HospitalInspections.org

Based on observation, and staff interviews it was determined the facility failed to ensure doors were maintained to prevent the passage of smoke.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following doors were not properly maintained to prevent the passage of smoke:
Door #13 failed to close and positive latch
Doors ED#9 closed to slowly(13 sec.)and has damage to door.
1st floor elevator closet door has screw missing on hinge.
Sterile supply door has screw holes in door.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101- 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Based on observation, and staff interviews it was determined the facility failed to ensured hazardous areas were properly sealed to prevent the passage of smoke in fully sprinkled building.
This could place 25 patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following hazardous areas had penetrations in rated walls:
Electrical rooms at ambulance entrance, North tower elevator room, Main electrical room, and boiler room.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101- 19.3.2.1

Based on observation, and staff interviews it was determined the facility failed to ensure the fire alarm system was free of all trouble alarms.
This could place all patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the fire alarm was showing a trouble alarm 1st floor electrical closet.
Smoke detectors need to placed in sleeping rooms for OB doctors #1 and #2.
These findings were confirmed by Staff M at the time of discovery.
NFPA 70 and 72. 9.6.1.4

Based on observation, and staff interviews it was determined the facility failed to ensure all areas where combustible material are being stored next to building is properly covered by sprinkler coverage.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that a covered exterior storage area where plastic empty laundry carts are stored does not have sprinkler coverage.
These findings were confirmed by Staff M at the time of discovery.
NFPA 13

Based on observation, and staff interviews it was determined the facility failed to ensure all sprinkler systems are properly maintained.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following violations were noted:
Dry sprinkler system yellow tagged at AHU10 & AHUO14
Riser Room door not labeled for AHUO14
Escutcheon Rings missing admissions, out patient entrance, OB corridor, and Med. room.
Adequate number and type of replacement sprinkler heads
Loaded sprinkler heads (lint and dust collecting on heads)
Fire hydrant located at FDC has damage to control nut flange
X-ray corridor has mixed heads down corridor at CT and Nuclear Med.
OB Doctors sleeping room #1 and #2 has foreign object tied to sprinkler head.
These findings were confirmed by Staff M at the time of discovery.
NFPA 13, NFPA 25, NFPA 101-4.6.12

Based on observation, and staff interviews it was determined the facility failed to ensure exit path is clear of obstruction.
This could place patient and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the exit egress path was partially blocked by a number of wheel chairs being stored in the main exit lobby and out patient lobby.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101-7.1.10

Based on observation, and staff interviews it was determined the facility failed to ensure O2 cylinder were properly stored in the outside storage area.
This could place staff at risk in the event of emergency.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that empty and full O2 cylinders were being stored mixed and in wooden racks.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99

Based on observation, and staff interviews it was determined the facility failed to ensure that the fuel supply for the emergency generator would be continuous without interruption.
This could place all patients and staff at risk in the event of emergency.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that leak detection system for the fuel supply was showing a trouble alarm.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99, 3.4.2.2, 3.4.2.1.4.

Based on observation, and staff interviews it was determined the facility failed to ensure that no storage was being placed in boiler room.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that items were being stored in the boiler room.
Electrical room behind maintenance shop not labeled.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101, NFPA 70

Based on observation, review of facility records, and staff interviews it was determined the facility failed to eye wash station in X-Ray storage is not being properly checked.
This could place staff at risk in the event of emergency.
The findings include:
During a review of facility records with Staff M on
04/07/15 between 09:00 am and 2:30 records revealed that no documentation on eye wash tag had been recorded.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99. 10.6

Based on observation, and staff interviews it was determined the facility failed to electrical equipment is properly maintained.
This could place patient and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the follow electrical equipment was not be properly maintained:
Multi-Plugs are located on the floor not secured minimum of 4 inch off the floor to prevent damage.
Blanket warmer in equipment storage room across from exam room 23 is not properly wired. (it appears that factory plug and cord has been replaced)
These findings were confirmed by Staff M at the time of discovery.
NFPA 70

Based on observation, and staff interviews it was determined the facility failed to ensure doors were maintained to prevent the passage of smoke.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following doors were not properly maintained to prevent the passage of smoke:
Door #13 failed to close and positive latch
Doors ED#9 closed to slowly(13 sec.)and has damage to door.
1st floor elevator closet door has screw missing on hinge.
Sterile supply door has screw holes in door.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101- 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Based on observation, and staff interviews it was determined the facility failed to ensured hazardous areas were properly sealed to prevent the passage of smoke in fully sprinkled building.
This could place 25 patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following hazardous areas had penetrations in rated walls:
Electrical rooms at ambulance entrance, North tower elevator room, Main electrical room, and boiler room.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101- 19.3.2.1

Based on observation, and staff interviews it was determined the facility failed to ensure the fire alarm system was free of all trouble alarms.
This could place all patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the fire alarm was showing a trouble alarm 1st floor electrical closet.
Smoke detectors need to placed in sleeping rooms for OB doctors #1 and #2.
These findings were confirmed by Staff M at the time of discovery.
NFPA 70 and 72. 9.6.1.4

Based on observation, and staff interviews it was determined the facility failed to ensure all areas where combustible material are being stored next to building is properly covered by sprinkler coverage.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that a covered exterior storage area where plastic empty laundry carts are stored does not have sprinkler coverage.
These findings were confirmed by Staff M at the time of discovery.
NFPA 13

Based on observation, and staff interviews it was determined the facility failed to ensure all sprinkler systems are properly maintained.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the following violations were noted:
Dry sprinkler system yellow tagged at AHU10 & AHUO14
Riser Room door not labeled for AHUO14
Escutcheon Rings missing admissions, out patient entrance, OB corridor, and Med. room.
Adequate number and type of replacement sprinkler heads
Loaded sprinkler heads (lint and dust collecting on heads)
Fire hydrant located at FDC has damage to control nut flange
X-ray corridor has mixed heads down corridor at CT and Nuclear Med.
OB Doctors sleeping room #1 and #2 has foreign object tied to sprinkler head.
These findings were confirmed by Staff M at the time of discovery.
NFPA 13, NFPA 25, NFPA 101-4.6.12

Based on observation, and staff interviews it was determined the facility failed to ensure exit path is clear of obstruction.
This could place patient and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the exit egress path was partially blocked by a number of wheel chairs being stored in the main exit lobby and out patient lobby.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101-7.1.10

Based on observation, and staff interviews it was determined the facility failed to ensure O2 cylinder were properly stored in the outside storage area.
This could place staff at risk in the event of emergency.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that empty and full O2 cylinders were being stored mixed and in wooden racks.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99

Based on observation, and staff interviews it was determined the facility failed to ensure that the fuel supply for the emergency generator would be continuous without interruption.
This could place all patients and staff at risk in the event of emergency.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that leak detection system for the fuel supply was showing a trouble alarm.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99, 3.4.2.2, 3.4.2.1.4.

Based on observation, and staff interviews it was determined the facility failed to ensure that no storage was being placed in boiler room.
This could place patients and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that items were being stored in the boiler room.
Electrical room behind maintenance shop not labeled.
These findings were confirmed by Staff M at the time of discovery.
NFPA 101, NFPA 70

Based on observation, review of facility records, and staff interviews it was determined the facility failed to eye wash station in X-Ray storage is not being properly checked.
This could place staff at risk in the event of emergency.
The findings include:
During a review of facility records with Staff M on
04/07/15 between 09:00 am and 2:30 records revealed that no documentation on eye wash tag had been recorded.
These findings were confirmed by Staff M at the time of discovery.
NFPA 99. 10.6

Based on observation, and staff interviews it was determined the facility failed to electrical equipment is properly maintained.
This could place patient and staff at risk in the event of fire.
The findings include:
On 04/07/15 between 09:00 am and 2:30 pm Observation revealed that the follow electrical equipment was not be properly maintained:
Multi-Plugs are located on the floor not secured minimum of 4 inch off the floor to prevent damage.
Blanket warmer in equipment storage room across from exam room 23 is not properly wired. (it appears that factory plug and cord has been replaced)
These findings were confirmed by Staff M at the time of discovery.
NFPA 70