HospitalInspections.org

Based on observation and staff interview, it was determined that the facility did not maintain the interior finish of rooms and spaces. Findings include:

During a tour on 12/13/12 at 2:15 PM with Maintenance Employee A, the following observation was made/acknowledged at the time of discovery:

1. Ceiling tiles were missing in the Old Security Area

Based on observation and staff interview, it was determined that the facility failed to maintain the interior finish of rooms and spaces. Findings include:

During a tour of the KGH Women's Center on 12/14/12 at 10:15 AM with Administrative Director of Ambulatory Care Services A, the following observation was made/acknowledged at the time of discovery:

1. Ceiling tiles were missing in the IT/Electrical Room

1. Based on observation and staff interview, it was determined that the facility failed to ensure that the corridor doors were maintained to resist the passage of smoke. Findings include:

During a tour on 12/14/12 at 11:45 AM with MEP Supervisor A, the following observation was made/acknowledged at the time of discovery:

a. 5th floor Unit Pharmacy's dutch door was lacking an astragal at the meeting edges of the upper and lower leaves

2. Based on observation and staff interview, it was determined that the facility failed to ensure that corridor doors had properly operating latching devices. Findings include:

During a tour with the Director of Safety and Security on 12/13/12, the following observations were made/acknowledged at the time of discovery:

a. 9:30 AM - Emergency Room door (1-FD-2-103-C) was not latching properly in the frame.

b. 10:00 AM - Double doors by Room 166G were not latching properly.

c. 2:10 PM - One (1) door (2-FD-C200-C) was not latching properly in the frame.

d. 2:15 PM - Two (2) maintenance doors (2-FD-1-C214-C and 2-FD-2-C210-C) were not latching properly in their frames.

Based on observation and staff interview, it was determined that the facility failed to ensure that the vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. Findings include:

On 12/14/12 at 1:00 PM, it was observed that the 6th floor doors to mechanical shaft doors were not equipped with self-closing, positive-latching devices. Per concurrent interview, MEP Supervisor A advised that the mechanical shaft doors on floors 2nd through the 5th were the same set-up. MEP Supervisor A also informed the surveyor that the Joint Commission cited the same deficiency on their recent Accreditation Survey.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke barrier walls. Findings include:

1. During a tour on 12/13/12 at 10:00 AM with Maintenance Employee A, the following observation was made/acknowledged at the time of discovery:

a. Several penetrations in the 2 hour fire barrier wall were observed on the 1st floor Outpatient Area above the smoke barrier door (KFCS-1-4-05-W).

2. During a tour on 12/13/12 at 11:15 AM with MEP Supervisor A, the following observation was made/acknowledged at the time of discovery:

a. 2x2 opening in the smoke barrier wall on the basement floor above the smoke barrier doors near the Operating Room locker rooms.

Based on observation and staff interview, it was determined that the facility failed to maintain hazardous areas. Findings include:

During a tour with Maintenance Employee A on 12/13/12, the following observations were made/acknowledged at the time of discovery:

1. 10:30 AM - penetrations in the ceiling in Room 1A

2. 2:35 PM - ceiling tiles were missing in the Nuclear Medicine Storage room

3. 3:15 PM - penetrations in the ceiling in Room 168C

Based on observation and staff interview, it was determined that the facility failed to ensure that the ground floor exit stair "A" door operated properly. Findings include:

During a tour with the Director of Safety and Security on 12/13/12, the following observation was made/acknowledged at the time of discovery:

1. 1:30 PM - exit door 1107E was not properly latching and was difficult to open

Based on observation and staff interview, it was determined that the facility failed to assure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour of the Bayhealth Medical Center Pain Treatment Center on 12/14/12 at 10:00 AM with the Director of Safety and Security, the following observation was made/acknowledged at the time of discovery:

1. The exit sign next to the Front Desk was not illuminated.

Based on observation and staff interview, it was determined that the facility failed to ensure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour with Maintenance Employee A on 12/13/12, the following observation was made/acknowledged at the time of discovery:

1. 1:10 PM - the exit sign next to the Environmental Services storage area cage was not illuminated

Based on observation and staff interview, it was determined that the facility failed to properly maintain the fire alarm system. Findings include:

During a tour of the Bayhealth Medical Center Pain Treatment Center on 12/14/12 at 10:30 AM with the Director of Safety and Security, the following observation was made/acknowledged at the time of discovery:

1. Annual inspection of the fire alarm system was overdue (last performed 11/19/2009).

Based on observation and staff interview, it was determined that the facility failed to properly maintain the fire alarm system. Findings include:

1. During a tour with the Director of Safety and Security on 12/12/12, the lack of smoke detectors in the following on-call sleeping room was observed and acknowledged at the time of discovery:

a. 10:30 AM - 6th floor on-call room 654

2. During a tour with MEP Supervisor A on 12/12 and 12/13/12, the lack of smoke detectors in the following on-call sleeping rooms was observed and acknowledged at the time of discovery:

a. 12/12/12:
- 12:45 PM - 6th floor Obstetrical (OB) on-call room 609
- 12:50 PM - 6th floor OB on-call room 614
- 1:25 PM - 4th floor on-call rooms 437 & 438

b. 12/13/12:
- 11:25 AM - basement Operating Room on-call rooms

Based on observation and staff interview, it was determined that the facility failed to provide a compliant sprinkler system. Findings include:

1. During a tour of the hospital on 12/13/12, the Director of Safety and Security acknowledged that the following areas were not protected by sprinklers:

a. 10:40 AM - Room 163E

b. 1:30 PM - AHU #8 Mechanical Room 7 (under obstructions)

2. During a tour of the hospital on 12/13/12 at 11:10 AM, MEP Supervisor A acknowledged that the following area was not protected by sprinklers:

a. Elevator Mechanical Room for elevator #'s 4 & 5

Based on observation and staff interview, it was determined that the facility failed to properly maintain the sprinkler system. Findings include:

1. During a tour with the Director of Safety and Security on 12/12/12, the following observations were made/acknowledged at the time of discovery:

a. 1:00 PM - Sprinkler head in the 3rd floor (West) Medical Room was missing an escutcheon.

b. 1:30 PM - Sprinkler head in the 2nd floor (West) Utility Room was missing an escutcheon.

c. 1:35 PM - Sprinkler head in Room 271B1 was missing an escutcheon.

d. 2:30 PM - Sprinkler head in the 2nd floor (West) toy closet had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

e. 2:35 PM - Sprinkler head in Room 295D had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

2. During a tour with Maintenance Employee A on 12/13/12, the following observations were made/acknowledged at the time of discovery:

a. 10:10 AM - Corroded sprinkler head in Room 181Q

b. 10:35 AM - Sprinkler head in Room 190D had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

c. 1:00 PM - Sprinkler head in the Elevator Control Room was missing an escutcheon.

d. 2:45 PM - Sprinkler head in Clinical Engineering had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

Based on observation and staff interview, it was determined that the facility failed to ensure that the decorative arrangements displayed were made of non-combustible material or were made flame retardant. Findings include:

1. During a tour with the Director of Safety and Security on 12/13/12 at 10:45 AM, the following observation was made/acknowledged at the time of discovery:

a. All doors in the Echo Lab (Room 165) were fully covered with Christmas type wrapping paper.

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress (2000, NFPA 101:21.2). Findings include:

During a tour of Outpatient Imaging of Dover on 12/14/12 at 11:15 AM with Employee #2, the following observation was made/acknowledged at the time of discovery:

1. West Side exit stairwell was being used for storage

Based on observation and staff interview, it was determined that the facility did not maintain the interior finish of rooms and spaces. Findings include:

During a tour on 12/13/12 at 2:15 PM with Maintenance Employee A, the following observation was made/acknowledged at the time of discovery:

1. Ceiling tiles were missing in the Old Security Area

Based on observation and staff interview, it was determined that the facility failed to maintain the interior finish of rooms and spaces. Findings include:

During a tour of the KGH Women's Center on 12/14/12 at 10:15 AM with Administrative Director of Ambulatory Care Services A, the following observation was made/acknowledged at the time of discovery:

1. Ceiling tiles were missing in the IT/Electrical Room

1. Based on observation and staff interview, it was determined that the facility failed to ensure that the corridor doors were maintained to resist the passage of smoke. Findings include:

During a tour on 12/14/12 at 11:45 AM with MEP Supervisor A, the following observation was made/acknowledged at the time of discovery:

a. 5th floor Unit Pharmacy's dutch door was lacking an astragal at the meeting edges of the upper and lower leaves

2. Based on observation and staff interview, it was determined that the facility failed to ensure that corridor doors had properly operating latching devices. Findings include:

During a tour with the Director of Safety and Security on 12/13/12, the following observations were made/acknowledged at the time of discovery:

a. 9:30 AM - Emergency Room door (1-FD-2-103-C) was not latching properly in the frame.

b. 10:00 AM - Double doors by Room 166G were not latching properly.

c. 2:10 PM - One (1) door (2-FD-C200-C) was not latching properly in the frame.

d. 2:15 PM - Two (2) maintenance doors (2-FD-1-C214-C and 2-FD-2-C210-C) were not latching properly in their frames.

Based on observation and staff interview, it was determined that the facility failed to ensure that the vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. Findings include:

On 12/14/12 at 1:00 PM, it was observed that the 6th floor doors to mechanical shaft doors were not equipped with self-closing, positive-latching devices. Per concurrent interview, MEP Supervisor A advised that the mechanical shaft doors on floors 2nd through the 5th were the same set-up. MEP Supervisor A also informed the surveyor that the Joint Commission cited the same deficiency on their recent Accreditation Survey.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke barrier walls. Findings include:

1. During a tour on 12/13/12 at 10:00 AM with Maintenance Employee A, the following observation was made/acknowledged at the time of discovery:

a. Several penetrations in the 2 hour fire barrier wall were observed on the 1st floor Outpatient Area above the smoke barrier door (KFCS-1-4-05-W).

2. During a tour on 12/13/12 at 11:15 AM with MEP Supervisor A, the following observation was made/acknowledged at the time of discovery:

a. 2x2 opening in the smoke barrier wall on the basement floor above the smoke barrier doors near the Operating Room locker rooms.

Based on observation and staff interview, it was determined that the facility failed to maintain hazardous areas. Findings include:

During a tour with Maintenance Employee A on 12/13/12, the following observations were made/acknowledged at the time of discovery:

1. 10:30 AM - penetrations in the ceiling in Room 1A

2. 2:35 PM - ceiling tiles were missing in the Nuclear Medicine Storage room

3. 3:15 PM - penetrations in the ceiling in Room 168C

Based on observation and staff interview, it was determined that the facility failed to ensure that the ground floor exit stair "A" door operated properly. Findings include:

During a tour with the Director of Safety and Security on 12/13/12, the following observation was made/acknowledged at the time of discovery:

1. 1:30 PM - exit door 1107E was not properly latching and was difficult to open

Based on observation and staff interview, it was determined that the facility failed to assure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour of the Bayhealth Medical Center Pain Treatment Center on 12/14/12 at 10:00 AM with the Director of Safety and Security, the following observation was made/acknowledged at the time of discovery:

1. The exit sign next to the Front Desk was not illuminated.

Based on observation and staff interview, it was determined that the facility failed to ensure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour with Maintenance Employee A on 12/13/12, the following observation was made/acknowledged at the time of discovery:

1. 1:10 PM - the exit sign next to the Environmental Services storage area cage was not illuminated

Based on observation and staff interview, it was determined that the facility failed to properly maintain the fire alarm system. Findings include:

During a tour of the Bayhealth Medical Center Pain Treatment Center on 12/14/12 at 10:30 AM with the Director of Safety and Security, the following observation was made/acknowledged at the time of discovery:

1. Annual inspection of the fire alarm system was overdue (last performed 11/19/2009).

Based on observation and staff interview, it was determined that the facility failed to properly maintain the fire alarm system. Findings include:

1. During a tour with the Director of Safety and Security on 12/12/12, the lack of smoke detectors in the following on-call sleeping room was observed and acknowledged at the time of discovery:

a. 10:30 AM - 6th floor on-call room 654

2. During a tour with MEP Supervisor A on 12/12 and 12/13/12, the lack of smoke detectors in the following on-call sleeping rooms was observed and acknowledged at the time of discovery:

a. 12/12/12:
- 12:45 PM - 6th floor Obstetrical (OB) on-call room 609
- 12:50 PM - 6th floor OB on-call room 614
- 1:25 PM - 4th floor on-call rooms 437 & 438

b. 12/13/12:
- 11:25 AM - basement Operating Room on-call rooms

Based on observation and staff interview, it was determined that the facility failed to provide a compliant sprinkler system. Findings include:

1. During a tour of the hospital on 12/13/12, the Director of Safety and Security acknowledged that the following areas were not protected by sprinklers:

a. 10:40 AM - Room 163E

b. 1:30 PM - AHU #8 Mechanical Room 7 (under obstructions)

2. During a tour of the hospital on 12/13/12 at 11:10 AM, MEP Supervisor A acknowledged that the following area was not protected by sprinklers:

a. Elevator Mechanical Room for elevator #'s 4 & 5

Based on observation and staff interview, it was determined that the facility failed to properly maintain the sprinkler system. Findings include:

1. During a tour with the Director of Safety and Security on 12/12/12, the following observations were made/acknowledged at the time of discovery:

a. 1:00 PM - Sprinkler head in the 3rd floor (West) Medical Room was missing an escutcheon.

b. 1:30 PM - Sprinkler head in the 2nd floor (West) Utility Room was missing an escutcheon.

c. 1:35 PM - Sprinkler head in Room 271B1 was missing an escutcheon.

d. 2:30 PM - Sprinkler head in the 2nd floor (West) toy closet had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

e. 2:35 PM - Sprinkler head in Room 295D had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

2. During a tour with Maintenance Employee A on 12/13/12, the following observations were made/acknowledged at the time of discovery:

a. 10:10 AM - Corroded sprinkler head in Room 181Q

b. 10:35 AM - Sprinkler head in Room 190D had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

c. 1:00 PM - Sprinkler head in the Elevator Control Room was missing an escutcheon.

d. 2:45 PM - Sprinkler head in Clinical Engineering had a clearance of less than 18 inches between the deflector plate and storage on a shelf.

Based on observation and staff interview, it was determined that the facility failed to ensure that the decorative arrangements displayed were made of non-combustible material or were made flame retardant. Findings include:

1. During a tour with the Director of Safety and Security on 12/13/12 at 10:45 AM, the following observation was made/acknowledged at the time of discovery:

a. All doors in the Echo Lab (Room 165) were fully covered with Christmas type wrapping paper.

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress (2000, NFPA 101:21.2). Findings include:

During a tour of Outpatient Imaging of Dover on 12/14/12 at 11:15 AM with Employee #2, the following observation was made/acknowledged at the time of discovery:

1. West Side exit stairwell was being used for storage