HospitalInspections.org

Based on observation and interview, the facility failed to maintain corridor openings in one instance on one of three floors.

Findings include:

1. Observation on May 27, 2015, revealed the following corridor opening deficiency:

a) At 8:40 a.m., the basement maintenance shop doors did not close and positively latch as the door was broken. The door is falling apart and has several penetrations.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the corridor opening issue.

Based on observation and interview, the facility failed to maintain the vertical openings in two instances on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following vertical opening deficiencies:

a) At 12:39 p.m., in the rear room in the basement maintenance shop there were penetrations by data wires going through the ceiling.
b) At 1:08 p.m., in the basement Radiology Storage Room there were vertical penetrations in the ceiling.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the vertical opening issues.

Based on observation and interview, the facility failed to maintain smoke barriers in four instances on two of three floors.

Findings include:

1. Observation on May 26, 2015, and May 27, 2015, revealed the following smoke barrier deficiencies:

a) On May 26, 2015, at 1:18 p.m., the first floor smoke barrier had penetrations in the ice room around cable and data wires. The penetrations can also be seen from the waiting room.
b) On May 26, 2015, at 1:23 p.m., the first floor smoke barrier had penetrations in the Med Room around cable and data wires behind room 112.
c) On May 27, 2015, at 8:55 a.m., the second floor operating room smoke barrier had penetrations around cable/ data wires above the smoke barrier doors by the stair tower.
d) On May 27, 2015, at 9:07 a.m., the second floor smoke barrier had penetrations in the waiting room by an electrical conduit and around cable/ data wires in the HVAC corner.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the smoke barrier issues.

Based on observation and interview, the facility failed to maintain exit access as readily available in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following exit access deficiency:

a) At 2:27 p.m., the first floor emergency room ambulance exit doors have locking arrangements that can be locked against egress.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the exit access issue.

Based on observation, interview, and document review the facility failed to comply with fire drill regulations for two of three shifts in eight of twelve fire drills conducted.

Findings include:

1. Observation on May 27, 2015, revealed the following fire drill deficiency:

a) At 9:39 a.m., during document review it was revealed that the second and third shift fire drills were not conducted at varied times as they were conducted in a one hour time period for all four quarters.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the fire drill issue.

Based on observation, interview, and document review the facility failed to comply with fire alarm inspection regulations in one instance of one of two semi-annual visual inspections.

Findings include:

1. Observation on May 27, 2015, revealed the following fire alarm inspection deficiency:

a) At 9:51 a.m., during document review it was revealed that the facility lacked documentation indicating that a semi-annual visual inspection was being conducted on the fire alarm system.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the fire alarm inspection issue.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following sprinkler maintenance deficiency:

a) At 12:37 p.m., in the rear room in the basement maintenance shop there were wires tied to the sprinkler line.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the sprinkler maintenance issue.

Based on observation and interview, the facility failed to maintain the piped in medical gas system in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following medical gas deficiency:

a) At 1:22 p.m., in the first floor Med Room behind room 112 there was cable wires tied to the medical vacuum line.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the medical gas issue.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment requirements in six instances on three of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following electrical issues:

a) At 12:42 p.m., in the basement maintenance shop there was a coffee pot, fan, and refrigerator plugged into a plug multiplier.
b) At 1:10 p.m., in the basement environmental services closet by the employee breakroom there was a floor machine being charged using an extension cord.
c) At 2:05 p.m., in exam room six in the first floor Ortho Clinic there was an extension cord plugged into a surge protector that had another surge protector plugged into it.
d) At 2:10 p.m., in the first floor Ortho Clinic there was microwave and toaster being plugged into a power strip.
e) At 2:17 p.m., in the first floor X-ray file room there was a microwave and refrigerator plugged into a plug multiplier extension cord device.
f) At 3:15 p.m., in the second floor Med Surge Physician Office there was an extension cord powering a coffee pot and computer. There was a heater being powered by a surge protector and a wall mounted air conditioner being powered by an extension cord.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the electrical wiring issues.

Based on observation and interview, the facility failed to maintain corridor openings in one instance on one of three floors.

Findings include:

1. Observation on May 27, 2015, revealed the following corridor opening deficiency:

a) At 8:40 a.m., the basement maintenance shop doors did not close and positively latch as the door was broken. The door is falling apart and has several penetrations.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the corridor opening issue.

Based on observation and interview, the facility failed to maintain the vertical openings in two instances on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following vertical opening deficiencies:

a) At 12:39 p.m., in the rear room in the basement maintenance shop there were penetrations by data wires going through the ceiling.
b) At 1:08 p.m., in the basement Radiology Storage Room there were vertical penetrations in the ceiling.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the vertical opening issues.

Based on observation and interview, the facility failed to maintain smoke barriers in four instances on two of three floors.

Findings include:

1. Observation on May 26, 2015, and May 27, 2015, revealed the following smoke barrier deficiencies:

a) On May 26, 2015, at 1:18 p.m., the first floor smoke barrier had penetrations in the ice room around cable and data wires. The penetrations can also be seen from the waiting room.
b) On May 26, 2015, at 1:23 p.m., the first floor smoke barrier had penetrations in the Med Room around cable and data wires behind room 112.
c) On May 27, 2015, at 8:55 a.m., the second floor operating room smoke barrier had penetrations around cable/ data wires above the smoke barrier doors by the stair tower.
d) On May 27, 2015, at 9:07 a.m., the second floor smoke barrier had penetrations in the waiting room by an electrical conduit and around cable/ data wires in the HVAC corner.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the smoke barrier issues.

Based on observation and interview, the facility failed to maintain exit access as readily available in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following exit access deficiency:

a) At 2:27 p.m., the first floor emergency room ambulance exit doors have locking arrangements that can be locked against egress.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the exit access issue.

Based on observation, interview, and document review the facility failed to comply with fire drill regulations for two of three shifts in eight of twelve fire drills conducted.

Findings include:

1. Observation on May 27, 2015, revealed the following fire drill deficiency:

a) At 9:39 a.m., during document review it was revealed that the second and third shift fire drills were not conducted at varied times as they were conducted in a one hour time period for all four quarters.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the fire drill issue.

Based on observation, interview, and document review the facility failed to comply with fire alarm inspection regulations in one instance of one of two semi-annual visual inspections.

Findings include:

1. Observation on May 27, 2015, revealed the following fire alarm inspection deficiency:

a) At 9:51 a.m., during document review it was revealed that the facility lacked documentation indicating that a semi-annual visual inspection was being conducted on the fire alarm system.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the fire alarm inspection issue.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following sprinkler maintenance deficiency:

a) At 12:37 p.m., in the rear room in the basement maintenance shop there were wires tied to the sprinkler line.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the sprinkler maintenance issue.

Based on observation and interview, the facility failed to maintain the piped in medical gas system in one instance on one of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following medical gas deficiency:

a) At 1:22 p.m., in the first floor Med Room behind room 112 there was cable wires tied to the medical vacuum line.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the medical gas issue.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment requirements in six instances on three of three floors.

Findings include:

1. Observation on May 26, 2015, revealed the following electrical issues:

a) At 12:42 p.m., in the basement maintenance shop there was a coffee pot, fan, and refrigerator plugged into a plug multiplier.
b) At 1:10 p.m., in the basement environmental services closet by the employee breakroom there was a floor machine being charged using an extension cord.
c) At 2:05 p.m., in exam room six in the first floor Ortho Clinic there was an extension cord plugged into a surge protector that had another surge protector plugged into it.
d) At 2:10 p.m., in the first floor Ortho Clinic there was microwave and toaster being plugged into a power strip.
e) At 2:17 p.m., in the first floor X-ray file room there was a microwave and refrigerator plugged into a plug multiplier extension cord device.
f) At 3:15 p.m., in the second floor Med Surge Physician Office there was an extension cord powering a coffee pot and computer. There was a heater being powered by a surge protector and a wall mounted air conditioner being powered by an extension cord.

Interview with the Facility Personnel on May 27, 2015, at 10:45 a.m., confirmed the electrical wiring issues.