HospitalInspections.org

Based on observation and interview, the hospital failed to ensure the gift shop is separated from the main corridor.

Findings include:

1. Observation on 12/11/12 at 9:00 am revealed that the gift shop was open to the corridor. The gift shop had two (2) open windows measuring approximately 36" by 36" and 48" by 48". There was no glass in the openings.

2. Interview with the maintenance director on 12/11/12 at approximately 9:00 a.m. confirmed the observation.

Based on observation and staff interview, it was determined the Hospital failed to maintain Dietary corridor doors to close and latch without impediment.

Findings include:

1. On 12/11/12 at approximately 9:50 a.m., the corridor doors to the dish room were observed to be propped open with wooden wedges.

2. These findings were discussed with the facility maintenance director on 12/11/12 at approximately 9:50 a.m. and the maintenance director agreed the above doors were held open with wooden wedges.

Based on observation and interview, the hospital failed to ensure that the stairways are constructed with a fire resistance rating of one-hour.

Findings include:

1. Observation of both stairways (North and South) on 12/11/12 at approximately 11:00 a.m. revealed penetrations at the top of both stairways. Neither stairway is sealed to the roof deck.

2. Interview with the Maintenance Tech on 12/11/12 at approximately 11:00 a.m. confirmed the observation.

Based on observation and interview, the hospital failed to ensure that all doors in rated walls are held open only with devices arranged to automatically close upon activation of the fire alarm system.

Findings include:

1. On 12/11/12 at approximately 9:50 a.m., the Emergency Department (ED) door entering into the main hallway was observed to be held open with a bind in the closure and would not close upon activation of the fire alarm system.

2. Interview with the maintenance director on 12/11/12 at approximately 9:50 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that access to all exits is marked by readily visible signs.

Findings include:

1. On 12/11/12 at approximately 10:00 a.m., it was observed that the exit sign by the ambulance exit was not clearly visible.

2. Interview with the maintenance director on 12/11/12 at approximately 10:00 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that smoke barriers do not have penetrations to prevent the passage of smoke.

Findings include:

1. Observation of the Emergency Department (ED)/Lab Mechanical room on 12/10/12 at 3:30 p.m., revealed penetrations in the room. Approximately a twelve (12) by sixteen (16) inch opening with conduits and corrugation was observed.

2. On 12/10/12 at 1:30 p.m., observation of the 2nd floor separation wall revealed four (4) penetrations at the roof deck.

3. Interview with the Maintenance director on 12/10/12 at 3:30 p.m., confirmed the ED/Lab mechanical room penetrations.

4. Interview with the Maintenance Tech on 12/10/12 at 1:30 p.m., confirmed the penetrations.

Based on observation and interview, the hospital failed to ensure that all exits are readily accessible at all times. The Emergency department (ED) entrance of the hospital is equipped with thumb latches.

Findings include:

1. Observation on 12/11/12 at approximately 9:45 a.m., revealed that the ED entrance doors can be locked with thumb latches. The locks are located on the two (2) glass sliding doors in the emergency room lobby, leading to the parking area.

2. The observation was confirmed by the Maintenance Director on 12/11/12 at 9:45 a.m.

Based on document review and interview, the hospital failed to ensure that the fire alarm system is tested to include smoke detector sensitively testing.

Findings include:

1. Review of the fire alarm inspection report dated 12/11/12 revealed no documented credible evidence of smoke detector sensitivity testing.

2. Interview with the Maintenance Director on 12/10/12 at 2:30 p.m., confirmed that there was no documentation to support the completion of sensitivity testing.

Based on observation and interview, the hospital failed to ensure that the linen chute system is sealed from fire by a fire door assembly with a fire protection rating of one (1) hour and that the linen chute system discharges into a room that provides one (1) hour fire protection..

Findings include:

1. Observation of the linen chute system on 12/11/12 at approximately 9:45 a.m., revealed that the chute doors had penetrations in the doors where unapproved locks had been installed.

2. Interview with the Maintenance Director on 12/11/12 at approximately 9:45 a.m., confirmed the observation.

3. Observation on 12/11/12 at approximately 9:45 a.m., revealed that the chute system discharged into the basement into a soiled linen room. Interview with the Maintenance Director on 12/11/12 at 9:45 a.m., revealed that the room was used for storage. The room did not have a closure on the door leading into the hallway.

4. The observations of the room, chute locks and door (without closure) were confirmed by the Maintenance Director on 12/11/12 at 9:45 a.m.

Based on observation and interview, the hospital failed to ensure that the piped medical gas system complies with National Fire Protection Association (NFPA) 99 Chapter 4. Gauges and signage are not in compliance with NFPA 99 Chapter 4.

Findings include:

1. Observation on 12/11/12 at approximately 10:20 a.m., revealed two (2) Zone Valve boxes on the second story were incorrectly labeled and four (4) Zone Valve boxes did not have any gauges.

2. Interview with the Maintenance Director on 12/11/12 at approximately 10:20 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that it transfers oxygen in accordance with National Fire Protection Association (NFPA) 99 8.6.2.5.2. The room is not vented, rated or signed in accordance with NFPA 99.

Findings include:

1. Observation of the Oxygen storage/transfer area on 12/11/12 at 10:40 a.m., revealed that the room was not mechanically vented and did not meet the requirements for oxygen transfer.

2. Interview with the Maintenance Director on 12/11/12 at 10:40 a.m., confirmed the observation.

1. Based on observation, record review and staff interview, it was determined not all facility Line Isolation Ground and electrical systems were not maintained according to National Fire Protection Association (NFPA) 99.

Findings include:

1. During a tour of the hospital operating room on 12/10/12 at approximately 2:55 p.m., two (2) of the safe lights for the Line Isolation Monitors located at the control center were observed not illuminated. In one (1) light, the bulb was missing.

2. During an interview with the Maintenance Director on 12/10/12 at 2:55 p.m., confirmed the observation. Record review verified there is no documented credible evidence of any testing or certification of the Line Isolation Monitors.

2. Based on observation and interview, the hospital failed to ensure that ground fault receptacles (GFI's) are located within six (6) feet of any water source.

Findings include:

1. Observation on 12/11/12 at 10:50 a.m., revealed three (3) receptacles in the kitchen within six (6) feet of the two (2) bowl pot sink, were not GFI protected.

2. Interview with the Maintenance Tech on 12/11/12 at 10:50 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure the gift shop is separated from the main corridor.

Findings include:

1. Observation on 12/11/12 at 9:00 am revealed that the gift shop was open to the corridor. The gift shop had two (2) open windows measuring approximately 36" by 36" and 48" by 48". There was no glass in the openings.

2. Interview with the maintenance director on 12/11/12 at approximately 9:00 a.m. confirmed the observation.

Based on observation and staff interview, it was determined the Hospital failed to maintain Dietary corridor doors to close and latch without impediment.

Findings include:

1. On 12/11/12 at approximately 9:50 a.m., the corridor doors to the dish room were observed to be propped open with wooden wedges.

2. These findings were discussed with the facility maintenance director on 12/11/12 at approximately 9:50 a.m. and the maintenance director agreed the above doors were held open with wooden wedges.

Based on observation and interview, the hospital failed to ensure that the stairways are constructed with a fire resistance rating of one-hour.

Findings include:

1. Observation of both stairways (North and South) on 12/11/12 at approximately 11:00 a.m. revealed penetrations at the top of both stairways. Neither stairway is sealed to the roof deck.

2. Interview with the Maintenance Tech on 12/11/12 at approximately 11:00 a.m. confirmed the observation.

Based on observation and interview, the hospital failed to ensure that all doors in rated walls are held open only with devices arranged to automatically close upon activation of the fire alarm system.

Findings include:

1. On 12/11/12 at approximately 9:50 a.m., the Emergency Department (ED) door entering into the main hallway was observed to be held open with a bind in the closure and would not close upon activation of the fire alarm system.

2. Interview with the maintenance director on 12/11/12 at approximately 9:50 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that access to all exits is marked by readily visible signs.

Findings include:

1. On 12/11/12 at approximately 10:00 a.m., it was observed that the exit sign by the ambulance exit was not clearly visible.

2. Interview with the maintenance director on 12/11/12 at approximately 10:00 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that smoke barriers do not have penetrations to prevent the passage of smoke.

Findings include:

1. Observation of the Emergency Department (ED)/Lab Mechanical room on 12/10/12 at 3:30 p.m., revealed penetrations in the room. Approximately a twelve (12) by sixteen (16) inch opening with conduits and corrugation was observed.

2. On 12/10/12 at 1:30 p.m., observation of the 2nd floor separation wall revealed four (4) penetrations at the roof deck.

3. Interview with the Maintenance director on 12/10/12 at 3:30 p.m., confirmed the ED/Lab mechanical room penetrations.

4. Interview with the Maintenance Tech on 12/10/12 at 1:30 p.m., confirmed the penetrations.

Based on observation and interview, the hospital failed to ensure that all exits are readily accessible at all times. The Emergency department (ED) entrance of the hospital is equipped with thumb latches.

Findings include:

1. Observation on 12/11/12 at approximately 9:45 a.m., revealed that the ED entrance doors can be locked with thumb latches. The locks are located on the two (2) glass sliding doors in the emergency room lobby, leading to the parking area.

2. The observation was confirmed by the Maintenance Director on 12/11/12 at 9:45 a.m.

Based on document review and interview, the hospital failed to ensure that the fire alarm system is tested to include smoke detector sensitively testing.

Findings include:

1. Review of the fire alarm inspection report dated 12/11/12 revealed no documented credible evidence of smoke detector sensitivity testing.

2. Interview with the Maintenance Director on 12/10/12 at 2:30 p.m., confirmed that there was no documentation to support the completion of sensitivity testing.

Based on observation and interview, the hospital failed to ensure that the linen chute system is sealed from fire by a fire door assembly with a fire protection rating of one (1) hour and that the linen chute system discharges into a room that provides one (1) hour fire protection..

Findings include:

1. Observation of the linen chute system on 12/11/12 at approximately 9:45 a.m., revealed that the chute doors had penetrations in the doors where unapproved locks had been installed.

2. Interview with the Maintenance Director on 12/11/12 at approximately 9:45 a.m., confirmed the observation.

3. Observation on 12/11/12 at approximately 9:45 a.m., revealed that the chute system discharged into the basement into a soiled linen room. Interview with the Maintenance Director on 12/11/12 at 9:45 a.m., revealed that the room was used for storage. The room did not have a closure on the door leading into the hallway.

4. The observations of the room, chute locks and door (without closure) were confirmed by the Maintenance Director on 12/11/12 at 9:45 a.m.

Based on observation and interview, the hospital failed to ensure that the piped medical gas system complies with National Fire Protection Association (NFPA) 99 Chapter 4. Gauges and signage are not in compliance with NFPA 99 Chapter 4.

Findings include:

1. Observation on 12/11/12 at approximately 10:20 a.m., revealed two (2) Zone Valve boxes on the second story were incorrectly labeled and four (4) Zone Valve boxes did not have any gauges.

2. Interview with the Maintenance Director on 12/11/12 at approximately 10:20 a.m., confirmed the observation.

Based on observation and interview, the hospital failed to ensure that it transfers oxygen in accordance with National Fire Protection Association (NFPA) 99 8.6.2.5.2. The room is not vented, rated or signed in accordance with NFPA 99.

Findings include:

1. Observation of the Oxygen storage/transfer area on 12/11/12 at 10:40 a.m., revealed that the room was not mechanically vented and did not meet the requirements for oxygen transfer.

2. Interview with the Maintenance Director on 12/11/12 at 10:40 a.m., confirmed the observation.

1. Based on observation, record review and staff interview, it was determined not all facility Line Isolation Ground and electrical systems were not maintained according to National Fire Protection Association (NFPA) 99.

Findings include:

1. During a tour of the hospital operating room on 12/10/12 at approximately 2:55 p.m., two (2) of the safe lights for the Line Isolation Monitors located at the control center were observed not illuminated. In one (1) light, the bulb was missing.

2. During an interview with the Maintenance Director on 12/10/12 at 2:55 p.m., confirmed the observation. Record review verified there is no documented credible evidence of any testing or certification of the Line Isolation Monitors.

2. Based on observation and interview, the hospital failed to ensure that ground fault receptacles (GFI's) are located within six (6) feet of any water source.

Findings include:

1. Observation on 12/11/12 at 10:50 a.m., revealed three (3) receptacles in the kitchen within six (6) feet of the two (2) bowl pot sink, were not GFI protected.

2. Interview with the Maintenance Tech on 12/11/12 at 10:50 a.m., confirmed the observation.