HospitalInspections.org

Findings Include:

A) Based upon observation, the surveyor finds that a 2nd Floor construction project has exposed several unprotected vertical openings in fire rated floor assemblies. These vertical openings were not protected either temporarily or permanently in accordance with 19.3.1.1. Interim Life Safety measures for this condition were not implemented (see also K130).

1) The 2nd Floor OB renovation project has demolished an area for a future reception area in the center of the wing. The demolition and construction have exposed a plumbing pipe chase. The floor penetrations of this pipe chase have open sleeves that are not sealed for fire rated construction and the space is open to the ceiling cavity of the floor below.

2) One 12" x 12" hole in the floor is covered with a piece of plywood. The hole in the floor is not protected as a fire rated assembly and the construction area is open to the ceiling cavity of the floor below.

3) One bundle of multiple wires and two insulated pipes penetrate the floor assembly; The three penetrations are not sealed for fire rated construction and the space is open to the ceiling cavity of the floor below. Fire or smoke can immediately and readily spread between floors without detection.

The above conditions will allow the spread of fire and smoke from floor to floor, undetected.

Findings Include:

A) Based upon observation, the surveyor finds that a 2nd Floor construction project has created a hazardous area (deemed hazardous based upon the use of temporary wiring, storage of construction materials and construction activities that include metal cutting). This hazardous area is not separated from all other areas by one hour fire rated construction. Interim Life Safety were not implemented for the deficiencies cited (see also K130).

The 2nd Floor OB renovation project has demolished an area for a future reception area in the center of the wing. The ceiling has been removed from this area and the sprinkler protection was not modified for this condition (pendent heads are now installed well below the deck above). The sprinkler system will not be effective as any kind of fire detection and will not activate in any kind of reasonable time frame to control a fire. With the current arrangement the exposed plastic sprinkler piping will probably fail before the heads go off.

The corridor walls around the construction area are drywalled on one side only. These walls do not comply with 19.3.2.1. There are multiple penetrations that are open to the ceiling cavities of the adjacent corridors (voids and openings are not sealed or closed off for one hour construction in accordance with 19.3.2.1 for a hazardous area). This will allow fire or smoke to spread undetected above ceilings in the required means of egress for patient occupied spaces.

The entire east wall of the construction area is open to the ceiling cavity of the adjacent corridor and elevator lobby.

This will allow fire and smoke to spread above ceiling cavities, undetected and will have an immediate impact on the means of egress for an adjacent nursery.

See also K020.

Findings Include:

A) Based upon observation the surveyor finds that the facility has locked doors in identified paths of egress that do not comply with 7.2.1.6:

1) The 3rd Floor center portion of the building is not a psychiatric area and allows free access via elevators to this portion of the building. There are multiple paths of egress from the center portion of the 3rd Floor. The exit paths to the west are directed with illuminated exit signs into a psychiatric unit.

a) The south corridor has an illuminated
exit sign above a door with a sign that
indicates "Do Not Enter" The two signs
conflict.

b) The north corridor has a door with an
illuminated exit sign. The door has
electronic locking hardware that does
not allow release within 15 seconds in
accordance with the provisions of
7.2.1.6.

Exit signs identify a path that is not available to everyone. The confusing identification of exit paths from this floor could cause a delay of evacuation during a fire particularly for any staff, patients or visitor that are not intimately familiar with this floor.

Findings Include:

A) Sprinkler systems are not installed and maintained in accordance with NFPA 25: There is a vestibule between the Emergency Room and the Ambulance Bay. The vestibule is sprinklered and has lay-in ceiling tiles. The ceiling tiles are displaced by wind or air pressure when a door is opened. This creates multiple 2' x 2' voids in the ceiling and compromises the sprinkler protection in this space. The ceiling lacks adequate hold-down clips to prevent displacement or the room lacks a ceiling that cannot be moved by wind or air pressure.

The sprinkler system will not perform as designed with missing ceiling tiles.

Findings Include:

A. Interim Life Safety Measures as an alternative to full compliance with NFPA 101 - 2000: Due to the severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under K020 and K029. Additionally, the frequency of the fire watch rounds identified by the provider were not adequate for the deficiencies observed.

B. The provider failed to provide and maintain a safe and sanitary environment for patients and staff.

1. 1st Floor Central Sterile is where surgical instruments are sterilized. The floors are covered with 12" x 12" vinyl tile and the ceiling has mylar faced lay in tiles with a gasketed grid system. The interior finishes in this space are damaged or deteriorated, as indicated below. Portions of the damaged floor finish were being repaired at the time of inspection.

a. The 12" x 12" vinyl floor tiles have
spread apart, (joints are not longer tight)
typically near any sterilizing equipment.
The open joints collect dirt and grime
and cannot be cleaned and sanitized.

b. The mylar ceilings are damaged with
small chips or flaps, throughout the
space and the mylar faced tiles are
severely damaged by high moisture and
heat with wrinkles and rips in the finish,
above one sterilizer.

3. Housekeeping is not adequate in many areas. This is evidence by:

a. The heavy build up of soap scum under
wall mounted soap dispensers in
multiple toilet rooms.

b. The general lack of cleanliness and build
up of mold in multiple patient shower
locations

c. The brown stains on the walls under
patient toilets in multiple locations that
appear to be leaks from the wall
mounted toilets

d. The grime on walls in the Trash
Compactor Room

e. The general conditions and lack of
cleanliness in the 1st Floor Kitchen and
Cafeteria which includes the observation
of heavy coats of grease, grime and food
products behind the cooking line, on the
walls of appliances in the cooking line,
on the floor of the cooking line and on
walls and cove bases where cleaning is
hard to reach or not immediately visible
without bending over.

4. The 1st Floor Kitchen and Cafeteria is not maintained in accordance with State or Nationally recognized food service and sanitation requirements:

a. See item 3a above

b. The only Janitor's Closet in Dietary had
a heavy build up of foreign material
and lacked a mop sink. The mop
sink in this space has been removed and
there is no dedicated mop sink for
Dietary.

c. The floor in Dietary is a wet location
that requires watertight joints and cove
bases. The cove bases are separated
from the walls in places and the cove
bases are cracked, chipped or missing
in multiple locations.

d. The cove base under stainless steel
cabinets in the Cafeteria is heavily coat
with grime, grease and food, roughly three
inches above the floor (where it cannot
be seen without bending over).

e. The joint at the floor between the walls
of the walk in coolers and freezers is
black and coated with something.

f. The intersection of fixed stainless steel
cabinets and counters has caulked joints
in some locations; many of these joints
have failed. Other locations with fixed
equipment at not sealed to the wall with
a water-tight joint. Cleaning behind such
locations is not possible.

5. Wall mounted toilets throughout the facility are not installed in accordance with the Plumbing Code and/or the manufacturer's requirements. The joint between the finish wall and the toilet is open and not sealed with a water resistant material. This allows moisture, cleaning fluids and debris to fall between the toiled and into the chase behind the toilet.

Findings Include:

A) Based upon observation, the surveyor finds that a 2nd Floor construction project has exposed several unprotected vertical openings in fire rated floor assemblies. These vertical openings were not protected either temporarily or permanently in accordance with 19.3.1.1. Interim Life Safety measures for this condition were not implemented (see also K130).

1) The 2nd Floor OB renovation project has demolished an area for a future reception area in the center of the wing. The demolition and construction have exposed a plumbing pipe chase. The floor penetrations of this pipe chase have open sleeves that are not sealed for fire rated construction and the space is open to the ceiling cavity of the floor below.

2) One 12" x 12" hole in the floor is covered with a piece of plywood. The hole in the floor is not protected as a fire rated assembly and the construction area is open to the ceiling cavity of the floor below.

3) One bundle of multiple wires and two insulated pipes penetrate the floor assembly; The three penetrations are not sealed for fire rated construction and the space is open to the ceiling cavity of the floor below. Fire or smoke can immediately and readily spread between floors without detection.

The above conditions will allow the spread of fire and smoke from floor to floor, undetected.

Findings Include:

A) Based upon observation, the surveyor finds that a 2nd Floor construction project has created a hazardous area (deemed hazardous based upon the use of temporary wiring, storage of construction materials and construction activities that include metal cutting). This hazardous area is not separated from all other areas by one hour fire rated construction. Interim Life Safety were not implemented for the deficiencies cited (see also K130).

The 2nd Floor OB renovation project has demolished an area for a future reception area in the center of the wing. The ceiling has been removed from this area and the sprinkler protection was not modified for this condition (pendent heads are now installed well below the deck above). The sprinkler system will not be effective as any kind of fire detection and will not activate in any kind of reasonable time frame to control a fire. With the current arrangement the exposed plastic sprinkler piping will probably fail before the heads go off.

The corridor walls around the construction area are drywalled on one side only. These walls do not comply with 19.3.2.1. There are multiple penetrations that are open to the ceiling cavities of the adjacent corridors (voids and openings are not sealed or closed off for one hour construction in accordance with 19.3.2.1 for a hazardous area). This will allow fire or smoke to spread undetected above ceilings in the required means of egress for patient occupied spaces.

The entire east wall of the construction area is open to the ceiling cavity of the adjacent corridor and elevator lobby.

This will allow fire and smoke to spread above ceiling cavities, undetected and will have an immediate impact on the means of egress for an adjacent nursery.

See also K020.

Findings Include:

A) Based upon observation the surveyor finds that the facility has locked doors in identified paths of egress that do not comply with 7.2.1.6:

1) The 3rd Floor center portion of the building is not a psychiatric area and allows free access via elevators to this portion of the building. There are multiple paths of egress from the center portion of the 3rd Floor. The exit paths to the west are directed with illuminated exit signs into a psychiatric unit.

a) The south corridor has an illuminated
exit sign above a door with a sign that
indicates "Do Not Enter" The two signs
conflict.

b) The north corridor has a door with an
illuminated exit sign. The door has
electronic locking hardware that does
not allow release within 15 seconds in
accordance with the provisions of
7.2.1.6.

Exit signs identify a path that is not available to everyone. The confusing identification of exit paths from this floor could cause a delay of evacuation during a fire particularly for any staff, patients or visitor that are not intimately familiar with this floor.

Findings Include:

A) Sprinkler systems are not installed and maintained in accordance with NFPA 25: There is a vestibule between the Emergency Room and the Ambulance Bay. The vestibule is sprinklered and has lay-in ceiling tiles. The ceiling tiles are displaced by wind or air pressure when a door is opened. This creates multiple 2' x 2' voids in the ceiling and compromises the sprinkler protection in this space. The ceiling lacks adequate hold-down clips to prevent displacement or the room lacks a ceiling that cannot be moved by wind or air pressure.

The sprinkler system will not perform as designed with missing ceiling tiles.

Findings Include:

A. Interim Life Safety Measures as an alternative to full compliance with NFPA 101 - 2000: Due to the severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under K020 and K029. Additionally, the frequency of the fire watch rounds identified by the provider were not adequate for the deficiencies observed.

B. The provider failed to provide and maintain a safe and sanitary environment for patients and staff.

1. 1st Floor Central Sterile is where surgical instruments are sterilized. The floors are covered with 12" x 12" vinyl tile and the ceiling has mylar faced lay in tiles with a gasketed grid system. The interior finishes in this space are damaged or deteriorated, as indicated below. Portions of the damaged floor finish were being repaired at the time of inspection.

a. The 12" x 12" vinyl floor tiles have
spread apart, (joints are not longer tight)
typically near any sterilizing equipment.
The open joints collect dirt and grime
and cannot be cleaned and sanitized.

b. The mylar ceilings are damaged with
small chips or flaps, throughout the
space and the mylar faced tiles are
severely damaged by high moisture and
heat with wrinkles and rips in the finish,
above one sterilizer.

3. Housekeeping is not adequate in many areas. This is evidence by:

a. The heavy build up of soap scum under
wall mounted soap dispensers in
multiple toilet rooms.

b. The general lack of cleanliness and build
up of mold in multiple patient shower
locations

c. The brown stains on the walls under
patient toilets in multiple locations that
appear to be leaks from the wall
mounted toilets

d. The grime on walls in the Trash
Compactor Room

e. The general conditions and lack of
cleanliness in the 1st Floor Kitchen and
Cafeteria which includes the observation
of heavy coats of grease, grime and food
products behind the cooking line, on the
walls of appliances in the cooking line,
on the floor of the cooking line and on
walls and cove bases where cleaning is
hard to reach or not immediately visible
without bending over.

4. The 1st Floor Kitchen and Cafeteria is not maintained in accordance with State or Nationally recognized food service and sanitation requirements:

a. See item 3a above

b. The only Janitor's Closet in Dietary had
a heavy build up of foreign material
and lacked a mop sink. The mop
sink in this space has been removed and
there is no dedicated mop sink for
Dietary.

c. The floor in Dietary is a wet location
that requires watertight joints and cove
bases. The cove bases are separated
from the walls in places and the cove
bases are cracked, chipped or missing
in multiple locations.

d. The cove base under stainless steel
cabinets in the Cafeteria is heavily coat
with grime, grease and food, roughly three
inches above the floor (where it cannot
be seen without bending over).

e. The joint at the floor between the walls
of the walk in coolers and freezers is
black and coated with something.

f. The intersection of fixed stainless steel
cabinets and counters has caulked joints
in some locations; many of these joints
have failed. Other locations with fixed
equipment at not sealed to the wall with
a water-tight joint. Cleaning behind such
locations is not possible.

5. Wall mounted toilets throughout the facility are not installed in accordance with the Plumbing Code and/or the manufacturer's requirements. The joint between the finish wall and the toilet is open and not sealed with a water resistant material. This allows moisture, cleaning fluids and debris to fall between the toiled and into the chase behind the toilet.