HospitalInspections.org

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the rating of structural support beams as required.

Findings:

Six inch by one foot sections of fire proofing were observed to be missing from structural support members exposed in electrical rooms.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the fire rating of the patient tower four story stairwell as required.

Findings:

Non-rated fire extinguisher cabinets on all four floors were observed to be installed in the corridor through the stairwell walls. The cabinets did not provide the required 2 hour fire rating.

These observations were made in the presence of the Director of Plant Operations.

This deficiency was corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide exit signs at all required locations per CMS regulations.

Findings:

An exit sign was observed to be lacking at the cross corridor doors at the 2nd floor tower addition.

This observation was made in the presence of the Director of Plant Operations.

This deficiency was corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain exit doors to be readily accessible at all times as required.

Findings:

Hook latch deadbolts were observed installed on the main and auxiliary entrance powered sliding doors to the hospital. When closed and latched, the break-a-away function of the doors was rendered inoperable.

These observations were made in the presence of the Director of Plant Operations.

These hook latch deadbolts were removed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide smoke detection at all required locations per CMS requirements.

Findings:

Integrated smoke detection was observed to be lacking at two auxiliary fire alarm panels.

These observations were made in the presence of the Director of Plant Operations.

The smoke detectors were installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide smoke detection at all required locations per CMS requirements.

Findings:

Integrated smoke detection was observed to be lacking in the 3rd floor west storage room auxiliary fire alarm panel location.

This observation was made in the presence of the Director of Plant Operations.

The smoke detector was installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide fire sprinkler coverage at all required locations in accordance with NFPA 13 and per CMS requirements.

Findings:

Sprinkler coverage was lacking in the walk-in freezer and in the radiology electrical room.

These observations were made in the presence of the Director of Plant Operations.

The sprinkler heads were installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the fire sprinkler system in accordance with NFPA 13 and per CMS requirements.

Findings:

1. Sprinkler heads were observed to be installed within 4' of each other in the ultrasound room.

2. Numerous sprinkler escutcheons were observed to be missing in the kitchen and pantry areas.

These observations were made in the presence of the Director of Plant Operations.

These two items were corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not prohibit the use of portable electric heating devices per CMS regulations.

Findings:

Portable electric heaters were observed in use in the patholgy area and in the physician dictation area.

These observations were made in the presence of the Director of Plant Operations.

The electric heaters were removed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain vertically displayed fabrics to be flame resistant per CMS requirements.

Findings:

1. Three 3' by 5' fabric tapestries displayed on the wall in the 3rd floor classroom were lacking documentation to verify that the fabric was either inherently flame retardant or treated to be flame resistant.

2. Fabric window valences above windows in patient rooms were lacking documentation to verify that the valences were flame resistant.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain and install electrical equipment in accordance with NFPA 70 and per CMS requirements.

Findings:

1. Extension cords were observed in use in the following locations: the 4th floor refrigerator in the Director's office, the 3rd floor respiratory offices, and the PBX area.

2. Daisy-chained powertaps were observed in use in the PBX office area.

These observations were made in the presence of the Director of Plant Operations.

The extension cords and the interconnected powertaps were removed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the rating of structural support beams as required.

Findings:

Six inch by one foot sections of fire proofing were observed to be missing from structural support members exposed in electrical rooms.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the fire rating of the patient tower four story stairwell as required.

Findings:

Non-rated fire extinguisher cabinets on all four floors were observed to be installed in the corridor through the stairwell walls. The cabinets did not provide the required 2 hour fire rating.

These observations were made in the presence of the Director of Plant Operations.

This deficiency was corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide exit signs at all required locations per CMS regulations.

Findings:

An exit sign was observed to be lacking at the cross corridor doors at the 2nd floor tower addition.

This observation was made in the presence of the Director of Plant Operations.

This deficiency was corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain exit doors to be readily accessible at all times as required.

Findings:

Hook latch deadbolts were observed installed on the main and auxiliary entrance powered sliding doors to the hospital. When closed and latched, the break-a-away function of the doors was rendered inoperable.

These observations were made in the presence of the Director of Plant Operations.

These hook latch deadbolts were removed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide smoke detection at all required locations per CMS requirements.

Findings:

Integrated smoke detection was observed to be lacking at two auxiliary fire alarm panels.

These observations were made in the presence of the Director of Plant Operations.

The smoke detectors were installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide smoke detection at all required locations per CMS requirements.

Findings:

Integrated smoke detection was observed to be lacking in the 3rd floor west storage room auxiliary fire alarm panel location.

This observation was made in the presence of the Director of Plant Operations.

The smoke detector was installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not provide fire sprinkler coverage at all required locations in accordance with NFPA 13 and per CMS requirements.

Findings:

Sprinkler coverage was lacking in the walk-in freezer and in the radiology electrical room.

These observations were made in the presence of the Director of Plant Operations.

The sprinkler heads were installed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain the fire sprinkler system in accordance with NFPA 13 and per CMS requirements.

Findings:

1. Sprinkler heads were observed to be installed within 4' of each other in the ultrasound room.

2. Numerous sprinkler escutcheons were observed to be missing in the kitchen and pantry areas.

These observations were made in the presence of the Director of Plant Operations.

These two items were corrected during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not prohibit the use of portable electric heating devices per CMS regulations.

Findings:

Portable electric heaters were observed in use in the patholgy area and in the physician dictation area.

These observations were made in the presence of the Director of Plant Operations.

The electric heaters were removed during the survey.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain vertically displayed fabrics to be flame resistant per CMS requirements.

Findings:

1. Three 3' by 5' fabric tapestries displayed on the wall in the 3rd floor classroom were lacking documentation to verify that the fabric was either inherently flame retardant or treated to be flame resistant.

2. Fabric window valences above windows in patient rooms were lacking documentation to verify that the valences were flame resistant.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 09/07/10, the hospital did not maintain and install electrical equipment in accordance with NFPA 70 and per CMS requirements.

Findings:

1. Extension cords were observed in use in the following locations: the 4th floor refrigerator in the Director's office, the 3rd floor respiratory offices, and the PBX area.

2. Daisy-chained powertaps were observed in use in the PBX office area.

These observations were made in the presence of the Director of Plant Operations.

The extension cords and the interconnected powertaps were removed during the survey.