HospitalInspections.org

While surveying Level 0 Penobscot Tower it was observed in the presence of surveyor 36434 and facilities management:

Fire damper installed at the 3 hour fire wall not in compliance with NFPA 80 2010 Edition.

Based on observation of surveyor 16732 on 03/05/2018


EMMC Emergency room corridor has IV machines plugged into an outlet being stored in the corridors.


The Director of Fire and Employee Safety was present during this observation



Based on observation of surveyors 33342 and 37695

Kagan building second floor near materials room had beds being repaired in the means of egress.

Exit from Vascular Care partially blocked with IV stands awaiting repair.

Haskell Floor 0 electrical vault room has hasp and padlock

Kelly Floor 3 at end of corridor has storage of several computer units









34673

While surveying Level 0 Penobscot Tower with surveyor 36434 and facilities management it was observed:

Crane work obstructing exiting at Level 0 Penobscot Tower on the East side of the building at two locations; sprinkler pump room exit and main corridor outside sprinkler pump room.



While surveying level ground floor:

Exit sign required at second exit from gift shop.
Exit corridor from gift shop obstructed by brooms, ladder and garbage.



Pedestal sign located on Penobscot Level 1 obstructing corridor.


Throughout Penobscot Tower:

Patient scales obstructing exit corridors on levels 5,6, and 7.








37696

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to:

1) the main exit corridor from the center "core" on Grant patient, G5, G4, G3 is used for storage and charging which has restricted the corridor width to 22".

Based on observation of surveyors 33342 and 37695

Door in Kagan Building out of the medical fitness office in Vascular care suite has both panic hardware and a bag lock as evidenced by a push to unlock door button.

Main door into Haskell Floor 3 does not latch







35163

Based on observations surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant-8 delayed egress door located near room 106 B had no labeling on door to indicate it was a delayed egress door.

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to the following doors not closing completely

1) GRT6 S654 AB door leaf hung up on frame
2) 90 minute door between Penobscot Pavilion & Grant, level 3 north leaf not latching
3) G3 rated door to Surgical Patient Reception hits on frame and is not closing
4) G2 cross corridor doors near employee locker room was not latching

Based on observation of surveyor 16732 on 03/05/2018


A yellow electric heater was being stored in the exit stair tower at Grant Zero by the river


The Director of Fire and Employee Safety was present during this observation


Based on observation of surveyors 33342 and 37695

Fire Door FDR-2-066 Located level 2 Kagan Building has top of door cut to allow door closer to function.

Fire Door FDR-2-054 Located Kagan building does not latch and there is excessive gap at top of door.

Door entering Haskell Floor 1 has foot peg installed on door

Door F 11008A Haskell Floor 1 has barrel bolt at top of one the leaf

While surveying Penobscot tower level 5 with surveyor 36434 and facilities management it was observed:


Wheeled equipment "Food cart" left unattended/ stored in corridor.

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to lack of exit signs in the following location:

1) to 2nd exit from CCU and Claison ICU

2) exit from center "core" of patient level G3, G4, G5

Based on observation of surveyors 33342 and 37695 on March 05, 2018

There is no visible exit sign on fourth floor of Kagan building from corridor

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to the vertical chase that houses the old kitchen exhaust duct is not sealed at access panels in mechanical rooms G8, G6, G5 and at the based of the vertical chase on G4, the sealant is falling off exposing the mineral wool insulation.

Based on observation of surveyors 33342 and 37695 on 03/05/2018

The wall in storage area between Kagan building and Vascular Care does not terminate at the floor.

Door to storage room on Kagan level 2 has gaps that exceed allowable gap

Rear Exit door to material supply room does not have self closer.

Fourth floor electrical room and storage room in Kagan building does not self close and latch

Haskell 3 IT room has openings in the wall and a cable box attached over a door frame that leads into the storage room

Door H 4005 in Haskell needs to have self closer as room is now used for storage

Kelly Floor 2 Neonatal/pediatric storage room needs to have a closer on the door.






34673

While surveying Level 6 in Penobscot Tower with surveyor 36434 and facilities management it was observed:


Laundry area not protected by one hour fire rating.


35163

Based on observations surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant-8 mechanical space door was missing self closing device.

2. Grant-8 mechanical space had penetrations in walls and floor ceiling assembly that would not prevent the passage of smoke/fire.

3.Grant-6 storage room C-12 had penetrations in the ceiling that would not prevent the passage of smoke.

4. Grant-4 mechanical space had penetrations in walls and floor ceiling assembly that would not prevent the passage of smoke/fire.

5. Grant-3 storage room # 114 (combustible storage room over 50 sq/ft) did not have self closing device for the door

6. Grant-2, The old sterilization room had penetrations that would not prevent the transfer/passage of smoke and did not have a self closing device for doors








37696

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to:

1) open penetrations found in the following areas:
mechanical G8,
across from kitchen storage small storage room to be smoke tight
High Voltage Rm PSS7E (G2) wall penetrations and bottom of wall not caulked
"hatch" in corridor wall would not be considered rated
Holes drilled through concrete floor to be sealed

2) The doors to the following hazardous areas were not self-closing and positive latching:
GRT6 RM6 73 clean storage
AH612 on G6 Mechanical Space
GRT5 RM 546 Housekeeping
GRT5 RM 554 Soiled Linen
GRT5 5 129 Storage
Housekeeping G3 by stairs to be self-closing
double doors to loading dock area & O2 storage

3) Gap between door leaf & frame exceeded allowable at Storage GRT8 Rm 106B

Based on observation of surveyors 33342 and 37695 on March 05, 2018


Haskell Floor 0 Mechanical tank room has spray foam in penetrations


35163

Based on observations and records review, surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant-2, No documentation could be provided to indicate that the composite panels and painted cedar shingles located at the entrance and inside of the pediatric sedation space meet interior finish requirements.

2. Grant- 2 , The old sterilization room had urethane spray foam insulation used to seal penetrations

Based on observation of surveyors 33342 and 32695 on March 5, 2018


Kagan 4th floor sprinkler room has excessive storage

Based on observation of surveyors 33342 and 37695 on March 05, 2018

Kagan building fitness gym have sprinkler heard that are obstructed by the light fixtures.

Closet within ultrasound room in Haskell is lacking sprinkler protection

Thermal Blanket within imaging room used to retain heat for equipment is blocking sprinkler coverage

Escutcheon plates missing in imaging reading room Haskell Floor 1


35163

Based on observations surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant-6 electrical room # 680 had no sprinkler protection

2. Grant-5 electrical room near medication room, had no sprinkler protection

3. Grant-3 electrical room had no sprinkler protection



36434

It was observed by inspectors 34673 & 36434 and the Facilities Supervisor that this was not met due to:

1) Informational signs missing on fire sprinkler valves throughout stairwells

2) fire sprinkler piping support missing electrical room 751

3) No fire sprinkler coverage in construction area of the 7th floor


37695

Based on observation of surveyor 37695 and 33342, sprinkler heads located in the medical fitness center in Kagan are obstructed by lighting fixtures. This was found in the presence of the Maintenance staff.

Based on observations surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant-6 storage closet c-8 had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.





36434

It was observed by inspectors 34673 & 36434 and the Facilities Supervisor that this was not met due to:


1) Level 4 fire sprinkler heads have fireproofing material on them

2) Level 4 fire sprinkler head leaking


37696

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to:

1) escutcheon rings missing:
G8 nurses station (x2)
outside continuing care nursing (vacant space)
staff lounge at GRT8 Rm 145
entry into Ped Sedation

2) Items stacked closer than 18" to bottom of sprinkler heads
GRTC C9 top shelf in closet
Scattered throughout, sprinklered small closets outside patient rooms items on top shelf too close to heads

3) bits of clear plastic were found on sprinkler heads in storage rooms on G5. The plastic was removed by Maintenance Supervisor at the time of the inspection

4) Medical Director Office in Nero Diagnostic:
has non-fire treated foam panels suspended from the ceiling that are shielding the sprinkler heads
full wall closet openings were covered with wide slat blinds which shielded sprinkler coverage

Based upon observation of surveyors 33342 and 37695 on March 05, 2018


Haskell Floor 3 patients rooms door numbered 370 and 376, have excessive gap at warping of door that is greater that 1/2 inch


34673

While surveying Penobscot Tower with surveyor 36434 and facilities management it was observed:


Level 5 P-5 sliding doors would not positively latch when closed.


35163

Based on observations surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. Grant 5, double smoke barrier doors S545A were not properly aligned when closed and had gap over 1/2" that would not prevent the passage of smoke.

2. Grant -4, double smoke barrier doors located near ICU had gap over 1/2" between doors and would not prevent the passage of smoke.

3. Grant 2, double smoke barrier doors GRT 2-N3-FDH-26 would not properly close (door hitting on frame) and had gap over 1/2" that would not prevent the passage of smoke.

4. Grant 2, double smoke barrier doors GRT 2-N3-FDH-13 would not properly close and latch



37695

Based on observation of surveyor 37695 and 33342 door located in the corridor of Kagen second floor leading to the stairway to the parking garage has been altered to fit the closing device installed. The door is a 1 1/2 hour rated fire door. This was found in the presence of maintenance staff.


37696

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to:

1) the following doors had gaps that exceeded allowable
G8 Peds 862, 860, 859,
storage off clean utility door behind CCU nurses, same with rear door to same room

2) the following doors did not latch at the time of the inspection
shower room GRT5 5 115
G2 door to employee locker room

Based on observation of surveyors 33342 and 37695 the following areas in the Kagen Building do not resist the passage of smoke

1) West wall on level 2 above ceiling has 3 conduits not sealed.

2) Kagan Door SDR-3-009A has one door leaf that will not close or latch

3) Haskell Floor 0 Room AHU 18 has multiple penetrations within the room

4) Haskell Floor 0 Room HSK-0-002 has multiple penetrations within the room

5) Haskell Floor 0 AH 49 IT room has multiple penetrations within the room










34673

While surveying Penobscot Tower at level 4 interstitial space with surveyor 36434 and facilities management it was observed:


One door in the smoke barrier tied back in the open position and another door with the self-closing device disconnected and propped open by wedging it up against the sprinkler piping located above the door.

Based on observations and interviews surveyors 35163 and 37696 on 06/21/17, in the presence of the maintenance director the following was not met:

1. The elevator machine/motor room located in the grant building had open/not covered containers that were being used to capture hydraulic fluid that was leaking from the elevator equipment. Upon interview with the maintenance technician that is responsible for the equipment in that area, he advised the equipment had been leaking for a period of years and that the containers were emptied weekly.

2. The elevator machine/motor room had oily rags being stored in a uncovered trash container



37695

Based on observation of surveyor 37695 and 33342 spray foam was located in the air handler room located on Kagen 2. This was found in the presence of the maintenance staff.

Based on observation of surveyors 33342 and 37695 on March 05, 2018


Haskell floor 1 has image table placed in front of electrical panels

Kelly Floor 3 Storage/Laundry room KLY3-08 has storage within 3 feet of electrical panel

Based on observation of surveyors 33342 and 37695 on March 05, 2018

Med gas room on Kagan 4 is missing a sprinkler escutcheon plate and is missing ceiling tiles

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to:

1) the doors to the loading dock that houses bulk O2 storage are not labeled.

2) the O2 is in a large storage room with combustibles

3) the windows / sidelight of the loading dock are covered with plywood

4) a ventilation system was not seen or heard in / near the O2 storage

It was observed by inspectors 37696 & 35163 and the Maintenance Supervisor that this was not met due to med gas shut off by O2 storage on G8 was labeled "not in use" however when tested, the O2 lines in the adjacent rooms were pressurized and emitting O2.

Based on observation of surveyor 37695 and 33342 a power strip was found supplying a refrigerator in an office located on Kagen 2. This was found in the presence of the maintenance staff.

Based on observations surveyors 35163 and 37696 on 03/205/18, in the presence of the maintenance director and safety coordinator the following was not met:

1. Grant-9 elevator machine room had a three outlet extension cord that was being used to constantly power computer equipment.

2. Grant-2 pediatric sedation had a multi outlet power strip being used to power a mini fridge and a toaster