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Based on observation and interview, the facility does not ensure that the rated smoke and fire walls are maintained throughout the Sisters of Charity Hospital (SOCH) facility.

Findings include:

During tour on 4/9/15 at 1:30 PM of the SOCH facility, it was observed that penetrations were present throughout the facility in the rated smoke and fire walls. These penetrations were repaired during the evening/night hours on 4/9/15 through 4/10/15.

Upon arrival to the facility on 4/10/15 at 8:30 AM, SOCH staff provided the surveyor with colored photos that revealed the identified penetrations had been repaired with a fire rated compound. Also at that time, facility staff provided policy #CH-HSE-2228 "Above Ceiling Work Policy" (effective 12/22/14), which indicated "anyone working above the ceiling shall comply with the requirements of the Above Ceiling Work Policy which includes, but not limited to, installation, repair and inspection activities".

These findings were verified by Director of Quality & Patient Safety Staff #37 and Chief Operating Officer Staff #39 on 4/9/15 at 4:00 PM.

Based on observation and interview, the hospital does not maintain all corridor doors that are part of the building egress to be readily accessible, as evidenced at the St. Joseph's Campus (SJC) facility.

Findings include:

During tour on 4/7/15 of the SJC facility, it was observed that the two corridor doors near the outpatient registration had locking devices on them. One door had a slide bolt in the upper corner on the latch side, higher than some staff could easily reach it. The other door had a dead-bolt, which was keyed on one side; the dead-turn lever did not function.

This finding was verified with Facility & Engineering Manager Staff #6 on 4/7/15.

Based on document review and interview, the hospital does not ensure that the medical gas system is maintained per NFPA 99, 1999 edition, as evidenced at the SOCH facility.

Findings include:

Review on 4/7/15 of the 2013 and 2014 Medical Gas and Vacuum Systems Inspection/Testing for the SOCH facility revealed that similar findings were identified during these inspections. Examples included:
- The area alarms for the SNF Nurses Station, Nursery and the 3rd floor nurses station were required to be replaced.
- The bulk oxygen tank had an improper surface under the storage container.
- Multiple zone valves required repair or replacement:
---The medical air gauges that are not accurate must be repaired or replaced.
---Zone valves must be located so they are not obstructed by a door that is normally in the open position or inaccessible.
---Patient terminals that have insufficient flow must have the flow increased.
---Leakage from the patient terminals requires they must be disassembled, cleaned and the O-rings replaced.
---Patient terminals that do not release the secondary equipment must be repaired or replaced.

Interview on 4/9/15 at 9:30 AM with Manager of Facilities & Engineering (SOCH) Staff #52 and Director of Facilities & Engineering (SJC and SOCH) Staff #61, and review of provided documentation, did not reveal evidence that the medical gas system repairs had been made.

Based on observation and interview, the facility does not ensure that the rated smoke and fire walls are maintained throughout the Sisters of Charity Hospital (SOCH) facility.

Findings include:

During tour on 4/9/15 at 1:30 PM of the SOCH facility, it was observed that penetrations were present throughout the facility in the rated smoke and fire walls. These penetrations were repaired during the evening/night hours on 4/9/15 through 4/10/15.

Upon arrival to the facility on 4/10/15 at 8:30 AM, SOCH staff provided the surveyor with colored photos that revealed the identified penetrations had been repaired with a fire rated compound. Also at that time, facility staff provided policy #CH-HSE-2228 "Above Ceiling Work Policy" (effective 12/22/14), which indicated "anyone working above the ceiling shall comply with the requirements of the Above Ceiling Work Policy which includes, but not limited to, installation, repair and inspection activities".

These findings were verified by Director of Quality & Patient Safety Staff #37 and Chief Operating Officer Staff #39 on 4/9/15 at 4:00 PM.

Based on observation and interview, the hospital does not maintain all corridor doors that are part of the building egress to be readily accessible, as evidenced at the St. Joseph's Campus (SJC) facility.

Findings include:

During tour on 4/7/15 of the SJC facility, it was observed that the two corridor doors near the outpatient registration had locking devices on them. One door had a slide bolt in the upper corner on the latch side, higher than some staff could easily reach it. The other door had a dead-bolt, which was keyed on one side; the dead-turn lever did not function.

This finding was verified with Facility & Engineering Manager Staff #6 on 4/7/15.

Based on document review and interview, the hospital does not ensure that the medical gas system is maintained per NFPA 99, 1999 edition, as evidenced at the SOCH facility.

Findings include:

Review on 4/7/15 of the 2013 and 2014 Medical Gas and Vacuum Systems Inspection/Testing for the SOCH facility revealed that similar findings were identified during these inspections. Examples included:
- The area alarms for the SNF Nurses Station, Nursery and the 3rd floor nurses station were required to be replaced.
- The bulk oxygen tank had an improper surface under the storage container.
- Multiple zone valves required repair or replacement:
---The medical air gauges that are not accurate must be repaired or replaced.
---Zone valves must be located so they are not obstructed by a door that is normally in the open position or inaccessible.
---Patient terminals that have insufficient flow must have the flow increased.
---Leakage from the patient terminals requires they must be disassembled, cleaned and the O-rings replaced.
---Patient terminals that do not release the secondary equipment must be repaired or replaced.

Interview on 4/9/15 at 9:30 AM with Manager of Facilities & Engineering (SOCH) Staff #52 and Director of Facilities & Engineering (SJC and SOCH) Staff #61, and review of provided documentation, did not reveal evidence that the medical gas system repairs had been made.