HospitalInspections.org

Based on observations and interviews the facility failed to ensure door openings closed to resist the passage of smoke into an exit corridor. This deficient practice could have potentially exposed patients, staffs, and visitors to smoke. Findings:

Observation during the Surgery Department tour on 7/10/14 at 8:36 am revealed the door to the medical gas bottle storage room failed to close and latch when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure fire doors on a self-closer would close and latch to resist fire and smoke passage in the corridor. This deficient practice could have potentially exposed patients, staffs, and visitors to fire and smoke. Findings:

During a facility tour, the following observations on:

· 7/8/14 at 2:51 pm revealed that the double doors in the fourth floor H building corridor (At transition to D building) failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the mental health area on the fourth floor of H building;

· 7/9/14 at 8:44 am revealed that the corridor doors (F3159), located on the third floor of building H by the pediatric unit, failed to close and latch when tested;

· 7/9/14 at 9:08 am revealed that the left door (G2075) at the G1 elevator lobby failed to latch when tested;

· 7/9/14 at 9:19 am revealed that the right corridor door (E2081), located on the second floor of building E in the Progressive Care Unit, failed to close and latch when tested;

· 7/9/14 at 9:50 am revealed that the door H2009 in the second patient care area of building H (At transition to D building) failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the Mental Health area on the fourth floor of H building;

· 7/9/14 at 9:58 am revealed that two of the three pairs of doors for the second floor elevator lobby in building D failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the mental health area on the fourth floor of H building;

· 7/9/14 at 10:20 am revealed a set of fire doors located in the second floor corridor between the vascular Access Team room and Pharmacy Break Room failed to close and latch and when tested;

· 7/9/14 at 10:45 am revealed that the elevator lobby fire doors (M2-001), located on the second floor of building M in the Mother Baby Unit, failed to close and latch when tested;

· 7/9/14 at 11:00 am revealed that the fire doors, located on the second floor of building M in the Mother Baby Unit between rooms 2503 and 2502, failed to close and latch when tested;

· 7/9/14 at 3:13 pm revealed that the corridor doors between Endo and Day Surgery on the first floor of building F failed to close and latch when tested;

· 7/9/14 at 3:38 pm revealed that the fire doors in the corridor between exam rooms 23 and 24 located on the first floor of building E in the Emergency Department failed to close and latch when tested; and

· 7/10/14 at 8:35 am revealed that the fire doors (1G125) in the Surgical Department corridor located on the first floor of building G failed to close and latch when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/214 at 4:20 pm.

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Based on observation and interview the facility failed to ensure that exits were properly marked with appropriate signage. This deficiency had the potential to delay access to an exit which could expose patients, staff, and visitors to a smoke or fire environment. Findings:

An observation during the facility tour on 7/9/14 at 11:07 am revealed door M2-023, located on the second floor of building M in the Mother Baby Unit, was marked with signage that read " Exit Only " . This door led to an exam room and it was not an exit door. Interview with the staff revealed that the room was used for circumcision procedures and they did not want unauthorized personnel to enter the room.

Further observation during the facility tour on 7/9/14 at 3:38 pm revealed that a door to the doctors lounge on the first floor of building E in the Emergency Department was marked with signage that read " Exit Only " . This door led to a lounge and it was not an exit door. Interview with the staff revealed that they did not want unauthorized personnel to enter the room.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and staff interview the facility failed to ensure that exits were properly marked with appropriate signage and/or that the marked exits lead to a path that could be followed without the use of a key or card for access. This deficiency had the potential to delay access to an exit which could expose patients, staff, and visitors to a smoke or fire environment. Findings:

Observations on 7/8/14 at 1:49 pm revealed that exit door from the atrium, located on the fifth floor of building H, locked when closed and the fire exit hardware failed to release the door. The door could only be opened with a key.

An observation on 7/9/14 at 1:49 pm revealed that normal secondary exit path from the Obstetric Triage area, located on the first floor of building C, was obstructed by construction. The alternate route required a security card to open a door to leave the area. When we identified the problem the Facilities Maintenance Director had the security card reader reprogramed so the door would not require a key card to exit.

Further observations on 7/9/14 at 2:08 pm revealed that normal secondary exit path from the admitting unit, located on the first floor of building D, was obstructed by construction. The exit sign was still in place marking the door as an exit.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation the facility failed to ensure illumination in a means of egress. This deficient practice had the potential to affect staff in the event of a power outage. Findings:

An observation during the facility tour on 7/9/14 at 10:37 am revealed that emergency light DB092, located in an electrical room in the basement of building D, failed to operate when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations, record review, and interview, the facility failed to maintain appropriate records for the inspection and testing of the automatic fire sprinkler system. This could potentially affect all patients, staff, and visitors. Findings:

Record review on 7/7/14 at 1:08 pm revealed that there were no documented reports of inspection for the individual automatic fire sprinkler system risers as required by NFPA 25 (1998 edition) Sections 2-1.3 and 1-8. The Facilities Support Director stated that the fire sprinkler technicians inspected the riser and completed main drain flow tests on the systems. The fire sprinkler technician left a tag indicating the date of service but did not provide a report of inspection. The Facility Support Director said that he did the fire alarm inspections and testing. In addition, he also looked at the fire sprinkler system piping and sprinkler heads throughout the buildings as the fire alarm devices were tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure all fire extinguishers were accessible to building personnel. This deficiency had the potential to delay access to fire extinguishers which could increase exposure of patients, staff, and visitors to a smoke or fire environment. Findings:

During a facility tour, the following observations on:

· 7/8/14 at 10:50 am revealed a fire extinguisher in Central Sterilization, located in the D building basement, was blocked from view and access by carts;

· 7/8/14 at 11:50 am revealed that a fire extinguisher in Pharmacy, located in the basement of D building, was blocked from view and access; and

· 7/10/14 at 8:40 am revealed that a fire extinguisher in the operating room equipment storage room, located on the first floor of building G, was blocked from view and access.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure a kitchen hood and duct fire suppression system was installed and maintained as required by NFPA 96 (1998 edition) Section 7-1.2. This deficiency had the potential to delay suppression of a kitchen fire which could potentially expose patients, staff, and visitors to a smoke or fire environment. Findings:

An observation during the facility tour on 7/8/14 at 1:30 pm revealed that two nozzles above the Deli griddle in the C building cafeteria were out of position. If the kitchen hood and duct fire suppression system were activated the extinguishing agent would not have been applied to the cooking surface.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations, record review, and interview, the facility failed to ensure window drapes and privacy curtains used in the facility were flame resistant. This deficient practice has the potential to affect patients, staff, and visitors. Findings:

An observation during the facility tour on 7/9/14 at 9:36 am revealed window curtains in room 257 in Patient Care Unit 5, located on the second floor of building G, did not have a tag indicating the curtains were flame resistant in accordance with NFPA 701.

Further observation during the facility tour on 7/9/14 at 2:17 pm revealed that the privacy curtain in room D1-093 in Electrocardiogram (EKG) testing area, located on the first floor of Building D, did not have a tag indicating the curtains were flame resistant in accordance with NFPA 701.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations and interviews the facility failed to ensure that proper humidity levels were monitored and maintained in the anesthetizing locations in the operating room as required by NFPA 99 (1999 edition) 5-4.1 and 5-4.1.1. This could affect the health and safety of patients and employees in the operating area. Findings:

Observation and interviews during the facility walk through on 7/10/14 at 9:40 am revealed no humidity monitor in Labor Operating Rooms (LOR) 1, 2, & 3 in building M. Further observations revealed humidity was being monitored in a supply room across the corridor from LOR 1 and in the corridor outside LOR 1.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations and interviews the facility failed to ensure appropriate surge protector/power taps were used in the operating rooms in accordance with electrical code. This could affect the health and safety of patients and employees in the operating room. Findings:

Observation during the facility tour on 7/9/14 at 2:41 pm revealed a power tap in cardiac procedure room (Cath Lab #6), located on the first floor of building D, was labeled " Not for use in a Medical Facility " . The Facility Support Director said that all of the power taps used in the operating rooms were supposed to have a label that stated " For use in a medical facility " .

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and staff interview the facility failed to ensure alcohol based hand rub dispensers were safely installed to prevent potential fire. This deficient practice could have potentially exposed patients, staffs, and visitors to fire and smoke. Findings:

Observation during the facility tour on 7/10/14 at 2:14 pm revealed an alcohol based hand rub dispenser that was installed above an electrical outlet in the CT Simulator room, located on the lower level of Building U in the Cancer Center.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations and interviews the facility failed to ensure door openings closed to resist the passage of smoke into an exit corridor. This deficient practice could have potentially exposed patients, staffs, and visitors to smoke. Findings:

Observation during the Surgery Department tour on 7/10/14 at 8:36 am revealed the door to the medical gas bottle storage room failed to close and latch when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure fire doors on a self-closer would close and latch to resist fire and smoke passage in the corridor. This deficient practice could have potentially exposed patients, staffs, and visitors to fire and smoke. Findings:

During a facility tour, the following observations on:

· 7/8/14 at 2:51 pm revealed that the double doors in the fourth floor H building corridor (At transition to D building) failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the mental health area on the fourth floor of H building;

· 7/9/14 at 8:44 am revealed that the corridor doors (F3159), located on the third floor of building H by the pediatric unit, failed to close and latch when tested;

· 7/9/14 at 9:08 am revealed that the left door (G2075) at the G1 elevator lobby failed to latch when tested;

· 7/9/14 at 9:19 am revealed that the right corridor door (E2081), located on the second floor of building E in the Progressive Care Unit, failed to close and latch when tested;

· 7/9/14 at 9:50 am revealed that the door H2009 in the second patient care area of building H (At transition to D building) failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the Mental Health area on the fourth floor of H building;

· 7/9/14 at 9:58 am revealed that two of the three pairs of doors for the second floor elevator lobby in building D failed to close and latch when tested. The Facilities Support Director stated the air pressure in the atrium and corridors of H and D buildings was out of balance due to construction taking place in the mental health area on the fourth floor of H building;

· 7/9/14 at 10:20 am revealed a set of fire doors located in the second floor corridor between the vascular Access Team room and Pharmacy Break Room failed to close and latch and when tested;

· 7/9/14 at 10:45 am revealed that the elevator lobby fire doors (M2-001), located on the second floor of building M in the Mother Baby Unit, failed to close and latch when tested;

· 7/9/14 at 11:00 am revealed that the fire doors, located on the second floor of building M in the Mother Baby Unit between rooms 2503 and 2502, failed to close and latch when tested;

· 7/9/14 at 3:13 pm revealed that the corridor doors between Endo and Day Surgery on the first floor of building F failed to close and latch when tested;

· 7/9/14 at 3:38 pm revealed that the fire doors in the corridor between exam rooms 23 and 24 located on the first floor of building E in the Emergency Department failed to close and latch when tested; and

· 7/10/14 at 8:35 am revealed that the fire doors (1G125) in the Surgical Department corridor located on the first floor of building G failed to close and latch when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/214 at 4:20 pm.

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Based on observation and interview the facility failed to ensure that exits were properly marked with appropriate signage. This deficiency had the potential to delay access to an exit which could expose patients, staff, and visitors to a smoke or fire environment. Findings:

An observation during the facility tour on 7/9/14 at 11:07 am revealed door M2-023, located on the second floor of building M in the Mother Baby Unit, was marked with signage that read " Exit Only " . This door led to an exam room and it was not an exit door. Interview with the staff revealed that the room was used for circumcision procedures and they did not want unauthorized personnel to enter the room.

Further observation during the facility tour on 7/9/14 at 3:38 pm revealed that a door to the doctors lounge on the first floor of building E in the Emergency Department was marked with signage that read " Exit Only " . This door led to a lounge and it was not an exit door. Interview with the staff revealed that they did not want unauthorized personnel to enter the room.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and staff interview the facility failed to ensure that exits were properly marked with appropriate signage and/or that the marked exits lead to a path that could be followed without the use of a key or card for access. This deficiency had the potential to delay access to an exit which could expose patients, staff, and visitors to a smoke or fire environment. Findings:

Observations on 7/8/14 at 1:49 pm revealed that exit door from the atrium, located on the fifth floor of building H, locked when closed and the fire exit hardware failed to release the door. The door could only be opened with a key.

An observation on 7/9/14 at 1:49 pm revealed that normal secondary exit path from the Obstetric Triage area, located on the first floor of building C, was obstructed by construction. The alternate route required a security card to open a door to leave the area. When we identified the problem the Facilities Maintenance Director had the security card reader reprogramed so the door would not require a key card to exit.

Further observations on 7/9/14 at 2:08 pm revealed that normal secondary exit path from the admitting unit, located on the first floor of building D, was obstructed by construction. The exit sign was still in place marking the door as an exit.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation the facility failed to ensure illumination in a means of egress. This deficient practice had the potential to affect staff in the event of a power outage. Findings:

An observation during the facility tour on 7/9/14 at 10:37 am revealed that emergency light DB092, located in an electrical room in the basement of building D, failed to operate when tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations, record review, and interview, the facility failed to maintain appropriate records for the inspection and testing of the automatic fire sprinkler system. This could potentially affect all patients, staff, and visitors. Findings:

Record review on 7/7/14 at 1:08 pm revealed that there were no documented reports of inspection for the individual automatic fire sprinkler system risers as required by NFPA 25 (1998 edition) Sections 2-1.3 and 1-8. The Facilities Support Director stated that the fire sprinkler technicians inspected the riser and completed main drain flow tests on the systems. The fire sprinkler technician left a tag indicating the date of service but did not provide a report of inspection. The Facility Support Director said that he did the fire alarm inspections and testing. In addition, he also looked at the fire sprinkler system piping and sprinkler heads throughout the buildings as the fire alarm devices were tested.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure all fire extinguishers were accessible to building personnel. This deficiency had the potential to delay access to fire extinguishers which could increase exposure of patients, staff, and visitors to a smoke or fire environment. Findings:

During a facility tour, the following observations on:

· 7/8/14 at 10:50 am revealed a fire extinguisher in Central Sterilization, located in the D building basement, was blocked from view and access by carts;

· 7/8/14 at 11:50 am revealed that a fire extinguisher in Pharmacy, located in the basement of D building, was blocked from view and access; and

· 7/10/14 at 8:40 am revealed that a fire extinguisher in the operating room equipment storage room, located on the first floor of building G, was blocked from view and access.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observation and interview the facility failed to ensure a kitchen hood and duct fire suppression system was installed and maintained as required by NFPA 96 (1998 edition) Section 7-1.2. This deficiency had the potential to delay suppression of a kitchen fire which could potentially expose patients, staff, and visitors to a smoke or fire environment. Findings:

An observation during the facility tour on 7/8/14 at 1:30 pm revealed that two nozzles above the Deli griddle in the C building cafeteria were out of position. If the kitchen hood and duct fire suppression system were activated the extinguishing agent would not have been applied to the cooking surface.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations, record review, and interview, the facility failed to ensure window drapes and privacy curtains used in the facility were flame resistant. This deficient practice has the potential to affect patients, staff, and visitors. Findings:

An observation during the facility tour on 7/9/14 at 9:36 am revealed window curtains in room 257 in Patient Care Unit 5, located on the second floor of building G, did not have a tag indicating the curtains were flame resistant in accordance with NFPA 701.

Further observation during the facility tour on 7/9/14 at 2:17 pm revealed that the privacy curtain in room D1-093 in Electrocardiogram (EKG) testing area, located on the first floor of Building D, did not have a tag indicating the curtains were flame resistant in accordance with NFPA 701.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations and interviews the facility failed to ensure that proper humidity levels were monitored and maintained in the anesthetizing locations in the operating room as required by NFPA 99 (1999 edition) 5-4.1 and 5-4.1.1. This could affect the health and safety of patients and employees in the operating area. Findings:

Observation and interviews during the facility walk through on 7/10/14 at 9:40 am revealed no humidity monitor in Labor Operating Rooms (LOR) 1, 2, & 3 in building M. Further observations revealed humidity was being monitored in a supply room across the corridor from LOR 1 and in the corridor outside LOR 1.

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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Based on observations and interviews the facility failed to ensure appropriate surge protector/power taps were used in the operating rooms in accordance with electrical code. This could affect the health and safety of patients and employees in the operating room. Findings:

Observation during the facility tour on 7/9/14 at 2:41 pm revealed a power tap in cardiac procedure room (Cath Lab #6), located on the first floor of building D, was labeled " Not for use in a Medical Facility " . The Facility Support Director said that all of the power taps used in the operating rooms were supposed to have a label that stated " For use in a medical facility " .

The above findings were acknowledged at the time by the Facilities Support Director. The findings were also acknowledged by the Facility Support Director and the Hospital Chief Executive Officer during the exit conference on 7/10/14 at 4:20 pm.

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