HospitalInspections.org

Based on observations, testing, and staff interviews the facility failed to insure that all corridor walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following corridor wall deficiencies were noted:

a. 3rd floor Treatment Room, has a louver in the corridor wall,
b. 3rd floor, this floor is not provided with automatic sprinkler protection and the corridor wall is not properly sealed at the deck above,
c. 1st floor, across from the elevator, has a louver in the corridor wall,

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all doors protecting corridor openings meet the requirements.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m., the following corridor door deficiencies were noted:

a. 6th floor, the corridor door to room #647 does not properly close and latch,
b 5th floor, the corridor doors to rooms #501, 502, 504, 505, 512, and 558 do not properly close and latch and have a gap at the top.

The findings were confirmed by staff interview.

Based on observations and staff interviews, the facility failed to insure that all vertical openings meet the requirements.

The finding are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. the following vertical openings deficiencies were noted:

a. 9th floor, South Main stairwell has a steel I-beam penetration of a fire wall that is not properly protected,
b. 7th floor, Elevator #6, a steel I-beam penetration that is not properly protected,
c. 6th floor, Elevator #9, a steel I-beam penetration that is not properly protected,
d. 5th floor, Elevator #9, a steel I-beam penetration that is not properly protected.

The findings were confirmed by staff interview.

Based on observations and staff interview, the facility failed to insure that smoke barrier walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier deficiencies were noted:

a. the 1st floor shell space has part of the rated wall assembly removed,
b. the 1st floor Breast Center has an unsealed sprinkler pipe penetrating the fire wall,


An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke barrier doors meet the requirements.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke barrier doors #1010 is not provided with a rabbet, bevel, or astragal and is not smoke tight.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all hazardous area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that a 50 gal storage cart was located in the corridor near to door #HT-401.

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hour of 9:00 a. m.- 4:30 p. m. the hazardous chemical storage room is not properly sealed around a steel I-beam.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all stairway requirements are being met. NFPA 101, 2000 Edition, para. 39.2.2.3.1.

The findings are:

During the tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stair deficiencies were noted:

a. The guard rails are not at least 42" in height,
b. There are spaces in the guard rails that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all exits were accessible at all times. NFPA 101, 2000 Edition, para. 39.2.7.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the exit ramp at the main entrance was not provided with a handrail on both sides.

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all emergency lighting requirements are met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p.m. revealed that the emergency lighting does not provide illumination on all outside exits.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional sign requirements are being met. NFPA 101, 2000 Edition, para. 39.2.10.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 it was noted that the exit sign located near the Appointment Desk was not illuminated.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interviews, the facility failed to insure that all emergency plan and fire drills meet the requirements.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m., it was noted that the fire drills were not being held at unexpected times under varying conditions on all shifts.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all fire alarm requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1 and 39.3.4.2.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. The fire alarm pull station is not located near the main entrance/exit,
b. a smoke detector in the corridor is located too close to an HVAC register,
c. a smoke detector in the clean linen storage room is located too close to an HVAC register.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, records review, and staff interviews, that facility failed to insure that all fire alarm system requirements were being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. 7th floor Room M-707, the smoke detector is located too close to an HVAC register,
b. 1st floor, Mechanical room, West Tower Annex, the smoke detectors area located greater than 12" from the ceiling,
c. Basement, Main Mechanical room, the smoke and heat detectors are located greater than 12" from the ceiling,
d. Basement, Main Corridor, the smoke detectors are located greater than 12" from the ceiling,
e. A review of the annual fire alarm system test documents revealed that several smoke detectors failed and no corrective action was noted, (see page 62 of the test documents).
f. A review of the annual fire alarm system test documents revealed that the fire door hold open device testing information was not dated,
g. A review of the annual fire alarm system test documents revealed that the smoke and fire damper testing does not include all equipment.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all smoke detector requirements are being met. NFPA 101. 2000 Edition. para. 39.3.4.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke detector #103 is located too close to an HVAC register.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interview, the facility failed to insure that all automatic sprinkler system requirements are being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following sprinkler system deficiencies were noted:

a. 2nd floor, Mechanical room #2, South, the ductwork on HVAC unit #66 is wider than 48" without adequate sprinkler coverage beneath,
b. 1st floor, the Lab, the sprinkler heads are blocked by equipment and cabinets,
c. 1st floor, Blood Storage Cooler is not provided with sprinkler protection,
d. Basement, sprinkler eschutcheon plates missing in Environmental Services,
e. Basement, sprinkler system does not cover the entire Communication Storage room,
f. A review of the sprinkler system's annual test documents revealed that the test does not include the static and residual pressures,
g. Not all sprinkler valves are identified as to the areas covered throughout the building.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all portable fire extinguisher requirements were being met.

The findings are:

During a tour of this facility on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the type K fire extinguisher was mounted farther than 5 feet from the automatic fire extinguishing system manual pull in the kitchen.

An interview with staff M confirms the findings.

Based on observations and staff interviews, the facility failed to insure that all heating, ventilation, and air-conditioning requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. it was noted that the ground floor Patient Access office is not provided with an HVAC return duct system.

An interview with staff M confirms the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all cooking facility requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the kitchen's range hood has combustible ceiling tile adjacent to it.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all laundry chute requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd the May 7th, 2010, between the hours of 9:00 a. m - 4:30 p. m. it was noted that the linen chute's fire damper was blocked by excess linens.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that the medical gas storage areas meet all requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the full and empty medical gas cylinders were not stored separately in properly identified areas.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all medical gas system requirements are being met.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th between the hour of 9:00 a. m. - 4:30 p. m. the following medical gas system deficiencies were noted:

a. no fire extinguisher provided for the med. gas bulk storage area,
b. the storage area is outside and is not provided with non-smoking or no- smoking signs.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all medical gas storage and use area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the Hyperbaric Treatment Area is not provided with adequate non-smoking and no smoking signs on the outside of the area.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interview, the facility failed to insure that all electrical wiring and equipment requirements were being met.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following electrical deficiencies were noted:

a. 8th floor, West Main stairwell, electrical junction box cover missing,
b. 6th floor, kitchenette, the receptacle near the sink is not a ground fault interceptor type,
c. 5th floor, coffee room, North Hall, the receptacle near the sink is not a ground fault interceptor type,
d. 4th floor, coffee room, Main, the receptacle near the sink is not a ground fault interceptor type,
e. 4th floor, electrical junction box cover missing in the ceiling above elevator #6,
f. 4th floor, Room #461, the receptacle near the sink is not a ground fault interceptor type.

An interview with staff S1 confirmed the findings.