HospitalInspections.org

Based on observations and interview the facility failed to ensure corridor doors did not contain roller latches. This failed practice placed occupants in the surgical department at risk for exposure to smoke/fire environment.

Observation on 6/29/16 at 9:00 am revealed the entry door to operating room #1 and operating room #5 contained a roller latch.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.



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Based on observations and interview the facility failed to ensure fire and smoke rated doors operated in a manner that would resist the passage of smoke and/or fire. This failed practice placed occupants in 11 out of 30 smoke compartments (on Floors 1-4) at risk for exposure to smoke/fire environment. Findings:
Floor 1:

Observation on 6/27/16 at 1:55 pm revealed a 90 minute door protecting the elevator 8 and 9 lobby that did not close and latch.

Observation on 6/27/16 at 3:12 pm revealed a 90 minute double doors leading into the atrium next to the IVY classroom #2 that did not close and latch in a manner to prevent the passage of fire and/or smoke. The observed door was located in a 2 hour fire/smoke barrier.


Floor 2:

Observation on 6/28/16 at 10:25 am revealed a fire rated door, leading from radiology to pre-op area, did not close in a matter to resist the passage of smoke or fire. The observed door was located in a 1 hour fire/smoke barrier.

Observation on 6/28/16 at 10:47 am revealed fire rated door, leading from the surgical department into post-anesthesia care unit did not close in a matter to resist the passage of smoke and fire. The observed door was located in a 1 hour fire/smoke barrier.

Observation on 6/29/16 at 9:49 am revealed a fire rated door outside of operating room 9 did not close in a manner to resist the passage of smoke and/or fire. The observed door was located in a 1 hour fire/smoke barrier.


Floor 3:

Observation on 6/28/16 at 11:20 am revealed a 20 minute fire rated door, leading from Labor and Delivery to the Surgical Care Unit did not close in a manner to prevent the passage of smoke or fire. The observed door was located in a 1 hour fire/smoke barrier.


Floor 4:

Observations on 6/28/16 from 1:05 pm to 1:30 pm revealed two fire rated doors in a one hour fire/smoke barrier did not close in a manner to prevent the passage of smoke or fire. The doors were located in the barrier separating the smoke compartment 4E from 4C and smoke compartments 4D from 4C.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.


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Based on observations and interviews the facility failed to ensure: 1) exit signs were posted and illuminated in 1 out of 39 smoke compartments. These failed practices placed occupants at risk for delay in egress during an emergency situation. Findings:

Floor 2:

Observation on 6/28/16 at 9:35 am revealed there was no exit signs that indicated the path of egress from emergency room nurses station through the "fast track" area leading to the emergency room waiting area. Further observation revealed, the exit sign provided at the receptionist's desk provided chevron pointing in both directions (left and right). No exit was observed to the left of the exit sign.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.

MOB:

Observation on 6/29/16 at 9:00 am of the cardio rehab area revealed four exit signs that were insufficiently illuminated.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




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Based on observations and interview the facility failed to ensure fire barriers were free from penetrations. These failed practices placed occupants in 8 out of 18 smoke compartments (on Floors 2, 4 and 5) at risk for exposure to smoke and fire environments. Findings:

Floor 2:

Observation on 6/28/16 at 8:55 am revealed five penetrations in the 1 hour fire/smoke barrier above the door leading from the atrium to the emergency department.

Observation on 6/28/16 at 9:55 am revealed five penetrations in the 1 hour fire/smoke barrier above the door leading from the corridor into radiology (next to elevators 4 & 5).


Floor 4:

Observation on 6/28/16 at 1:36 pm revealed 2 penetrations in the 1 hour fire/smoke barrier above the door leading from the smoke compartment 4B to 4A.


Floor 5:

Observation on 6/28/16 at 2:10 pm revealed a penetration in the 1 hour fire/smoke barrier above the door leading from the smoke compartment medical overflow unit to the medical/surgical oncology department.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




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Based on observations and interview the facility failed to ensure hazardous areas were fully protected via appropriate use and faction of fire resistive devices and free of penetrations. These failed practices placed occupants in 12 out of 24 smoke compartments (on floors 1, 2 and 4) at risk for exposure to smoke and/or fire environment: Findings:

Floor 1:

Observation on 6/27/16 at 12:30 pm revealed a 90 minute fire rated door leading from central storage to a mechanical space did not close and latch resisting the passage of fire and/or smoke.

Observation of the central pharmacy on 6/27/16 at 1:49 pm revealed a 90 minute fire rated door was propped open between two electrical rooms.

Observation of the linen chute (located outside of lab) on 6/27/16 at 2:15 pm revealed large amounts of bagged soiled linen causing the chute itself to back up due to overflow. Further observation revealed the fire door designed to shut and occlude the chute was unable to operate due to the excessive amount of soiled linen.

Observation of the trash chute (located outside of lab) on 6/27/16 at 2:16 pm revealed large amounts of trash causing the chute itself to back up due to overflow. Further observation revealed the fire door designed to shut and occlude the chute was unable to operate due to the excessive amount of trash accumulation.

Observation on 6/27/16 at 3:15 pm of the elevator machine room next to elevator 12 and 13 revealed an approximate 4 inch circular hole in the ceiling that was covered by duct tape.

Observation of the switch gear room on 6/28/16 at 8:20 am revealed the fired rated door protecting the area did not close and latch in a manner to prevent the passage of smoke and/or fire.

Observation of the generator room on 6/28/16 at 8:25 am revealed the fired rated door protecting the area did not close in a manner to prevent the passage of smoke and/or fire.


Floor 2:

Observation of the emergency room on 6/28/16 at 9:20 am revealed an environmental services closet that contained a 90 minute fire rated door that did not close appropriately to resist the passage of smoke or fire.

Observation of the emergency room on 6/28/16 at 9:25 am revealed an storage closet that contained a 90 minute fire rated door that did not close appropriately to resist the passage of smoke or fire.

Observation of the pre-operative area on 6/28/16 at 10:35 am revealed a soiled utility room that contained a rated door, located in a smoke partition that did not close in a manner to resist the passage of smoke.


Floor 4:

Observation of the cardiovascular surgical unit on 6/28/16 at 1:20 pm revealed a soiled utility room that was protected by a fire rated door that did not close in a manner to prevent the passage of fire and smoke.

Observation of the critical care unit on 6/28/16 at 1:40 pm revealed a soiled utility room that was protected by a fire rated door did not close in a manner to prevent the passage of fire and smoke.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




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Based on observations and interview the facility failed to ensure the sprinkler system components were maintained in a fashion to ensure reliable functioning of sprinkler heads. This failed practice placed occupants in 9 out of 24 smoke compartments (on floors 1, 2 and 4) at risk for exposure to a smoke and/or fire environment. Findings:

Floor 1:

Observation on 6/27/16 at 12:35 am revealed an air handling ductwork suspended from the ceiling did not contain a sufficient amount of sprinkler coverage. The area observed formed an L-shape measuring approximately 64 square feet. A sprinkler head was located several feet from observed area. The spray pattern from this sprinkler head was obstructed by the design and placement of the ductwork. In addition, there were multiple cardboard boxes located under the L-shaped ductwork.

Observation central laundry storage room on 6/27/16 at 1:05 pm revealed hospital gowns stacked near a sprinkler head. Further observation revealed the space between the top of the gowns and the sprinkler head was approximately 6 to 8 inches.

Observation of the central laboratory on 6/27/16 at 2:30 pm revealed a sprinkler head without an escutcheon plate located in the laboratory bathroom.

Observation of the central kitchen dishwashing area on 6/27/16 at 2:35 pm revealed three sprinkler heads contained paint, dust and/or debris. Further observation revealed the janitor's closet located in the dishwashing area contained a sprinkler head without an escutcheon plate.

Observation of the central kitchen's dry storage on 6/27/16 at 2:39 pm revealed multiple cardboard boxes stacked up less than 18 inches from the ceiling.

Observation of the central kitchen on 6/27/16 at 2:50 pm revealed a large ceiling tile was not in place next to sprinkler head.

Observation of the IVY classroom #1 on 6/27/16 at 3:10 pm revealed the storage closet contained a sprinkler head without an escutcheon plate.


Floor 2:

Observation of the ambulance bay on 6/28/16 at 9:15 am revealed a sprinkler head that was completely covered by a metallic foil.

Observation on 6/28/16 at 10:45 am revealed a sprinkler head without an escutcheon plate located in endoscopy department's environmental services room.

Observation on 6/29/16 at 10:00 am revealed a sprinkler head with significant amounts of dust and debris located in the clean side of the sterile processing department.


Floor 4:

Observation on 6/25/16 at 1:23 pm revealed a sprinkler head with significant amounts of dust and debris located in the critical care unit staff lounge bathroom.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




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Based on observation and interview the facility failed to ensure the cooking area was free from grease build up. This failed practice placed occupants within the smoke compartment at risk for accelerated fire spread. In addition, this failed practice placed all patients, staff and visitors at risk for loss of dietary services due to potential fire occurrence. Findings:

Observation on 6/27/16 at 2:41 pm revealed the area and equipment located behind the deep fryer was coated in an excessive amount of grease and debris build up.
During an interview on 6/27/16 at 2:41 pm the Safety Officer stated the area observed that was covered in grease build up and the area should have been cleaned.




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Based on observation and interview the facility failed to ensure exit egress pathways were free from obstruction or impediments. This failed practice placed occupants in 3 out of 21 smoke compartments (on floors 1, 2 and 7) at risk for delay in egress during an emergency situation. Findings:

Floor 1:

Observation on 6/27/16 at 12:38 pm revealed an exit door leading from facilities air handling storage room to outside was partially blocked by a metal cart with storage and multiple cardboard boxes on the ground.


Floor 2:

Observation of the post-anesthesia care unit on 6/28/16 at 11:00 am revealed 3 soiled linen carts partially obstructing an exit door.


Floor 7:

Observations on 6/28/16 revealed a "no exit" sign hanging on a chain that was latched to itself off the 7th floor stairwell #1 and #2. The chain had to be unlatched from itself and unwrapped from stair hand rail in order to be removed. This chain prevented easy egress access to any individual coming off of the roof area.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.





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Based on observations and interview the facility failed to ensure curtains used in the facility were in compliance with NFPA 701 fire resistance rating. This failed practice placed occupants in 5 our 14 smoke compartments (on floors 2, 5 and 7) at risk for accelerated fire spread. Findings:

Floor 2:

Observation on 6/28/16 at 10:05 am revealed radiology room 2 contained a curtain that did not meet the standards for NFPA 701. Additional observations revealed the radiology dressing rooms contained 4 additional curtains that did not meet the standards for NFPA 701.

Observation on 6/28/16 at 10:45 am revealed one curtain not meeting the standards of NFPA 701 located in endoscopy department's locker room.


Floor 5:

Observation of the wound care room on 6/28/16 at 2:45 pm revealed four curtains that did not comply with the standards of NFPA 701.


Floor 7:

Observation of the 7th floor medical units on 6/28/16 at 3:30 pm revealed rooms 701, 702, 703, 704, 705, 706, 710, 729 and 730 contained curtains (without any mesh top) were mounted flush with the ceiling. In addition the observed curtains did not meet the standards of NFPA 701. Additional observation revealed rooms 711 and 712 contain curtains that did not meet the standards of NFPA 701.


MOB:

Observation of the MRI department on 6/29/16 at 8:30 am revealed a curtain that did not comply with the standards of NFPA 701.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




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Based on observation and interview the facility failed to ensure a medical gas zone valve was properly working and free from leaks. This failed practice placed occupants in 1 out 5 smoke compartments on floor 4 at risk for a fire emergency due to an oxygen enriched environment. Findings:

Observation in Respiratory Therapy Department on 6/28/16 at 1:10 pm revealed a medical gas (oxygen) zone valve that was actively leaking at a slow rate. The issue was resolved immediately onsite.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




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Based on observation and interview the facility failed to ensure: 1) power strips were used in a safe manner; 2) ground fault interrupted outlets were used in wet locations; 3) electrical panels were labeled and contained no gaps in the panel; 4) electrical junction boxes were covered; and 5) extension cords were used appropriately. These failed practices placed occupants in 15 out of 24 smoke compartments (on floors 1, 2 and 5) at risk for electrocution, loss of electrical services or a fire environment. Findings:

Floor 1:

Observation of central supply department on 6/27/16 at 12:20 pm revealed a non-ground fault interrupted (GFI) six outlet receptacle located next to two sinks. Additional review revealed a receptacle face plate cover that was loosely hanging over an outlet exposing live wires.

Observation of central supply break room on 6/27/16 at 12:45 pm revealed a coffee pot, microwave, refrigerator and toaster plugged into a power strip (15 amp max load). Additional observation revealed the power strip was supplying power to another power strip.

During an interview on 6/27/16 at 12:45 pm the Facility Engineer stated the plugged in items exceeded the 15 amp max load as indicated by the power strip's listing. In addition, he added the items needed to be unplugged from the power strip.

Observation on 6/27/16 at 1:40 pm revealed an unlabeled electrical panel in the central pharmacy's Pyxis room.

Observation in the pharmacy on 6/27/16 at 1:47 pm revealed an electrical panel (E1LL1) had no breaker in place.

Observation of the physician's dining area on 6/28/16 at 8:37 am revealed a power strip that was suspended under a desk.


Floor 2:

Observation of the ambulance bay on 6/28/16 at 9:15 am revealed a junction box leading to the garage door that was uncovered exposing live wires.

Observation on 6/28/16 at 9:55 am revealed an open junction box in the ceiling above the door leading from corridor into radiology (next to elevators 4 & 5).

Observations of cath lab control room on 6/28/16 at 10:15 am revealed two unlabeled electrical panels.

Observation on 6/28/16 at 10:55 am revealed a non GFI outlet next to a sink was located in the staff lounge of the post-anesthesia care.

Observation on 6/29/16 at 9:00 am revealed a power strip was being supplied electricity via an extension cord in operating room #5.

Observation on 6/29/16 at 9:20 am revealed a power strip was being supplied electricity via another power strip in operating room #1.

Observation on 6/29/16 at 9:30 am revealed a non-hospital grade power strip was being used in operating room #10.

Observation of the anesthesia supply room on 6/28/16 at 10:47 am revealed a power strip that was suspended under a desk via rigid metal wires.
The Safety Officer acknowledged and confirmed the findings at the time of their discovery.

Floor 5:

Observation of the ADL (Activities of Daily Living) kitchen on 6/28/16 at 2:48 pm revealed a non-GFI outlet located beside the sink.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.





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Based on observations and interview the facility failed to ensure corridor doors did not contain roller latches. This failed practice placed occupants in the surgical department at risk for exposure to smoke/fire environment.

Observation on 6/29/16 at 9:00 am revealed the entry door to operating room #1 and operating room #5 contained a roller latch.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.



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Based on observations and interview the facility failed to ensure fire and smoke rated doors operated in a manner that would resist the passage of smoke and/or fire. This failed practice placed occupants in 11 out of 30 smoke compartments (on Floors 1-4) at risk for exposure to smoke/fire environment. Findings:
Floor 1:

Observation on 6/27/16 at 1:55 pm revealed a 90 minute door protecting the elevator 8 and 9 lobby that did not close and latch.

Observation on 6/27/16 at 3:12 pm revealed a 90 minute double doors leading into the atrium next to the IVY classroom #2 that did not close and latch in a manner to prevent the passage of fire and/or smoke. The observed door was located in a 2 hour fire/smoke barrier.


Floor 2:

Observation on 6/28/16 at 10:25 am revealed a fire rated door, leading from radiology to pre-op area, did not close in a matter to resist the passage of smoke or fire. The observed door was located in a 1 hour fire/smoke barrier.

Observation on 6/28/16 at 10:47 am revealed fire rated door, leading from the surgical department into post-anesthesia care unit did not close in a matter to resist the passage of smoke and fire. The observed door was located in a 1 hour fire/smoke barrier.

Observation on 6/29/16 at 9:49 am revealed a fire rated door outside of operating room 9 did not close in a manner to resist the passage of smoke and/or fire. The observed door was located in a 1 hour fire/smoke barrier.


Floor 3:

Observation on 6/28/16 at 11:20 am revealed a 20 minute fire rated door, leading from Labor and Delivery to the Surgical Care Unit did not close in a manner to prevent the passage of smoke or fire. The observed door was located in a 1 hour fire/smoke barrier.


Floor 4:

Observations on 6/28/16 from 1:05 pm to 1:30 pm revealed two fire rated doors in a one hour fire/smoke barrier did not close in a manner to prevent the passage of smoke or fire. The doors were located in the barrier separating the smoke compartment 4E from 4C and smoke compartments 4D from 4C.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.


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Based on observations and interviews the facility failed to ensure: 1) exit signs were posted and illuminated in 1 out of 39 smoke compartments. These failed practices placed occupants at risk for delay in egress during an emergency situation. Findings:

Floor 2:

Observation on 6/28/16 at 9:35 am revealed there was no exit signs that indicated the path of egress from emergency room nurses station through the "fast track" area leading to the emergency room waiting area. Further observation revealed, the exit sign provided at the receptionist's desk provided chevron pointing in both directions (left and right). No exit was observed to the left of the exit sign.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.

MOB:

Observation on 6/29/16 at 9:00 am of the cardio rehab area revealed four exit signs that were insufficiently illuminated.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




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Based on observations and interview the facility failed to ensure fire barriers were free from penetrations. These failed practices placed occupants in 8 out of 18 smoke compartments (on Floors 2, 4 and 5) at risk for exposure to smoke and fire environments. Findings:

Floor 2:

Observation on 6/28/16 at 8:55 am revealed five penetrations in the 1 hour fire/smoke barrier above the door leading from the atrium to the emergency department.

Observation on 6/28/16 at 9:55 am revealed five penetrations in the 1 hour fire/smoke barrier above the door leading from the corridor into radiology (next to elevators 4 & 5).


Floor 4:

Observation on 6/28/16 at 1:36 pm revealed 2 penetrations in the 1 hour fire/smoke barrier above the door leading from the smoke compartment 4B to 4A.


Floor 5:

Observation on 6/28/16 at 2:10 pm revealed a penetration in the 1 hour fire/smoke barrier above the door leading from the smoke compartment medical overflow unit to the medical/surgical oncology department.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




.

Based on observations and interview the facility failed to ensure hazardous areas were fully protected via appropriate use and faction of fire resistive devices and free of penetrations. These failed practices placed occupants in 12 out of 24 smoke compartments (on floors 1, 2 and 4) at risk for exposure to smoke and/or fire environment: Findings:

Floor 1:

Observation on 6/27/16 at 12:30 pm revealed a 90 minute fire rated door leading from central storage to a mechanical space did not close and latch resisting the passage of fire and/or smoke.

Observation of the central pharmacy on 6/27/16 at 1:49 pm revealed a 90 minute fire rated door was propped open between two electrical rooms.

Observation of the linen chute (located outside of lab) on 6/27/16 at 2:15 pm revealed large amounts of bagged soiled linen causing the chute itself to back up due to overflow. Further observation revealed the fire door designed to shut and occlude the chute was unable to operate due to the excessive amount of soiled linen.

Observation of the trash chute (located outside of lab) on 6/27/16 at 2:16 pm revealed large amounts of trash causing the chute itself to back up due to overflow. Further observation revealed the fire door designed to shut and occlude the chute was unable to operate due to the excessive amount of trash accumulation.

Observation on 6/27/16 at 3:15 pm of the elevator machine room next to elevator 12 and 13 revealed an approximate 4 inch circular hole in the ceiling that was covered by duct tape.

Observation of the switch gear room on 6/28/16 at 8:20 am revealed the fired rated door protecting the area did not close and latch in a manner to prevent the passage of smoke and/or fire.

Observation of the generator room on 6/28/16 at 8:25 am revealed the fired rated door protecting the area did not close in a manner to prevent the passage of smoke and/or fire.


Floor 2:

Observation of the emergency room on 6/28/16 at 9:20 am revealed an environmental services closet that contained a 90 minute fire rated door that did not close appropriately to resist the passage of smoke or fire.

Observation of the emergency room on 6/28/16 at 9:25 am revealed an storage closet that contained a 90 minute fire rated door that did not close appropriately to resist the passage of smoke or fire.

Observation of the pre-operative area on 6/28/16 at 10:35 am revealed a soiled utility room that contained a rated door, located in a smoke partition that did not close in a manner to resist the passage of smoke.


Floor 4:

Observation of the cardiovascular surgical unit on 6/28/16 at 1:20 pm revealed a soiled utility room that was protected by a fire rated door that did not close in a manner to prevent the passage of fire and smoke.

Observation of the critical care unit on 6/28/16 at 1:40 pm revealed a soiled utility room that was protected by a fire rated door did not close in a manner to prevent the passage of fire and smoke.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.




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Based on observations and interview the facility failed to ensure the sprinkler system components were maintained in a fashion to ensure reliable functioning of sprinkler heads. This failed practice placed occupants in 9 out of 24 smoke compartments (on floors 1, 2 and 4) at risk for exposure to a smoke and/or fire environment. Findings:

Floor 1:

Observation on 6/27/16 at 12:35 am revealed an air handling ductwork suspended from the ceiling did not contain a sufficient amount of sprinkler coverage. The area observed formed an L-shape measuring approximately 64 square feet. A sprinkler head was located several feet from observed area. The spray pattern from this sprinkler head was obstructed by the design and placement of the ductwork. In addition, there were multiple cardboard boxes located under the L-shaped ductwork.

Observation central laundry storage room on 6/27/16 at 1:05 pm revealed hospital gowns stacked near a sprinkler head. Further observation revealed the space between the top of the gowns and the sprinkler head was approximately 6 to 8 inches.

Observation of the central laboratory on 6/27/16 at 2:30 pm revealed a sprinkler head without an escutcheon plate located in the laboratory bathroom.

Observation of the central kitchen dishwashing area on 6/27/16 at 2:35 pm revealed three sprinkler heads contained paint, dust and/or debris. Further observation revealed the janitor's closet located in the dishwashing area contained a sprinkler head without an escutcheon plate.

Observation of the central kitchen's dry storage on 6/27/16 at 2:39 pm revealed multiple cardboard boxes stacked up less than 18 inches from the ceiling.

Observation of the central kitchen on 6/27/16 at 2:50 pm revealed a large ceiling tile was not in place next to sprinkler head.

Observation of the IVY classroom #1 on 6/27/16 at 3:10 pm revealed the storage closet contained a sprinkler head without an escutcheon plate.


Floor 2:

Observation of the ambulance bay on 6/28/16 at 9:15 am revealed a sprinkler head that was completely covered by a metallic foil.

Observation on 6/28/16 at 10:45 am revealed a sprinkler head without an escutcheon plate located in endoscopy department's environmental services room.

Observation on 6/29/16 at 10:00 am revealed a sprinkler head with significant amounts of dust and debris located in the clean side of the sterile processing department.


Floor 4:

Observation on 6/25/16 at 1:23 pm revealed a sprinkler head with significant amounts of dust and debris located in the critical care unit staff lounge bathroom.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




.

Based on observation and interview the facility failed to ensure the cooking area was free from grease build up. This failed practice placed occupants within the smoke compartment at risk for accelerated fire spread. In addition, this failed practice placed all patients, staff and visitors at risk for loss of dietary services due to potential fire occurrence. Findings:

Observation on 6/27/16 at 2:41 pm revealed the area and equipment located behind the deep fryer was coated in an excessive amount of grease and debris build up.
During an interview on 6/27/16 at 2:41 pm the Safety Officer stated the area observed that was covered in grease build up and the area should have been cleaned.




.

Based on observation and interview the facility failed to ensure exit egress pathways were free from obstruction or impediments. This failed practice placed occupants in 3 out of 21 smoke compartments (on floors 1, 2 and 7) at risk for delay in egress during an emergency situation. Findings:

Floor 1:

Observation on 6/27/16 at 12:38 pm revealed an exit door leading from facilities air handling storage room to outside was partially blocked by a metal cart with storage and multiple cardboard boxes on the ground.


Floor 2:

Observation of the post-anesthesia care unit on 6/28/16 at 11:00 am revealed 3 soiled linen carts partially obstructing an exit door.


Floor 7:

Observations on 6/28/16 revealed a "no exit" sign hanging on a chain that was latched to itself off the 7th floor stairwell #1 and #2. The chain had to be unlatched from itself and unwrapped from stair hand rail in order to be removed. This chain prevented easy egress access to any individual coming off of the roof area.

The Safety Officer acknowledged and confirmed the findings at the time of their discovery.





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Based on observations and interview the facility failed to ensure curtains used in the facility were in compliance with NFPA 701 fire resistance rating. This failed practice placed occupants in 5 our 14 smoke compartments (on floors 2, 5 and 7) at risk for accelerated fire spread. Findings:

Floor 2:

Observation on 6/28/16 at 10:05 am revealed radiology room 2 contained a curtain that did not meet the standards for NFPA 701. Additional observations revealed the radiology dressing rooms contained 4 additional curtains that did not meet the standards for NFPA 701.

Observation on 6/28/16 at 10:45 am revealed one curtain not meeting the standards of NFPA 701 located in endoscopy department's locker room.


Floor 5:

Observation of the wound care room on 6/28/16 at 2:45 pm revealed four curtains that did not comply with the standards of NFPA 701.


Floor 7:

Observation of the 7th floor medical units on 6/28/16 at 3:30 pm revealed rooms 701, 702, 703, 704, 705, 706, 710, 729 and 730 contained curtains (without any mesh top) were mounted flush with the ceiling. In addition the observed curtains did not meet the standards of NFPA 701. Additional observation revealed rooms 711 and 712 contain curtains that did not meet the standards of NFPA 701.


MOB:

Observation of the MRI department on 6/29/16 at 8:30 am revealed a curtain that did not comply with the standards of NFPA 701.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




.

Based on observation and interview the facility failed to ensure a medical gas zone valve was properly working and free from leaks. This failed practice placed occupants in 1 out 5 smoke compartments on floor 4 at risk for a fire emergency due to an oxygen enriched environment. Findings:

Observation in Respiratory Therapy Department on 6/28/16 at 1:10 pm revealed a medical gas (oxygen) zone valve that was actively leaking at a slow rate. The issue was resolved immediately onsite.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.




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Based on observation and interview the facility failed to ensure: 1) power strips were used in a safe manner; 2) ground fault interrupted outlets were used in wet locations; 3) electrical panels were labeled and contained no gaps in the panel; 4) electrical junction boxes were covered; and 5) extension cords were used appropriately. These failed practices placed occupants in 15 out of 24 smoke compartments (on floors 1, 2 and 5) at risk for electrocution, loss of electrical services or a fire environment. Findings:

Floor 1:

Observation of central supply department on 6/27/16 at 12:20 pm revealed a non-ground fault interrupted (GFI) six outlet receptacle located next to two sinks. Additional review revealed a receptacle face plate cover that was loosely hanging over an outlet exposing live wires.

Observation of central supply break room on 6/27/16 at 12:45 pm revealed a coffee pot, microwave, refrigerator and toaster plugged into a power strip (15 amp max load). Additional observation revealed the power strip was supplying power to another power strip.

During an interview on 6/27/16 at 12:45 pm the Facility Engineer stated the plugged in items exceeded the 15 amp max load as indicated by the power strip's listing. In addition, he added the items needed to be unplugged from the power strip.

Observation on 6/27/16 at 1:40 pm revealed an unlabeled electrical panel in the central pharmacy's Pyxis room.

Observation in the pharmacy on 6/27/16 at 1:47 pm revealed an electrical panel (E1LL1) had no breaker in place.

Observation of the physician's dining area on 6/28/16 at 8:37 am revealed a power strip that was suspended under a desk.


Floor 2:

Observation of the ambulance bay on 6/28/16 at 9:15 am revealed a junction box leading to the garage door that was uncovered exposing live wires.

Observation on 6/28/16 at 9:55 am revealed an open junction box in the ceiling above the door leading from corridor into radiology (next to elevators 4 & 5).

Observations of cath lab control room on 6/28/16 at 10:15 am revealed two unlabeled electrical panels.

Observation on 6/28/16 at 10:55 am revealed a non GFI outlet next to a sink was located in the staff lounge of the post-anesthesia care.

Observation on 6/29/16 at 9:00 am revealed a power strip was being supplied electricity via an extension cord in operating room #5.

Observation on 6/29/16 at 9:20 am revealed a power strip was being supplied electricity via another power strip in operating room #1.

Observation on 6/29/16 at 9:30 am revealed a non-hospital grade power strip was being used in operating room #10.

Observation of the anesthesia supply room on 6/28/16 at 10:47 am revealed a power strip that was suspended under a desk via rigid metal wires.
The Safety Officer acknowledged and confirmed the findings at the time of their discovery.

Floor 5:

Observation of the ADL (Activities of Daily Living) kitchen on 6/28/16 at 2:48 pm revealed a non-GFI outlet located beside the sink.

The Safety Officer acknowledged and confirmed the finding at the time of its discovery.





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