HospitalInspections.org

Building A1-Main Hospital

Through observation, during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other facilities.

During the walk through of the facility, with the Maintenance Director, the facility contained an unsealed wire penetration in the 2 hour wall adjacent to the IR control room.
Per Section 19.1.2.3 states "Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions per 19.1.1.4."

Note: This deficiency was corrected during the survey

The deficiency effecetd 1 smoke compartment of the facility.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through, with the Maintenance Director;
1) The double door to "Little Miss Latte" area would not shut and latch into the frame
2) Patient care being conducted in the corridor of the Emergency department during the survey. Patient #1 was being treated outside room, the patient was lying on a gurney and was not being attended to. Patient #2 was being treated outside room #7 and was sitting on the gurney and was being treated by a physician.
Note: The emergency department measured larger than 10,000 square feet in size and cannot be categorized as a "suite".
3) One (1) large industrial size wheeled trash canwas being stored in the corridor outside the AD of Emergency Services. This trash can was full of large trash bags (approximately 15 trash bags) and was noticed in the corridor for approximately 4 hours.
4) Four (4) doors in admitting area were covered with wrapping paper to similate presents.
Note: This wrapping paper was removed during survey

These deficiencies effected 3 smoke compartments within the facility.

Building A5-Wolf Surgery

Through observation during the survey, December 11, 2014, it was determined that the facility failed to maintain the stairway doors at the vertical opening.
 
During the walk through of the facility with the Maintenance Director, the the door to the elevator contained boxes iblocking the door from closing. The door also contained a sign that stated "Fire Door No parking".

This deficiency effected 1 door in the space.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, two (2) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:
1) One (1) unsealed wire penetration in the smoke barrier adjacent to EM Services office
2) One (1) unsealed copper pipe penetration on 6th floor North
Note: All deficiencies were corrected during survey

These deficiencies effected 4 smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Maintenance Director,the second (2nd) floor smoke barrier door at east entrance to pre-op door #9-12 contained a left leaf that would not latch into the frame when closing.
Note: Corrected during the survey

This deficiency effecetd two smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director:
1) The door to ED storage room opens to the corridor and was propped open with the hinge prop open device--it was not attached the fire alarm system. Room contains high amount of combustible storage and is considered a hazardous area.
2) Soiled linen door at door #272 in the Pavilion Bldg would not latch into the frame.
Note: Corrected during survey
3) One (1) unsealed wire penetration in a janitors closet on the 2nd floor of the Pavilion Bldg.

These deficiencies effected three smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director;
1) Two (2) delayed egress door contained a nuisance alarm on the delayed egress alarm. This alarm provided 3 short beeps prior to start the irreversible process.
a) The sixth (6th) floor NW stairwell
b) The third (3rd) floor East stairwell near LDR #7
Note: The nuisance alarm was removed and corrected from both doors during the survey
2) Signage on three (3) delayed egress doors were not compliant with NFPA 101. The letters were not the size required in stroke width.
a) The third (3rd) floor central stairwell
b) Two delayed egress exit doors from NICU area.
Note: All three signage issues were corrected during the survey

These deficiencies effected 5 exits from 2 different areas of the facility.

Building A5-Wolf Surgery

Through observation during the survey, December 11, 2014, it was determined that the exit discharge was blocked by equipment.
 
During the walk through of the facility, with the Maintenance Director, the exit path from the thirs floor sterile area contained five (5) steel wheeled carts blocking the exit path to the required exit door.
Per the 2000 Edition of NFPA 101, Chapter 7, Section 7.7 requires that all exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. The means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would include any type of barrier that is an impediment to free movement in the means of egress.

This deficiency effected 1 exit and five (5) staff.

Building A1-Main Hospital

Through record review and discussions with the staff during the survey, December 8 through December 11, 2014, it was determined that the facility failed to conduct fire drills at on each shift quarterly.

During the review of the facility records, with the Maintenance Director, the facility utilized an actual fire alarm as a fire drill during the 3rd quarter, 2nd shift of 2014.

This deficiency potentially effected all areas within the hospital.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to install a fire alarm system in accordance with NFPA 101.

During record review, interviews and testing of the fire alarm system, with the Maintenance Director, the operating rooms contained no visual fire alarm notification and/or contained coverings over the windows in the following areas;
1) Three (3) labor/delivery OR's, located on the third (3rd) floor, contained no visual notification in the operating rooms and the doors, which had small windows located in the doors as the possibly of seeing the visual notification in the corridor, contained covers over the windows.
2) Second (2nd) floor OR's, #1, 2, 3, 8, 9, did not have visual notification inside the room and the strobes outside in the corridor were not visible from inside the room.

The following areas contained visual notification that was installed incorrectly per NFPA 72 or were not working properly.
1) Third (3rd) floor central corridor has 1 strobe at the end of the corridor but no strobe adjacent or close to the nurse station which violates the spacing requirements for strobe notification
4) Horn strobe in the corridor of L&D OR Suite was not functioning during a test.
Note: corrected during survey
5) Two (2) Family Med sleep rooms have 73db of alarm sound with a 68 db ambient sound inside the room during a fire alarm test. The rooms contained no visual notification in the room and no other audible notification in the rooms.

These areas effected five smoke compartments throughout the facility.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined the facility failed to maintain automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, four 94) sprinkler heads were loaded with dust and debris from the ventilation vents. These four heads were located in the PACU area.

Note: The deficiency was corrected by staff during the survey

This deficiency effected 1 smoke compartment within the facility.

Building A1-Main Hospital

Through observation and record review during the survey, December 8 through December 11, 2014, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, one (1) curtain in office of Cardio Vas Nurse Practitioner does not contain documentation that it is fire retardent.

This deficiency effected 1 smoke compartment and 1 room.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility, with the Maintenance Director;
1) Three (3) anesthetizing operating rooms, located within the Labor and Delivery area, did not contain ground fault or line isolation electrical protection.
Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).
2) The facility failed to provide a means by which to exhaust the three (3) windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, in the Labor and delivery area.
Per NFPA 99, 5-4.1.2. Per discussions with the Maintenance Director, he believed that the operating room HVAC unit did contain fire dampers, however he was unsure if the HVAC unit only shut down during smoke detection or if the unit did contain exhaust. The system could not be tested due to procedures occurring during the survey.

This deficiency effected 3 operating rooms in the Labor and delivery suite.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, the facility utilized extension cord as a substitute for the fixed wiring of the structure in the second (2nd) floor ICU staff room.
Per NFPA 70, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

Note: Corrected and removed during the survey

This deficiency effected 1 smoke compartment in the facility.

Building A1-Main Hospital

Through observation, during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other facilities.

During the walk through of the facility, with the Maintenance Director, the facility contained an unsealed wire penetration in the 2 hour wall adjacent to the IR control room.
Per Section 19.1.2.3 states "Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions per 19.1.1.4."

Note: This deficiency was corrected during the survey

The deficiency effecetd 1 smoke compartment of the facility.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through, with the Maintenance Director;
1) The double door to "Little Miss Latte" area would not shut and latch into the frame
2) Patient care being conducted in the corridor of the Emergency department during the survey. Patient #1 was being treated outside room, the patient was lying on a gurney and was not being attended to. Patient #2 was being treated outside room #7 and was sitting on the gurney and was being treated by a physician.
Note: The emergency department measured larger than 10,000 square feet in size and cannot be categorized as a "suite".
3) One (1) large industrial size wheeled trash canwas being stored in the corridor outside the AD of Emergency Services. This trash can was full of large trash bags (approximately 15 trash bags) and was noticed in the corridor for approximately 4 hours.
4) Four (4) doors in admitting area were covered with wrapping paper to similate presents.
Note: This wrapping paper was removed during survey

These deficiencies effected 3 smoke compartments within the facility.

Building A5-Wolf Surgery

Through observation during the survey, December 11, 2014, it was determined that the facility failed to maintain the stairway doors at the vertical opening.
 
During the walk through of the facility with the Maintenance Director, the the door to the elevator contained boxes iblocking the door from closing. The door also contained a sign that stated "Fire Door No parking".

This deficiency effected 1 door in the space.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, two (2) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:
1) One (1) unsealed wire penetration in the smoke barrier adjacent to EM Services office
2) One (1) unsealed copper pipe penetration on 6th floor North
Note: All deficiencies were corrected during survey

These deficiencies effected 4 smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Maintenance Director,the second (2nd) floor smoke barrier door at east entrance to pre-op door #9-12 contained a left leaf that would not latch into the frame when closing.
Note: Corrected during the survey

This deficiency effecetd two smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director:
1) The door to ED storage room opens to the corridor and was propped open with the hinge prop open device--it was not attached the fire alarm system. Room contains high amount of combustible storage and is considered a hazardous area.
2) Soiled linen door at door #272 in the Pavilion Bldg would not latch into the frame.
Note: Corrected during survey
3) One (1) unsealed wire penetration in a janitors closet on the 2nd floor of the Pavilion Bldg.

These deficiencies effected three smoke compartments within the facility

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director;
1) Two (2) delayed egress door contained a nuisance alarm on the delayed egress alarm. This alarm provided 3 short beeps prior to start the irreversible process.
a) The sixth (6th) floor NW stairwell
b) The third (3rd) floor East stairwell near LDR #7
Note: The nuisance alarm was removed and corrected from both doors during the survey
2) Signage on three (3) delayed egress doors were not compliant with NFPA 101. The letters were not the size required in stroke width.
a) The third (3rd) floor central stairwell
b) Two delayed egress exit doors from NICU area.
Note: All three signage issues were corrected during the survey

These deficiencies effected 5 exits from 2 different areas of the facility.

Building A5-Wolf Surgery

Through observation during the survey, December 11, 2014, it was determined that the exit discharge was blocked by equipment.
 
During the walk through of the facility, with the Maintenance Director, the exit path from the thirs floor sterile area contained five (5) steel wheeled carts blocking the exit path to the required exit door.
Per the 2000 Edition of NFPA 101, Chapter 7, Section 7.7 requires that all exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. The means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would include any type of barrier that is an impediment to free movement in the means of egress.

This deficiency effected 1 exit and five (5) staff.

Building A1-Main Hospital

Through record review and discussions with the staff during the survey, December 8 through December 11, 2014, it was determined that the facility failed to conduct fire drills at on each shift quarterly.

During the review of the facility records, with the Maintenance Director, the facility utilized an actual fire alarm as a fire drill during the 3rd quarter, 2nd shift of 2014.

This deficiency potentially effected all areas within the hospital.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to install a fire alarm system in accordance with NFPA 101.

During record review, interviews and testing of the fire alarm system, with the Maintenance Director, the operating rooms contained no visual fire alarm notification and/or contained coverings over the windows in the following areas;
1) Three (3) labor/delivery OR's, located on the third (3rd) floor, contained no visual notification in the operating rooms and the doors, which had small windows located in the doors as the possibly of seeing the visual notification in the corridor, contained covers over the windows.
2) Second (2nd) floor OR's, #1, 2, 3, 8, 9, did not have visual notification inside the room and the strobes outside in the corridor were not visible from inside the room.

The following areas contained visual notification that was installed incorrectly per NFPA 72 or were not working properly.
1) Third (3rd) floor central corridor has 1 strobe at the end of the corridor but no strobe adjacent or close to the nurse station which violates the spacing requirements for strobe notification
4) Horn strobe in the corridor of L&D OR Suite was not functioning during a test.
Note: corrected during survey
5) Two (2) Family Med sleep rooms have 73db of alarm sound with a 68 db ambient sound inside the room during a fire alarm test. The rooms contained no visual notification in the room and no other audible notification in the rooms.

These areas effected five smoke compartments throughout the facility.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined the facility failed to maintain automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, four 94) sprinkler heads were loaded with dust and debris from the ventilation vents. These four heads were located in the PACU area.

Note: The deficiency was corrected by staff during the survey

This deficiency effected 1 smoke compartment within the facility.

Building A1-Main Hospital

Through observation and record review during the survey, December 8 through December 11, 2014, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, one (1) curtain in office of Cardio Vas Nurse Practitioner does not contain documentation that it is fire retardent.

This deficiency effected 1 smoke compartment and 1 room.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility, with the Maintenance Director;
1) Three (3) anesthetizing operating rooms, located within the Labor and Delivery area, did not contain ground fault or line isolation electrical protection.
Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).
2) The facility failed to provide a means by which to exhaust the three (3) windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, in the Labor and delivery area.
Per NFPA 99, 5-4.1.2. Per discussions with the Maintenance Director, he believed that the operating room HVAC unit did contain fire dampers, however he was unsure if the HVAC unit only shut down during smoke detection or if the unit did contain exhaust. The system could not be tested due to procedures occurring during the survey.

This deficiency effected 3 operating rooms in the Labor and delivery suite.

Building A1-Main Hospital

Through observation during the survey, December 8 through December 11, 2014, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, the facility utilized extension cord as a substitute for the fixed wiring of the structure in the second (2nd) floor ICU staff room.
Per NFPA 70, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

Note: Corrected and removed during the survey

This deficiency effected 1 smoke compartment in the facility.