HospitalInspections.org

K15

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 08-06-12, at approximately 2:05PM, by observation and interview of the Facilities Manager it was discovered the use of four small square corkboard bulletin boards in the emergency room suites nurses station. These findings were verified with the Facilities Manager at the time of discovery.

K21

Based upon observation and staff interview, it was determined that the facility failed to ensure proper operation of a smoke barrier door located in accordance with LSC, Section 19.2.2.2.6. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 10:40AM, by observation and interview of the Facilities Manager it was discovered that the fifth floor east exit stairway door sticks and does not close the entire way and positive latch. These findings were verified with the Facilities Manager at the time of discovery.

K29

Based upon observation and staff review, it was determined the facility failed to ensure storage in areas with one hour fire rated construction or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice could affect all residents, staff, and visitors.

Findings Include:

On 08-06-12, at approximately 11:29AM, by observation and interview of the Facilities Manager it was discovered that on the third floor O.B. area, C section hallway, the soiled utility room corridor door was found blocked open with a trash can. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 1:26PM, by observation and interview of the Facilities Manager it was discovered that the O.R. housekeeping closet door was blocked open with a floor wedge device. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 2:27PM, by observation and interview of the Facilities Manager it was discovered that the Physicians Billing Office corridor door was blocked open with a box. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 3:44PM, by observation and interview of the Facilities Manager it was discovered that the Imagery Medical records corridor door does not close the entire way and positive latch. These findings were verified with the Facilities Manager at the time of discovery.

On 08-07-12, at approximately 9:24AM, by observation and interview of the Facilities Manager it was discovered there is missing ceiling tile in the cafeteria vending machine storage room. These findings were verified with the Facilities Manager at the time of discovery.

K52

Based on observation the facility failed to provide a fire alarm system that is installed, tested, and maintained in accordance with NFPA 70 and the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings Include:

On 08-06-12, at approximately 11:29AM, by observation and interview of the Facilities Manager it was discovered during a functional test of the facilities fire alarm system, visual devices were not in synchronization at the following locations:

11:29AM, 5th floor east wing,
10:40AM, Pharmacy & Kemo prep area
10:54AM, East hallway-ambulatory
11:05AM, Basement East North/South hallway &
the hallway by cafeteria.

These findings were verified with the Facilities Manager at the time of discovery.

In addition during records review it was discovered that there are at least five separate fire alarm devices that were indicated on the fire alarm panel as incorrect locations/devices for that location:

5 smoke detection devices and 1 pull station.

These findings were verified with the Facilities Manager at the time of discovery.

K56

Based upon observation and staff interview, it was determined the facility failed to ensure that the sprinkler system was inspected and tested in accordance with NFPA 101 19.3.5. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 11:17AM, by observation and interview of the Facilities Manager it was discovered storage on top of a metal storage cabinet that violates the 18 inch rule of being clear beneath a sprinkler head, in the Nursing office next to Social Service office. These findings were verified with the Facilities Manager at the time of discovery.

K64
Based upon observation and staff interview, it was determined the facility failed to ensure that the fire extinguishers were displayed according to NFPA 10. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 11:30AM, by observation and interview of the Facilities Manager it was discovered that the portable fire extinguisher in the ICC suite was blocked by the storage of a service cart and is also more than 5 feet off the floor surface. These findings were verified with the Facilities Manager at the time of discovery.

On 08-07-12, at approximately 9:24AM, by observation and interview of the Facilities Manager it was discovered that portable fire extinguishers in the following locations are more than 5 feet off the floor surface:

Kitchen stove area
Kitchen storage room area at 2
separate locations

These findings were verified with the Facilities Manager at the time of discovery.

K-130

Based on observation and/or review of records the facility failed to provide a safe environment. This deficient practice could potentially affect all occupants of the facility.

Findings Include:

On 08-06-12, at approximately 10:21AM, by observation and interview of the Facilities Manager it was discovered that the two Doctors offices on the fifth floor, both have a large amount of disorganized papers, combustibles literally piled on the floors near their desk areas thus increasing the fire loads of those two office areas to a large extent for a general office situation. These findings were verified with the Facilities Manager at the time of discovery.

K147

Based upon observation and staff interview, it was determined the facility failed to ensure electrical wiring to be in accordance with NFPA70, National Electrical Code. 9.1.2. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 2:30PM, by observation and interview of the Facilities Manager it was discovered the use of several extension cords in the basement education/training room. These findings were verified with the Facilities Manager at the time of discovery.

K15

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 08-06-12, at approximately 2:05PM, by observation and interview of the Facilities Manager it was discovered the use of four small square corkboard bulletin boards in the emergency room suites nurses station. These findings were verified with the Facilities Manager at the time of discovery.

K21

Based upon observation and staff interview, it was determined that the facility failed to ensure proper operation of a smoke barrier door located in accordance with LSC, Section 19.2.2.2.6. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 10:40AM, by observation and interview of the Facilities Manager it was discovered that the fifth floor east exit stairway door sticks and does not close the entire way and positive latch. These findings were verified with the Facilities Manager at the time of discovery.

K29

Based upon observation and staff review, it was determined the facility failed to ensure storage in areas with one hour fire rated construction or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice could affect all residents, staff, and visitors.

Findings Include:

On 08-06-12, at approximately 11:29AM, by observation and interview of the Facilities Manager it was discovered that on the third floor O.B. area, C section hallway, the soiled utility room corridor door was found blocked open with a trash can. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 1:26PM, by observation and interview of the Facilities Manager it was discovered that the O.R. housekeeping closet door was blocked open with a floor wedge device. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 2:27PM, by observation and interview of the Facilities Manager it was discovered that the Physicians Billing Office corridor door was blocked open with a box. These findings were verified with the Facilities Manager at the time of discovery.

On 08-06-12, at approximately 3:44PM, by observation and interview of the Facilities Manager it was discovered that the Imagery Medical records corridor door does not close the entire way and positive latch. These findings were verified with the Facilities Manager at the time of discovery.

On 08-07-12, at approximately 9:24AM, by observation and interview of the Facilities Manager it was discovered there is missing ceiling tile in the cafeteria vending machine storage room. These findings were verified with the Facilities Manager at the time of discovery.

K52

Based on observation the facility failed to provide a fire alarm system that is installed, tested, and maintained in accordance with NFPA 70 and the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings Include:

On 08-06-12, at approximately 11:29AM, by observation and interview of the Facilities Manager it was discovered during a functional test of the facilities fire alarm system, visual devices were not in synchronization at the following locations:

11:29AM, 5th floor east wing,
10:40AM, Pharmacy & Kemo prep area
10:54AM, East hallway-ambulatory
11:05AM, Basement East North/South hallway &
the hallway by cafeteria.

These findings were verified with the Facilities Manager at the time of discovery.

In addition during records review it was discovered that there are at least five separate fire alarm devices that were indicated on the fire alarm panel as incorrect locations/devices for that location:

5 smoke detection devices and 1 pull station.

These findings were verified with the Facilities Manager at the time of discovery.

K56

Based upon observation and staff interview, it was determined the facility failed to ensure that the sprinkler system was inspected and tested in accordance with NFPA 101 19.3.5. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 11:17AM, by observation and interview of the Facilities Manager it was discovered storage on top of a metal storage cabinet that violates the 18 inch rule of being clear beneath a sprinkler head, in the Nursing office next to Social Service office. These findings were verified with the Facilities Manager at the time of discovery.

K64
Based upon observation and staff interview, it was determined the facility failed to ensure that the fire extinguishers were displayed according to NFPA 10. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 11:30AM, by observation and interview of the Facilities Manager it was discovered that the portable fire extinguisher in the ICC suite was blocked by the storage of a service cart and is also more than 5 feet off the floor surface. These findings were verified with the Facilities Manager at the time of discovery.

On 08-07-12, at approximately 9:24AM, by observation and interview of the Facilities Manager it was discovered that portable fire extinguishers in the following locations are more than 5 feet off the floor surface:

Kitchen stove area
Kitchen storage room area at 2
separate locations

These findings were verified with the Facilities Manager at the time of discovery.

K-130

Based on observation and/or review of records the facility failed to provide a safe environment. This deficient practice could potentially affect all occupants of the facility.

Findings Include:

On 08-06-12, at approximately 10:21AM, by observation and interview of the Facilities Manager it was discovered that the two Doctors offices on the fifth floor, both have a large amount of disorganized papers, combustibles literally piled on the floors near their desk areas thus increasing the fire loads of those two office areas to a large extent for a general office situation. These findings were verified with the Facilities Manager at the time of discovery.

K147

Based upon observation and staff interview, it was determined the facility failed to ensure electrical wiring to be in accordance with NFPA70, National Electrical Code. 9.1.2. This deficient practice could affect all occupants including residents, staff, and visitors.

Findings include:

On 08-06-12, at approximately 2:30PM, by observation and interview of the Facilities Manager it was discovered the use of several extension cords in the basement education/training room. These findings were verified with the Facilities Manager at the time of discovery.