Admit/Discharge (T-1W06) - Soiled Utility Room:
door failed to latch when tested.

During the survey tour of 01/13/2014, between the hours of 1000 and 1330, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility is lacking battery-operated emergency lights in surgical procedure rooms. This could result in loss of lighting in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during surgical procedures. This finding was acknowledged by the Chief Safety Officer.

The findings are as follows:

1. South Pavilion Cath Labs are lacking battery back-up emergency lighting in the rooms.
2. Tower OR Heart Room 9 is lacking battery back-up emergency lighting.

3. In the old generator room there is no battery back-up task lighting to illuminate the area in the event the emergency generator should fail.

4. During the survey of the ASC in the Franciscan Medical Pavillion it was observed that there is no battery back-up task lighting in the generator building to provide lighting in the event the emergency generator should fail.

5. In the ASC OR's there are no battery back-up lighting to provide immediate lighting in the event of a power outage.

During the survey tour of 01/13/2014, between the hours of 1330 and 1430, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility is lacking battery-operated emergency lights in surgical procedure rooms. This could result in loss of lighting in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during surgical procedures. This finding was acknowledged by the Chief Safety Officer.

The findings are as follows:
1. OR 1 is lacking battery back-up emergency lighting.
2. OR 6 is lacking battery back-up emergency lighting.
3. Note: all of the other ORs were in use and the lighting could not be checked.

During the survey tour of 01/13/2014, between the hours of 1430 and 1600, while accompanied by the Chief Safety Officer, through observation and staff interview, it was discovered that the facility has failed to install and maintain the fire alarm system in accordance with the requirements of NFPA 72. Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire. This finding was acknowledged by the Chief Safety Officer.

The findings include but are not limited to: There is no smoke detector installed in the south pavilion doctors' sleep room (S-GW47).

FRANCISCAN MEDICAL PAVILLION

During the survey of the ASC in the Franciscan Medical Pavillion on 1/14/2014 between the hours of 0845 to 1015 and review of the facility fire alarm confidence test report it was observed that the following deficiencies were noted, these deficiencies have not been corrected at this time. These findings were acknowledged at the time of the survey by the facility engineer.

The findings include but are not limited to:

1. The smoke detector in OR#1 is to close to the HVAC vent.
2. The smoke detector in the 1st floor Pediatrics is to close to the HVAC vent.
3. The elevator pit and machine room shut off valves are not equipt with tamper switches.

During the survey tour of 1/14/2014 between the hours of 0830 to 1015, while accompanied by the lead engineer, through observation and staff interviews , it was discovered that the facility failed to maintain the sprinkler system in the building free of obstructions. This has the potential for the delay of the sprinkler heads to extinguish a fire. These findings were acknowledged at the time of the survey by the facility lead engineer.

The findings include but are not limited to:

1. In OR #1 there are sprinkler heads that have been painted.
2. In OR #2 there are sprinkler heads that have been painted.

During the survey tour of 01/13/2014, between the hours of 1000 and 12300, while accompanied by the Chief Safety Officer and Lead Engineer, through
observation and staff interview, it was discovered that the facility has failed to provide the correct portable fire extinguishers. This could result in a delay in controlling or extinguishing a fire. This finding was acknowledged by the Chief Safety Officer.

This standard is not being met as evidenced by:

1. On the roof of the South Pavilion, at the Heliport Lobby, there is one FE 36 Clean Agent 13.25# portable fire extinguisher. Outside the lobby, mounted in cases on either side of the pad are 2 Class 20A 120 BC portable fire extinguishers.

NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy this requirement.