HospitalInspections.org

Based on records review, the facility failed to include policies and procedures for sheltering in place in the emergency preparedness program.

The finding included:

Records review on 9/25/18 at 9:30 AM, revealed the facility had not developed policies and procedures for sheltering in place.

This finding was verified by the maintenance supervisor during record review and was acknowledged by the facility administration during the exit conference on 9/25/18.

Based on record review, the facility failed to develop a written emergency preparedness training and testing program that is based on the emergency plan.

The findings included:

Record review on 9/25/18 at 9:30 AM, revealed the facility could not provide a copy of their written emergency preparedness training and testing program.

This finding was verified by the maintenance supervisor during record review and was acknowledged by the facility administration during the exit conference on 9/25/18.

Based on record review, the facility failed to maintain the emergency preparedness training program.

The finding included:

Record review on 9/25/18 at 9:30 AM, revealed the facility could not provide emergency preparedness training records for staff.

This finding was verified by the maintenance supervisor during record review and was acknowledged by the facility administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the means of egress

The finding included:

Observation on 9/25/18 at 9:01 AM, revealed a chain was installed on the roof access door located at stairwell 2 level 6 not allowing the door to open 90 degrees. NFPA 101, 19.2.1 (2012 Ed), NFPA 101, 7.2.1.2.3.1 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the egress doors.

The finding included:

Observation on 9/25/18 at 9:05 AM, revealed the egress door located at the pent house elevator lobby 5 & 6 was locked not allowing egress from the area. NFPA 101, 19.2.2.2.4 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the doors with self-closing devices.

The finding included:

Observation on 9/25/18 at 9:00 AM, revealed the self-closing device was disconnected from the roof access door located at stairwell 2 level 6. NFPA 101, 19.2.2.2.7 (2012 Ed), NFPA 101, 7.2.1.8.1 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the corridor width.

The finding included:

Observation on 9/25/18 at 12:15 PM, revealed equipment stored in the corridor next to OR 9 and the surgery storage room. NFPA 101, 19.2.3.4 (2012 Ed), NFPA 101, 19.2.3.5 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the hazardous areas.

The finding included:

Observations on 9/25/18 between 9:59 AM and 12:35 PM revealed the following deficiencies;

a. Mechanical room located in the 3200 area had furniture stored in the room without the room being fire rated.
b. Mechanical room located in the 3100 area had furniture stored in the room without the room being fire rated.
c. Mechanical room located in the 2200 area had bed stored in the room without the room being fire rated.
d. The main nitrous and CO2 storage room wall was not sealed at the deck.
NFPA 101, 19.3.2.1 (2012 Ed) NFPA 101, 4.6.12.2 (2012 Ed), NFPA 101, 18.3.2.1 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the cooking facilities.

The finding included:

Observations on 9/25/18 between 12:50 PM and 12:55 PM revealed the following deficiencies;

a. Kitchen deep fryer located under hood #3 had no safety cable installed.
b. Grill located under Kitchen's hood #3 was not center under the hood's fire extinguisher nozzles.
c. Deep fryer and stove located under Kitchen's hood #1 were not center under the hood's fire extinguisher nozzles.
NFPA 96, 12.1.2.2 (2011 Ed), NFPA 96, 13.2.3 (2011 Ed), NFPA 54, 9.6.1.2 (2011 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the sprinkler system.

The findings included:

1. Observations on 9/25/18 between 11:59 AM and 1:00 PM revealed the following areas had all corroded sprinklers;

Exterior Canopies
a. Imaging mobile parking
b. Patient pickup/drop off
c. Emergency (ER) patient entrance
d. ER ambulance
e. Main entrance
f. Hospital/MOB entrance

Kitchen
a. Dishwashing room above hose reel.

NFPA 101, 19.3.5.3 (2012 Ed), NFPA 101, 9.7.5 (2012 Ed), NFPA 25, 5.2.1.1.2 (2011 Ed)

2. Observations on 9/25/18 between 12:00 PM and 1:10 PM revealed the following sprinkler deficiencies;

a. Same day surgery soiled utility room located across room 20 had a piece of a plastic bag wrap on the sprinkler.
b. Kitchen freezers R-2 and R-4 had dirty (lint) sprinklers

NFPA 101, 19.3.5.3 (2012 Ed), NFPA 101, 9.7.5 (2012 Ed), NFPA 25, 5.2.1.1.1 (2011 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the corridor doors.

The finding included:

Observations on 9/25/18 between 9:50 AM and 10:46 AM revealed the following deficiencies;

a. 200 clean linen room door did not latch within the door frame.
b. 2100 soiled utility located next to room 2112, door did not latch within the door frame.
NFPA 101, 19.3.6.3.5 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain smoke barriers.

The finding included:

Observations on 9/25/18 between 9:00 AM and 1:00 PM, revealed the following fire/smoke barriers were not properly firestopped;

1st Floor
a. 2-hour drywall Fire/Smoke barrier by education office- (1) unsealed yellow cable penetration.
b. 2-hour drywall Fire/Smoke barrier by communications- (1) ½ in. metal sleeve not sealed, (1) 1 in. metal sleeve not sealed, (1) 2 in. sleeve with black cable bundle sealed with mixed fire calk.
c. 1-hour drywall Fire/Smoke barrier by ENDO- (1) 3 in. metal sleeve not sealed.
d. 2-hour drywall Fire/Smoke barrier above doors B-206- (1) ½ in. metal sleeve with cable bundle not sealed.
e. 2 hour drywall Fire/Smoke barrier above door B-186- (1) 6 inch square sealed with fire calk, ½ in. metal sleeve not sealed.
f. 2-hour drywall Fire/Smoke barrier above door B-233- (1) 1 in. insulated line not sealed.
g. 1-hour drywall Fire/Smoke barrier above door E-237- (1) 1 in. metal sleeve sealed with mixed calk.
h. 2-hour drywall Fire/Smoke barrier by material management - (1) 1 in. metal sleeve with white cable with mixed caulk.
i. 2-hour drywall Fire/Smoke barrier by heart cath lab- (9) cable bundles with mixed caulk, (1) 1/2 in metal conduit with orange cable not sealed.
j. 2-hour drywall Fire/Smoke barrier by door B-186 - (4) 1in. metal conduits with cables bundles not sealed, (1) 4 in sprinker pipe not sealed.
k. 1-hour drywall Fire/Smoke barrier in the storage room B-206A - (1) 4 in. sprinkler pipe not sealed.
l. 1-hour drywall Fire/Smoke barrier by door 139B - (1) ¼ in. metal conduit with blue and grey cable wire with mixed caulk.
m. 1-hour drywall Fire/Smoke barrier in the board room storage closet - 1 inch open hole not sealed.

2nd floor
n. 1-hour drywall Fire/Smoke barrier by the 2300 crash cart room - (3) 1 in. metal conduits not sealed.
o. 2-hour drywall Fire/Smoke barrier by door 2A-129 - (2) 5 in. metal sleeves with mixed caulk, multiple cable bundles not sealed,
(1) 2 in. open hole with mixed caulk.
p. 1- hour drywall Fire/Smoke barrier on 2100 by communications room - (1) blue cable bundle and sleeve not sealed.

NFPA 101, 19.3.7.3 (2012 Ed), NFPA 101, 8.5.6.2 (2012 Ed), NFPA 101, 8.5.6.3 (2012 Ed), NFPA 101, 8.3.5.1 (2012 Ed)

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observations, the facility failed to maintain the electrical wiring and equipment.

The finding included:

Observations on 9/25/18 between 9:15 AM and 11:40 AM revealed the following deficiencies;

a. 5100 storage room located by mechanical room 5A had water leaking from the roof onto the ceiling tile located above the electrical panels.
b. 5100 electrical room had equipment and mop buckets blocking the panels.
c. Electrical room located across exam room 30 had a ladder blocking a panel.
NFPA 70, 110.26 (2011 Ed), NFPA 70, 110.11 (2011Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.

Based on observation, the facility failed to maintain the gas equipment.

The finding included:

Observations on 9/25/18 between 9:45 AM and 10:40 PM revealed the following deficiencies;

a. The 4300 RT equipment storage room had over 7,415 cubic feet of oxygen (3H) cylinders stored in the room. 3000 cubic feet or more of oxidizing gases require a dedicated storage room.
b. The 2200 crash cart room had oxygen stored in the room with no precautionary signs posted on the door.
c. The storage room next to room 2319 had oxygen stored in the room with no precautionary signs posted on the door.
NFPA 99, 11.3.4.1 (2012 Ed), NFPA 99, 11.3.1 (2012 Ed), NFPA 99. 5.1.3.3.2 (2012 Ed)

This finding was verified by the plant operations director during the survey and was acknowledged by the facility's administration during the exit conference on 9/25/18.