HospitalInspections.org

Based on observation, document review and interview, it was determined the facility failed to maintain portable floor plans outlining designated rated partitions, affecting two of two levels within the facility.

Findings Include:

Observation and document reviewed on June 14, 2017, between 9:30 am and 11:30 am, revealed the floor plans provided by the failed to accurately reflect the smoke barrier on the second floor and showed a door on the first floor that no longer exists.

The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plans on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

1. Smoke Barrier Walls (outside wall to outside wall);

2. Fire Barrier Walls (2-hour walls);

3. Horizontal Exit Walls;

4. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;

5. Required Exits should be clearly noted;

6. Shaft Walls.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the floor plans provided were not accurate.

Based on observation and interview, it was determined the facility failed to ensure building construction type was maintained, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 10:25 am, revealed the second floor above the ceiling of office #241, there were two light fixtures with broken bonnet protection. The bonnets are part of the rated ceiling assembly.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the broken bonnets inside the office ceiling.

Based on observation and interview, it was determined the facility failed to ensure there were no impediments to egress, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 1:47 pm, revealed the exit discharge door by room #140 had a delayed egress lock installed. Signage was not installed indicating the door will open in 15 seconds while pressure is applied.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the lack of signage on the exit discharge door.

Based on observation and interview, it was determined the facility failed to ensure exit signage was displayed properly, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017 at 11:01 am, revealed the first floor West wing corridor had an exit sign above the door directing into the Group meeting room in lieu of the corridor means of egress. The exit inside the room leads into a fenced-in area.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the exit sign lacked appropriate directional arrows.

Based on observation and interview, it was determined the facility failed to ensure the fire resistance ratings of vertical openings were maintained, affecting two of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 10:17 am, revealed inside the second floor West wing stair tower, above the ceiling, there were unsealed penetrations by a sprinkler pipe, metal trusses and a red fire alarm cable next to a drywall patch.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations inside the stair tower wall.


2. Observations made on June 14, 2017, between 11:00 am and 11:07 am, revealed unsealed stair penetrations in the following locations:

a. 11:00 am, inside stairwell by room 128;
b. 11:07 am, inside stairwell by room 101.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations in the above named locations.

Based on observation and interview, it was determined the facility failed to ensure smoke detectors were maintained in operable condition, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 1:21 pm, revealed inside the first floor Day room, there was a ceiling mounted smoke detector within three feet of an air supply diffuser and had a build up of dust from the air flow.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the smoke detector was in close proximity to the ceiling diffuser.

Based on observation and interview, it was determined the facility failed to ensure sprinkler systems were secured properly, maintained within a smoke tight assembly and were free obstructions, affecting two of two levels within this component.

Findings include:

1. Observations made on June 14, 2017, between 9:36 am and 11:20 am, revealed monolithic ceiling assemblies with unsealed penetrations, which would not resist the passage of smoke, in the following locations:

a. 9:36 am, second floor Fire Panel Control room, penetration by a pipe;
b. 11:20 am, ground floor exterior accessed rear air handler room, penetration by a bundle of pipes.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations of the ceiling assemblies in the above named locations.


2. Observation made on June 14, 2017, at 9:43 am, revealed the 2nd floor ceiling grid was supported by sprinkler piping between rooms 225 & 227.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the sprinkler piping was used to secure the ceiling grid.


3. Observation made on June 14, 2017, at 9:47 am, revealed the second floor West wing supply closet had storage on the top shelf which within eighteen inches of the sprinkler head.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the storage was too close to the sprinkler head.


4. Observation made on June 14, 2017, at 10:00 am, revealed the 2nd floor laundry room had an unsealed penetration in the ceiling that could delay activation of the automatic sprinkler system.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetration.


5. Observation made on June 14, 2017, at 10:38 am, revealed inside the first floor Core elevator lobby, above the ceiling, there was a bundle of blue data cables laying on the sprinkler pipe.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the wires were supported by sprinkler piping.

Based on observation and interview, it was determined the facility failed to ensure sprinklers are maintained free of dirt & debris, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 1:36 pm, revealed the 1st floor Admissions Office had a sprinkler covered with dirt & debris.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the sprinkler covered with dirt & debris.

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were maintained in operable condition, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 9:55 am, revealed the 2nd floor East Multi-purpose room portable fire extinguisher security pin was unsecured.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the security pin was missing a security tie.

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when closed, affecting two of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 12:46 pm, revealed the second floor Vending machine room door had been removed. The missing door is part of the atrium that is part of the stairs.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed a door had been removed, which was part of the facility floor plan.


2. Observation made on June 14, 2017, at 1:53 am, revealed first floor patient room
#138 had a gap greater than one half inch between the active and inactive leaves of the corridor doors, which would not resist the passage of smoke.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the excessive gap between the corridor double doors.

Based on observation and interview, it was determined the facility failed to ensure corridor doors were smoke resistant and maintained positively latching in their frames, affecting two of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 9:46 am, revealed the second floor West wing Doctor's office corridor door was damaged and was starting to delaminate, exposing the inner core.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the door was damaged and delaminating.


2. Observation made on June 14, 2017, at 9:52 am, revealed the second floor West wing Personal Laundry room #243 B door failed to positively latch when tested.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the door failed to positively latch when tested.


3. Observations made on June 14, 2017, between 10:00 am and 11:07 am, revealed corridor doors with gaps greater than one half inch between the door and frame, which would not resist the passage of smoke, in the following locations:

a. 10:00 am, second floor West wing patient room #245;
b. 10:06 am, second floor West wing patient room #248;
c. 11:07 am, first floor West wing patient room #102.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the doors had gaps, which would not resist the passage of smoke in the above named locations.

Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were maintained free of unsealed penetrations, affecting two of two levels within this component.

Findings include:

1. Observations made on June 14, 2017, between 12:52 pm and 1:40 pm, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 12:52 pm, second floor above the ceiling by the conference room and the Men's room, penetration by a bundle of Armor cables;
b. 1:40 pm, first floor above the ceiling by room #147, penetration by red and white data cables on both sides of the smoke barrier.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations of the smoke barriers walls in the above named locations.

Based on observation and interview, it was determined the facility failed to ensure the fire resistance rating of smoke barrier partitions, affecting two of two levels within this component.

Findings include:

1. Observations made on June 14, 2017, between 9:33 am and 10:44 am, revealed unsealed penetrations and incomplete sections of smoke barrier walls in the following locations:

a. 9:33 am, second floor smoke barrier wall from the Core to West wing, above the double doors, there was an unsealed penetration by a conduit pipe and also a gap around ductwork,
b. 10:32 am, second floor above the ceiling of office #234, there was an incomplete smoke barrier at the top where the drywall meets the deck and also a gap around the beam in the corner;
c. 10:44 am, first floor West wing in the Anti Hallway, there was an unsealed penetration by a bundle of Data cables.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations and incomplete sections of smoke barrier walls in the above named locations.


2. Observations made on June 14, 2017, at 9:43 am, revealed East side had unsealed penetrations of the smoke barrier walls in the following locations:

a. 10:02 am, 2nd floor above the ceilings inside the Multi-purpose room, Restroom, Laundry, smoke barrier doors and the Nurse Station;
b. 10:25 am, 2nd floor room 238;
c. 10:37 am, 1st floor, above the smoke barrier doors, by the Commons Entrance.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unsealed penetrations in the above named locations.

Based on observation and interview, it was determined the facility failed to ensure ventilating equipment was maintained in operable condition, affecting one of two levels within this component.

Findings Include:

1. Observation made on June 14, 2017, at 10:03 am, revealed the 2nd floor East Laundry room had dryer exhaust discharge above the ceiling, with a thick layer/build-up of combustible lint atop the ceiling.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the large amount of combustible material above the ceiling.

Based on observation and document review, it was determined the facility failed to ensure fire drills were conducted at unexpected times, affecting 3 of 12 required fire drills.

Findings include:

1. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the first shift fire drills were conducted within the same hour, in three of four quarters: 1st quarter at 10:50 am, 3rd quarter at 10:12 am, 4th quarter at 10:30 am.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the first shift fire drills were not conducted at unexpected times.

Based on observation and interview, it was determined the facility failed to ensure electrical outlets were protected from damage, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 9:58 am, revealed inside second floor patient room #207, both patient beds were pushed against duplex electrical outlets behind the head boards.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the beds were against the electrical outlets.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 9:31 am, revealed the second floor Core area above the ceiling to the West wing smoke barrier, there was an open junction box with exposed inner wiring on a conduct pipe.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the open junction box in the ceiling.

Based on observation and interview, it was determined the facility failed to ensure wiring was protected, affecting two of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 12:51 pm, revealed on the second floor above the ceiling of the smoke barrier by the Men's room, there was an open junction box mounted to a conduit pipe.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the open junction box in the ceiling.


2. Observation made on June 14, 2017, at 1:15 pm, revealed on the first floor above the ceiling by the nurse station and the access hatch, there was abandoned contractor's wiring and light fixture.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the abandoned contractor's wiring and fixture in the ceiling.


3. Observation made on June 14, 2017, at 1:38 pm, revealed inside the first floor Janitor's closet above the ceiling access hatch, there were cut wires with exposed inner wiring.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the exposed inner wiring.

Based on observation, interview and document review, it was determined the facility failed to ensure required testing and inspections of the emergency generator were performed, affecting two of two levels within this component.

Findings include:

1. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the generator sets inspection log sheets indicated weekly visual inspections lacked detailed information as to what was inspected, such as, oil and fuel levels, condition of belts and hoses, battery electrolyte and specific gravity and other relevant data. The only listing was "weekly visual inspection of generator set. " The last inspection listed was dated May 30, 2017.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed documentation did not specify the components visually inspected for the generator set.


2. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the facility could not produce documentation of either an annual or semi annual servicing of the generator set during the time of the survey.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the lack of preventative maintenance inspection documentation.


3. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the facility could not produce documentation of an annual two hour load bank test of the diesel powered emergency generator.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed verification of required testing of the emergency generator was not available during the time of the survey.

Based on observation, interview and document review, it was determined the facility failed to ensure required testing and inspections of the emergency generator were performed, affecting two of two levels within this component.

Findings include:

1. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the generator sets inspection log sheets indicated weekly visual inspections lacked detailed information as to what was inspected, such as, oil and fuel levels, condition of belts and hoses, battery electrolyte and specific gravity and other relevant data. The only listing was "weekly visual inspection of generator set. " The last inspection listed was dated May 30, 2017.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed documentation did not specify the components visually inspected for the generator set.


2. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the facility could not produce documentation of either an annual or semi annual servicing of the generator set during the time of the survey.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the lack of preventative maintenance inspection documentation.


3. Document review made on June 14, 2017, between 8:15 am and 9:20 am, revealed the facility could not produce documentation of an annual two hour load bank test of the diesel powered emergency generator.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed verification of required testing of the emergency generator was not available during the time of the survey.


4. Observation made on June 14, 2017, at 11:17 am, revealed inside the ground floor exterior accessed generator room, the ATS panel "normal power" indicating bulb was not illuminated.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the ATS bulb was inoperable.

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, affecting two of two levels within this component.

Findings include:

1. Observations made on June 14, 2017, between 9:43 am, and 10:55 am, revealed the improper and unauthorized use of powerstrips in the following locations:

a. 9:43 am second floor West wing Nurse station, refrigerator plugged into a powerstrip;
b. 10:55 am, first floor West wing staff breakroom, coffee maker and microwave oven plugged into a powerstrip daisy chained into another powerstrip.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unauthorized use of powerstrips in the above named locations.

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices, affecting one of two levels within this component.

Findings include:

1. Observation made on June 14, 2017, at 12:50 pm, revealed the st floor, room 206 D, had a coffee maker and microwave plugged into a power strip.

Interview with the Chief Operating Officer, Director of Facilities and the Regulatory Representative at the exit conference on June 14, 2017, at 2:40 pm, confirmed the unauthorized use of a power strip.