HospitalInspections.org

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain the egress corridor. The egress corridor contained oxygen and vacuum and air outlets at women ' s building ' s second floor nurse station. Patient care can not occur in an egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the tour of the facility on the morning of 10/15/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to assure the doors in egress corridors had the required smoke control amenities. Pavilion building ' s operating rooms 4 and 6 double doors had a gap between the door ' s meeting edges. This could allow smoke from the egress corridor to enter the patient care room. A smoke tight seal at the meeting edges of the doors when closed should be provided.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations, the facility failed to provide acceptable exiting out the designated exit door. The door required two operations to open in an emergency. This was at the Heights building ' s outpatient department ' s smoke barrier doors. Only one operation is allowed to open an exit door per NFPA 101, 2003: 7.2.1.5.9.2 ..... The releasing mechanism shall open the door with not more than one releasing operation



Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to provide acceptable exiting out the designated exit door at the SKS building ' s many clinic departments like breast care. The sign shall be readily visible, durable and letters not less than 1 inch high on contrasting background that reads as follows: THIS DOOR TO REMAIN OPEN WHEN THE BUILDING IS OCCUPIED.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain a clear and unobstructed egress path. Pavilion building ' s corridor, outside of sterile corridor near operating room 3, contained flammable linen carts/sterile dressing and impeded egress path. This also occurred outside the dietary department leading into an existing stairwell, which had mop heads and trash and furniture in the egress path.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain fire alarm system. Yellow tag from the fire department was at the pavilion building ' s mezzanine at the fire pump and women ' s building ' s fire pump controller.



Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility ' s fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at mental health building ' s third floor laundry room.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the cabinet top was less than 18 underneath sprinkler head in the Heights pharmacy.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain access to fire extinguishers. GWS building ' s eighth floor ' s behavior health medical ward, the fire extinguishers were locked in a cabinet and none of the staff on duty had quick access to a key to the fire extinguisher cabinet.

Based on observations during the tour of the facility on the morning of 10/15/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to provide proper distance between open flames and deep fry at kitchen. NFPA 96: 12.1.2.4 ..... All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to secure many med gas cylinders located at the Heights building ' s med gas outdoor locked oxygen park. NFPA 99 requires ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.


Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to cylinders protected against the sun at the Heights building ' s med gas outdoor locked park. NFPA 99, 2002: 5.1.3.5.4... ...Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain egress corridors. Unattended coffee pot with no smoke detection was at mental health building ' s second floor nourishment, which opened into the egress corridor.


Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain patient safety. Coffee Makers on burners were left on when unattended in the conference room at mental health building' s first floor conference room.



Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to protect the sterile environment at the Heights building ' s operating room near the stairwell. A pipe penetration opened into the plenum space.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the Heights building failed to provide documentation of the testing of grounding system at inpatient care areas. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. The facility must initiate a file on site to retain these records.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle. (Visual)
Continuity of the grounding of each receptacle. (Test)
Correct polarity of hot and neutral connections in each receptacle. (Test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain the egress corridor. The egress corridor contained oxygen and vacuum and air outlets at women ' s building ' s second floor nurse station. Patient care can not occur in an egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the tour of the facility on the morning of 10/15/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to assure the doors in egress corridors had the required smoke control amenities. Pavilion building ' s operating rooms 4 and 6 double doors had a gap between the door ' s meeting edges. This could allow smoke from the egress corridor to enter the patient care room. A smoke tight seal at the meeting edges of the doors when closed should be provided.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations, the facility failed to provide acceptable exiting out the designated exit door. The door required two operations to open in an emergency. This was at the Heights building ' s outpatient department ' s smoke barrier doors. Only one operation is allowed to open an exit door per NFPA 101, 2003: 7.2.1.5.9.2 ..... The releasing mechanism shall open the door with not more than one releasing operation



Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to provide acceptable exiting out the designated exit door at the SKS building ' s many clinic departments like breast care. The sign shall be readily visible, durable and letters not less than 1 inch high on contrasting background that reads as follows: THIS DOOR TO REMAIN OPEN WHEN THE BUILDING IS OCCUPIED.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain a clear and unobstructed egress path. Pavilion building ' s corridor, outside of sterile corridor near operating room 3, contained flammable linen carts/sterile dressing and impeded egress path. This also occurred outside the dietary department leading into an existing stairwell, which had mop heads and trash and furniture in the egress path.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain fire alarm system. Yellow tag from the fire department was at the pavilion building ' s mezzanine at the fire pump and women ' s building ' s fire pump controller.



Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility ' s fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at mental health building ' s third floor laundry room.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the cabinet top was less than 18 underneath sprinkler head in the Heights pharmacy.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain access to fire extinguishers. GWS building ' s eighth floor ' s behavior health medical ward, the fire extinguishers were locked in a cabinet and none of the staff on duty had quick access to a key to the fire extinguisher cabinet.

Based on observations during the tour of the facility on the morning of 10/15/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to provide proper distance between open flames and deep fry at kitchen. NFPA 96: 12.1.2.4 ..... All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to secure many med gas cylinders located at the Heights building ' s med gas outdoor locked oxygen park. NFPA 99 requires ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.


Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to cylinders protected against the sun at the Heights building ' s med gas outdoor locked park. NFPA 99, 2002: 5.1.3.5.4... ...Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain egress corridors. Unattended coffee pot with no smoke detection was at mental health building ' s second floor nourishment, which opened into the egress corridor.


Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, Project Manager of Plant Operations and Electrician; the facility failed to maintain patient safety. Coffee Makers on burners were left on when unattended in the conference room at mental health building' s first floor conference room.



Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the facility failed to protect the sterile environment at the Heights building ' s operating room near the stairwell. A pipe penetration opened into the plenum space.

Based on observations during the tour of the facility on the afternoon of 10/14/2015, with Director of Plant Operations, Manager of Plant Operations, and Project Manager of Plant Operations; the Heights building failed to provide documentation of the testing of grounding system at inpatient care areas. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. The facility must initiate a file on site to retain these records.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle. (Visual)
Continuity of the grounding of each receptacle. (Test)
Correct polarity of hot and neutral connections in each receptacle. (Test)
The retention force of the grounding blade shall be not less than 4 oz. (test)