HospitalInspections.org

Based on observation and interview, the facility failed to maintain the means of egress, being free of all obstructions, for one of over five exits within this facility.

Findings include:

Observation on October 23, 2024, at 10:26 a.m., revealed the second floor cardiac cath lab exit corridor, next to S-2 stairwell, was obstructed with multiple carts.

Interview with the maintenance technician on October 23, 2024, at 10:26 a.m., confirmed the exit discharge was obstructed.

Based on observation and interview, the facility failed to maintain vertical openings for one of over four chute doors.

Findings include:

Observation on October 23, 2024, at 12:33 p.m., revealed the fourth floor, south wing, soiled linen chute door failed to properly close and self-latch.

Interview with the maintenance technician on October 23, 2024, at 12:33 p.m., confirmed the chute door deficiency.


49939

Based on observation and interview, the facility failed to maintain vertical door openings for two of two vertical door openings.
Findings include:
Observation on October 23, 2024, between 12:12 p.m. and 12:35 p.m., revealed the following vertically opening doors failed to properly close and self-latch:
A. (12:12 p.m.) Three X, three north, third floor, soiled linen room, chute door;
B. (12:35 p.m.) Three X, three south, third floor, soiled linen room, chute door.

Interview with the operations manager on October 23, 2024, at 12:35 p.m., confirmed the vertical door deficiencies.

Based on observation, document review, and interview, the facility failed to meet ANSI/UL 300 requirements for one of one cooking facility.

Findings include:

Observation on October 23, 2024, at 1:40 p.m., revealed the cooking facility failed to have automatic extinguishing equipment that met UL 300 systems using wet chemicals. The facility had the first layer of protection by a wet pipe sprinkler system. Upon investigation, the kitchen was occasionally cooking using oil. A buildup of black sludge covered one silver sprinkler head over the grill. The sludge may limit the sprinkler's ability to work properly in the event of an emergency. In addition, the facility failed to provide proper placard signage to meet NFPA 96 10.2.2 requirements, identifying the second layer of extinguishment protection of the K-type fire extinguisher.

Interview with the director of facilities on October 23, 2024, at 1:40 pm., confirmed the deficiencies and stated the facility is in the process of replacing the system.

Based on observation and interview, the facility failed to meet alcohol-based hand rub requirements for one of three components.

Findings include:

Observation on October 23, 2024, at 11:20 a.m., revealed the pharmacy storage room had over 30 gallons of 200-proof, 100% alcohol hand sanitizer stored in boxes in a single smoke compartment.

Interview with the regional facilities director on October 23, 2024, at 11:20 a.m., confirmed the alcohol-based hand sanitizer stored exceeded quantity requirements.

Based on observation and interview, the facility failed to meet fire alarm system requirements for one of over three fire alarm panels.

Findings include:

Observation on October 23, 2024, at 11:10 a.m., revealed first floor electrical closet 1 main ADD 15, outside of the pharmacy, had a fire alarm panel that was not functioning. No information was provided to indicate the panel was outdated or still in use.

Interview with the facilities regional director on October 23, 2024, at 11:10 a.m., confirmed the fire alarm panel was not functioning.

Based on observation and interview, the facility failed to maintain the fire alarm system, affecting the main building.

Findings include:

Observation on October 23, 2024, at 11:22 a.m., revealed the fire alarm panel displayed multiple trouble signals. Through interview, the trouble mode was bypassed due to approved construction activities at the facility. The facility did not want the construction to inadvertently activate the alarm system. The alarm panel is still monitored by the facility dispatch center.

Interview with the director of facilities on October 23, 2024 at 11:22 a.m., confirmed the fire alarm panel deficiency.

Based on document review and interview, the facility failed to meet sprinkler system requirements for one of three components.

Findings include:

Document review on October 23, 2024, at 9:32 a.m., revealed the last annual fire pump inspection occurred on September 7, 2023.

Interview with the facilities director on October 23, 2024, at 9:32 a.m., confirmed the facility lacked documentation for a more-recent inspection, and stated a vendor was scheduled to complete the inspection soon.


43722

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

Findings include:

Observation on October 23, 2024, at 9:30 a.m., revealed the seventh floor S main 7 stairwell had a sprinkler gauge with a 2015 date, without documentation that calibration took place within the last five years.

Interview with the maintenance technciain on October 23, 2024, at 9:30 a.m., confirmed the sprinkler gauge deficiency.

Based on observation and interview, the facility failed to maintain the smoke barrier requirements in two of over ten rooms.

Findings include:
Observation on October 23, 2024, between 8:59 a.m. and 9:07 a.m., revealed the following deficiencies:
A. (8:59 a.m.) Ground floor corridor connecting to the new addition, near door 36, had two penetrations in the wallboard;
B. (9:07 a.m.) Ground floor electrical room had cinderblock and wall joint openings, allowing smoke passage.

Interview with the maintenance supervisor on October 23, 2024, at 9:07 a.m., confirmed the smoke barrier deficiencies.

Based on document review and interview, the facility failed to meet fire drill requirements for three of three components.

Findings include:

Document review on October 23, 2024, at 9:44 a.m., revealed the facility lacked documentation for incorporating all staff members in fire drills for each shift, per quarter.

Interview with the facilities director on October 23, 2024, at 9:44 a.m., confirmed the facility lacked the documentation.

Based on document review and interview, the facility failed to meet fire drill requirements for three of three components.

Findings include:

Document review on October 23, 2024, at 9:44 a.m., revealed the facility lacked documentation for incorporating fire drills with all staff members each shift, per quarter.

Interview with the facility director on October 23, 2024, at 9:44 a.m., confirmed the facility lacked the documentation.

Based on observation and interview, the facility failed to maintain combustible decorations on seven of over fourteen doors.

Findings include:

Observation on October 23, 2024, at 12:32 p.m., revealed building three X, third floor, three south, had seven doors with decorations that exceeded the allowable rate of coverage (= thirty percent).
Interview with the maintenance supervisor on October 23, 2024, at 12:32 p.m., confirmed the combustible decoration deficiencies.

Based on observation and interview, the facility failed to manage quantities of soiled linen/trash in approved containers in one of more than seven soiled linen/trash rooms.

Findings include:

Observation on October 23, 2024, at 9:10 a.m., First floor, soiled linen/trash room, chute discharge area, revealed excessive amounts, and overflowing trash bins onto the floor and not in approved containers, from the trash discharge of the trash chute. Plastic bags and loose trash was on the floor, creating a fire hazard.

Interview with the maintenance supervisor on October 23, 2024, at 9:10 a.m., confirmed the deficiency.

Based on document review and interview, the facility failed to meet door maintenance, inspection, and testing requirements for three of three components.

Findings include:

Document review on October 23, 2024, at 10:00 a.m., revealed the facility's 2023 and 2024 inspection reports listed multiple doors that were not inspected due to access and multiple doors with deficiencies. Corrective documentation was unavailable at the time of the survey.

Interview with the facilities director on October 23, 2024, at 10:00 a.m., confirmed the facility lacked corrective documentation.

Based on document review and interview, the facility failed to meet door maintenance, inspection, and testing requirements for three of three components.

Findings include:

Document review on October 23, 2024, at 10:00 a.m., revealed the facility's 2023 and 2024 inspection reports listed multiple doors that were not inspected due to access issues and multiple doors with deficiencies. The facility lacked corrective documentation at the time of the survey.

Interview with the facility director on October 23, 2024, at 10:00 a.m., confirmed the facility lacked corrective documentation.

Based on document review, observation, and interview, the facility failed to meet door maintenance, inspection, and testing requirements for three of three components.

Findings include:

1. Document review on October 23, 2024, at 10:00 a.m., revealed the facility's 2023 and 2024 inspection reports listed multiple doors not inspected due to access issues and multiple doors with deficiencies. Corrective documentation was unavailable at the time of the survey.

Interview with the facilities director on October 23, 2024, at 10:00 a.m., confirmed the facility lacked corrective documentation.

2. Observation on October 23, 2024, at 11:49 a.m. revealed the seventh floor tower 01 door 7A938 failed to latch in the frame when tested.

Interview with the facility regional director on October 23, 2024, at 11:49 a.m., confirmed the door failed to latch.

Based on document review and interview, the facility failed to meet gas and vacuum-piped system requirements for one of one system.

Findings include:

Document review on October 23, 2024, at 9:01 a.m., revealed the following system deficiencies were documented on the April 24, 2024, inspection report. Corrective documentation was unavailable at the time of the survey:

Outlets/Inlets
A. Seventh floor, med surg - medical vacuum, W#2 bent faceplate;
B. Seventh floor, med surg - oxygen, leak with the connector in;
C. Third floor, OR 10 - nitrogen, CB#1 regulator knob broken;
D. First floor, OR 3 - medical vacuum, medpipe boom service to further investigate low flow;
E. Third floor, OR7- nitrogen, cb31 - N2 regulator knob missing;
F. Third floor, peri op room 6- oxygen, CO#1 faceplate replacement required.

Interview with the facilities director on October 23, 2024, at 9:01 a.m., confirmed the facility lacked corrective documentation.

Based on observation and interview, the facility failed to meet electrical system requirements in one of over ten storage rooms.

Findings include:

Observation on October 23, 2024, at 11:00 a.m., revealed the first floor storage room, located across from the lab window entrance, had blocked access to electrical panel "UPS C".

Reference: 70-110.26(A)

Interview with the facility regional director on October 23, 2024, at 11:00 a.m., confirmed access to the electric panel was blocked.

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, on two of seven building levels.

Findings include:

Observation on October 23, 2024, between 9:10 a.m. and 9:44 a.m., revealed the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed in the following locations:
A. (9:10 a.m.) Sixth floor therapy room, water cooler;
B. (9:41 a.m.) Third floor west soiled utility room, sink;
C. (9:44 a.m.) Third floor nursery.

Interview with the maintenance technician on October 23, 2024, at 9:44 a.m., confirmed the receptacle deficiencies.

Based on observation and interview, the facility failed to maintain nine of more than fifty electrical receptacles.

Findings include:

Observation on October 23, 2024, between 10:18 a.m. and 11:40 a.m., revealed the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed in the following locations:
1. (10:18 a.m.) Third floor short stay nurse's station, receptacle within six feet of the sink;
2. (10:25 a.m.) Third floor PAC-U soiled utility, receptacle within six feet of the sink;
3. (10:29 a.m.) Third floor PAC-U patient headboards, receptacles within six feet of the sink;
4. (10:41 a.m.) Third floor anesthesia lounge, coffee pot and water cooler;
5. (10:44 a.m.) Third floor physician lounge, SPU, coffee pot, and water cooler;
6. (10:50 a.m.) Third floor staff lounge, receptacle within six feet of the sink;
7. (11:14 p.m.) Third floor nourishment room, short stay, coffee pot, and water cooler;
8. (11:29 a.m.) Fifth floor ICU, near door T5031 staff lounge, receptacle within six feet of the sink;
9. (11:40 a.m.) Fifth floor, refrigerator and ice machine on emergency circuit, receptacle within six feet of the sink.

Interview with the maintenance supervisor on October 23, 2024, at 11:40 a.m., confirmed the electrical outlet deficiencies.

Based on observation and interview, the facility failed to maintain two of more than twenty electrical receptacles.

Findings include:

Observation on October 23, 2024, between 12:36 p.m. and 12:38 p.m., revealed the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed in the following locations:
1. (12:36 p.m.) Three south, third floor, clean utility room, receptacle within six feet of the sink;
2. (12:38 p.m.) Three south, third floor, laundry room, washing machine.

Interview with the maintenance supervisor on October 23, 2024, at 12:38 p.m., confirmed the electrical outlet deficiencies.

Based on observation and interview, the facility failed to maintain electrical power cords in one of over twenty rooms.

Findings include:

Observation on October 23, 2024, at 12:19 p.m., revealed the three X, three north, third floor employee lounge had a microwave oven plugged into a surge protector power strip.

Interview with the maintenance supervisor on October 23, 2024, at 12:19 p.m., confirmed the power cord deficiency.

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of four cylinder storage areas.

Findings include:

Observation on October 23, 2024, at 9:59 a.m., revealed the Tower building first-floor oxygen storage room, located near the chapel and outpatient nutritional room, contained six oxygen cylinders without quantity labeling.

Interview with the maintenance supervisor on October 23, 2024, at 9:59 a.m., confirmed the deficiency.