HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain the means egress free of all obstructions to the full use, in case of emergency, on one of four levels.

Findings include:

1. Observation on April 6, 2017 at 10:45 AM revealed the Basement exit corridor by the maintenance shop, had multiple non-wheeled items stored in the corridor.

Interview with the Director Facilities and Environmental Servives (DFES) on April 6, 2017 at 10:45 AM confirmed the non-wheeled items were stored in the exit corridor.

Based on observation and interview, it was determined that doors to stairwell enclosures lacked positive latching with the self-closer.

Findings include:

1. Observation on April 6, 2017 at 1:50 PM revealed the facility had stairwell door that did not latch consistently at the following locations:
A. First floor North stairwell door did not latch consistently.
B. Second floor stairwell in the Cardio-Pulmonary back hall did not latch consistently

Interview with the Maintenance Technician on April 6, 2017 at 1:50 PM confirmed the above listed stairwell doors did not latch consistently.

Based on observation and interview, it was determined that the facility failed to maintain fire rated doors on two of four levels.

Findings include:

1. Observation on April 6, 2017 between 11:20 AM and 12:05 PM revealed the following fire rated doors had the following deficiencies:
A. Basement fire rated door frame fire rated label, by Central Sterile, could not be read due to paint over the rated frame label. (11:20 AM)
B. Ground Floor, fire rated doors by Outpatient Lab lacked a fire rated label on the door hardware. (11:30 AM)
C. Ground Floor, by the "Authorized Lab Staff Only" door, the cross corridor fire rated doors lacked fire rated labels on the doors and frame. (11:50 AM)
D. Ground Floor by Emergency Room #6, the cross corridor door fire rated door frame lacked a rated label. (12:05 PM)

Interview with the DFES on April 6, 2017 at 12:05 PM confirmed the fire door deficiencies listed above existed.

Based on observation and interview, it was determined that the facility failed to maintain exit signage on one of more than seven exterior doors.

Findings include:

1. Observation on April 6, 2017 at 1:10 PM revealed the Ground Floor, Garbage room had an exterior door, equipped with panic hardware, that was obstructed on the exterior with trash cans. The door was not labeled as "No Exit".

Interview with the DFES on April 6, 2017 at 1:10 PM confirmed the exterior door was obstructed and lacked a "NO EXIT" sign.

Based on observation and interview, it was determined that the facility failed to maintain Hazardous areas with a protected 1-hour fire resistance barrier, in a non sprinklered area, on one of four levels.

Findings include:

1. Observation on April 6, 2017 at 1:15 PM revealed the Ground Floor, Biohazard Waste Room had two unsealed penetrations in the ceiling at each end of the light fixture.

Interview with the DFES on April 6, 2017 at 1:15 PM confirmed the unsealed penetrations in the ceiling existed.

Based on observation and interview, it was determined that the facility failed to install Alcohol Based Hand Rub Dispensers in accordance with 8.7.3.1 on two of four levels.

Findings include:

1. Observation on April 6, 2017 between 11:15 AM and 1:40 PM revealed Alcohol Based Hand Rub Dispensers were installed in non-sprinklered areas over carpeted flooring in the following locations:
A. Basement, Fiscal Services Office. (11:15 AM)
B. Ground Floor, Business Office/Financial Aid Office. (1:30 AM)
C. Ground Floor, Administrative Conference Room (1:40 PM)

Interview with the DFES on April 6, 2017 at 1:40 PM confirmed the Alcohol Based Hand Rub Dispensers were installed in non-sprinklered areas over carpeted flooring.

Based on document review and interview, it was determined that the facility failed to maintain, inspect and test the automatic sprinkler system on one of one systems.

Findings include:

1. Document review on April 6, 2017 at 9:30 AM revealed the facility failed to inspect and test the automatic sprinkler system for the second, third and fourth quarters of 2016.

Interview with the DFES on April 6, 2017 at 9:30 AM confirmed the lack of automatic sprinkler testing and inspection documentation for the second, third and fourth quarters of 2016.

Based on observation, document review and interview, it was determined that the facility failed to inspect and maintain the fire suppression system on one of four levels.

Findings include:

1. Document review on April 6, 2017 at 9:30 AM revealed the facility failed to inspect and test the automatic sprinkler system for the second, third and fourth quarters of 2016.

Interview with the DFES on April 6, 2017 at 9:30 AM confirmed the lack of automatic sprinkler testing and inspection documentation for the second, third and fourth quarters of 2016.

2. Observation on April 6, 2017 at 11:00 AM revealed the Basement IT equipment room, Heptafloropropane suppression system lacked a monthly check for March 2017.

Interview with the DFES on April 6, 2017 at 11:00 AM confirmed the suppression system lacked the monthly check for March 2017.

Based on observation and interview, it was determined the facility failed to inspect and maintain portable fire extinguishers on one of four levels.

Findings include:

1. Observation on April 6, 2017 at 10:30 AM revealed the portable fire extinguisher in the Pharmacy had not received a monthly "quick check" since January 2017.

Interview with the Maintenance Technician on April 6, 2017 at 10:30 AM confirmed the portable fire extinguisher did not receive a monthly "quick check" since January 2017.

Based on observation and interview, it was determined the facility failed to equip areas open to the corridor with adequate smoke detectors.

Findings include:

1. Observation on April 6, 2017 at 11:00 AM revealed the facility had two waiting rooms on the first floor that had areas open to the corridor that were not in view of a nurse station that was occupied continuously and lacked smoke detection in the rooms at the following locations:
A. Obgyn waiting room (room 113)
B. Waiting room 112

Interview with the Maintenance Technician on April 6, 2017 at 11:00 AM confirmed the above listed areas open to the corridor lacked smoke detectors that are part of the fire alarm system.

Based on observation and interview, it was determined the facility failed to maintain the electrical wiring and/or equipment in compliance on one of three floors.

Findings include:

1. Observation on April 6, 2017 between 9:15 AM and 1:40 PM revealed the facility was utilizing extension cords at the following locations:
A. The new penthouse had an a key machine plugged into an extension cord
B. Ground floor storage room had an extension cord plugged into another extension cord

Interview with the Maintenance Technician on April 6, 2017 confirmed the facility was utilizing extension cords at the above listed locations.

Based on observation and interview, it was determined that the facility failed to ensure that extension cords were not used as a substitute for fixed wiring of a structure on three of four levels.

Findings include:

1. Observation on April 6, 2017 at 11:40 AM revealed the Ground floor, Main Laboratory had three extension cords in use on portable cooling devices located within the main laboratory.

Interview with the DFES on April 6, 2017 at 11:40 AM confirmed that three extension cords were in use.

2. Observation on April 6, 2017 between 9:50 AM and 10:25 AM revealed the facility was utilizing surge protectors for unapproved applications at the following locations:
A. ICU had two refrigerators plugged into a surge protector (9:50 AM)
B. Billing office had a surge protector plugged into another surge protector (10:20 AM)
C. First floor Pharmacy computer room was utilizing a surge protector plugged into an extension cord (10:25 am)

Interview with the Maintenance Technician on April 6, 2017 at 10:25 AM confirmed the facility was utilizing surge protectors for unapproved applications at the above listed locations.