HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain the building construction type as required on one of four levels.

Findings include:

1. Observation on January 30, 2017 at 11:00 AM revealed the Second Floor, 2D nursing unit, Communications closet had unsealed penetrations through the floor, around data cables placed in conduit.

Interview with Tech #2 on January 30, 2017 at 11:00 AM confirmed the unsealed floor penetrations existed.

Based on observation and interview, it was determined that the facility failed to maintain a clear path of egress in one of two floors.

Findings include:

1. Observation on January 30, 2017 at 12:52 PM revealed that the basement of the Cancer Center had extreme storage in the main path of egress. In one area, the path of egress was obstructed by doors, desk and christmas decorations leaving a two foot clearance.

Interview with Tech#1 on January 30 at 12:52 PM confirmed the large amount of storage in the basement corridor.

Based on observation and interview, it was determined that the facility failed to maintain vertical openings between floors with enclosures having a fire resistance rating of at least 1 hour on one of four levels.

Findings include:

1. Observation on January 31, 2017 at 9:20 AM revealed the First Floor, Main Lobby Stairwell "B" had a 6"x 6" unsealed penetration to the left side of the door, corridor side, above the lay-in ceiling.

Interview with Tech #3 and the Director of Facilities on January 31, 2017 at 9:20 AM confirmed the unsealed penetration at Stairwell "B" existed.

Based on observation and interview, it was determined that the facility failed to maintain Hazardous Areas protected by a fire barrier having 1- hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 on two of four levels.

Findings include:

1. Observation on January 30, 2017 at 11:15 AM revealed that all the rated doors on the third floor are not labelled to verify the rating integrity. Facility states they have documentation but were unable to provide this at the time of the survey.

Inteview with Tech #1 on January 30, at 11:16 AM confirmed the doors did not have labels to verify the ratings.


2. Observation on January 31, 2017 at 10:35 AM revealed the First Floor, Ultrasound, bulk file storage room had a double pane, non-rated glass window on a common wall with a non-rated room.

Interview with Tech #3 and the Facilities Director on January 31, 2017 at 10:35 AM confirmed the non-rated window existed.

Based on observation and interview, it was determined that the facility failed to maintain cooking equipment protection in accordance with NFPA 96 on one of two cooking locations.

Findings include:

1. Observation on January 31, 2017 at 9:10 AM revealed the Fist Floor, Hospitality Shop had a K-Type fire extinguisher that lacked the required signage.

Interview with Tech #3 and the Director of Facilities on January 31, 2017 at 9:10 AM confirmed the K-Type fire extinguisher lacked the required signage.

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system on one of two levels.

Findings include:

1. Observation on January 30, 2017 at 1:25 PM revealed that in the center corridor, near the Physician's office, there were communication wires, data cables and HVAC supports attached to the sprinkler pipes.

Interview with Tech #1 on January 30, 2017 at 1:26 PM confirmed multiple wires were attached to the sprinkler pipe.

Based on observation and interview, it was determined that the facility failed to maintain, test and inspect the automatic sprinkler system in accordance with NFPA 25 on two of four levels.

Findings include:

1. Observation on January 30, 2017 at 11:30 AM revealed in the Third floor, house keeping closet in the Cath Lab the Escutcheon plate was broken and hanging from the ceiling.

Interview with the Tech#1 on January 30, 2017 at 11:31 AM confirmed the broken Escutcheon plate.

2. Observation on January 31, 2017 at 9:46 AM revealed the First Floor, Corridor Door to the left of the CT/ Nuclear Medicine double doors had a sprinkler drain valve above the lay-in ceiling that lacked required signage.

Interview with Tech #3 and the Director of Facilities on January 31, 2017 at 9:46 AM confirmed the sprinkler valve lacked required signage.

Based on observation and interview, it was determined that the facility failed to maintain corridor walls with construction of at least 1/2 hour fire resistance rating in a partially sprinklered building on two of four levels.

Findings include:

1. Observation on January 30, 2017 at 1:00 PM revealed the Second Floor, Psych Unit corridor wall had unsealed penetrations above the ceiling in the following locations:
A. By the Activity/Sitting alcove, around a bundle of data cables.
B. Above Room # 221 corridor door, a conduit with one data wire through the conduit.

Interview with Tech #2 on January 30, 2017 at 1:00 PM confirmed the unsealed penetrations listed above existed.

2. Observation on January 31, 2017 between 9:40 AM and 9:45 AM revealed the following corridor wall, unsealed penetrations above the lay-in ceiling:
A. First Floor, across from the Laboratory Entrance Door, unsealed penetration around a grey conduit. (9:40 AM)
B. First Floor, Corridor door, left of the CT/Nuclear Medicine entrance doors, unsealed penetrations around four medical gas pipes and one armaflex electrical wire. (9/45 AM)

Interview with Tech #3 and the Director of Facilities on January 31, 2017 at 9:45 AM confirmed the unsealed penetrations in the corridor walls listed above existed.

Based on observation and interview, it was determined that the facility failed to maintain corridor doors capable of resisting fire for at least 20 minutes and provide a means suitable for keeping the door closed on one of two levels.

Findings include:

1. Observation on January 30, 2017 at 1:00 PM revealed the corridor door to the Specimen Collection room, would not latch in its frame.

Interview with Tech #1 on January 30, 2017 at 1:00 PM confirmed the corridor door to the Specimen Collection room would not latch in its frame.

Based on observation and interview, it ws determined that the facility failed to maintain corridor doors capable of resisting fire for at least 20 minutes and provide a means suitable for keeping the door closed on two of four levels.

Findings include:

1. Observation on January 30, 2017 between 11:05 AM and 1:15 PM revealed:
A. Second Floor, Room # 282 corridor door had a gap on the latch side, between the door stop and door face greater than 1/4" that would not resist fire. (11:05 AM)
B. . Second Floor, Room # 206 corridor door had a gap on the latch side, between the door stop and door face greater than 1/4" that would not resist fire. (1:15 PM)

Interview with Tech #2 on January 30, 2017 at 1:15 PM confirmed the corridor doors had gaps on the latch side greater than 1/4".

2. Observation on January 31, 2017 at 11:20 AM revealed the First Floor, Emergency Department Lobby corridor housekeeping closet door had a self closing device that failed to close and latch.

Interview with Tech #3 and the Director of Facilities on January 31, 2017 at 11:20 AM confirmed the Emergency Room Housekeeping closet door failed to close and latch.

Based on observation and interview, it was determined that the facility failed to provide documentation verifying that combustible decorations were flame retardant or are treated with approved fire-retardant coating that is a listed and labeled product on one of four levels.

Findings include:

1. Observation on January 31, 2017 at 10:25 AM revealed the First Floor Lab Breakroom had an artificial tree greater than 4 feet that lacked flame retardant documentation or labeling.

Interview with Tech #3 and the Director of Facilities on January 31, at 10:25 AM confirmed the artificial tree lacked flame retardant documentation.

Based on observation and interview, it was determined that the facility failed to maintain the use of portable space heating devices in sleeping areas of the facility on one of four levels.

Findings include:

1. Observation on January 30, 2017 at 11:34 AM revealed the Second Floor, Unit 2B, Registered Nurse Assessment Coordinator Office had a portable electrical heater.

Interview with Tech #2 on January 30, 2017 at 11:34 AM confirmed the Nursing office had a portable electrical heater.

Based on observation and interview, it was determined that the facility failed to maintain power strips and extension cords as required on two of four levels.

Findings include:

1. Observation on January 30, 2017 at 11:05 AM revealed the Second Floor, 2 D Nurse Station had (2 EA) surge protectors suspended by the power supply cord and attached to the desk with zip ties.

Interview with Tech #2 on January 30, 2017 at 11:05 AM confirmed the surge protectors were suspended by the power cords and attached to the desk by zip ties.

2. Observation on January 31, 2017 at 9:25 AM revealed the First Floor, Laboratory Pathologist Office had a surge protector permanently attached to the desk.

Interview with Tech #3 and the Facility Director on January 31, 2017 at 9:25 AM confirmed the surge protector was permanently attached to the desk.