HospitalInspections.org

Based upon observation and interview, it was determined the building construction type and height does not meet regulations on one of seven floors.

Findings include:

Observation on April 29, 2014, at 12:55 pm revealed the fourth floor phone room had an unsealed penetration of the rated ceiling assembly.

Interview with Maintenance Technician (MT) on April 29, 2014, at 12:55 pm confirmed the unsealed penetration.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on three of seven floors.

Findings include:

Observation on April 29, 2014, between 10:35 am and 1:45 pm revealed corridor doors lacked positive latching at the following locations:
1. Patient room 714 (potty chair blocking door from closing and latching).
2. Patient room 613 (potty chair blocking door from closing and latching).
3. Third floor corridor door to lab lacks positive latching with the closure.

Interview with MT on April 29, 2014, at 1:45 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #2 at the time of the survey.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 11:20 am and 2:50 pm revealed hazardous area doors lack positive latching at the following locations:
A. Fourth floor O.R. soiled utility room door held open with unauthorized hold-open device.
B. Second floor radiology supply closet door.

Interview with MT on April 29, 2014, at 2:50 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #A during the time of the survey.

2. Observation on April 30, 2014, at 9:12 am revealed the second floor respiratory work room storage room was held open with an unauthorized hold-open device.

Interview with MT on April 30, 2014, at 9:12 am confirmed the storage room door was held open.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination on one of seven floors.

Findings include:

Observation on April 29, 2014, at 11:30 am revealed the fourth floor cardiac cath lab exit light was burned out.

Interview with MT on April 29, 2014, at 11:30 am confirmed the exit light was burned out.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per regulations on one of seven floors.

Findings include:

Observation on April 29, 2014, at 2:35 pm revealed the second floor ER equipment room lacks a fire sprinkler under duct that is wider than four feet.

Interview with MT on April 29, 2014, at 2:35 pm confirmed the duct lacked a fire sprinkler.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on four of seven floors.

Findings include:

1. Observation on April 29, 2014, between 10:50 am and 1:20 pm revealed fire sprinkler escutcheons missing at the following locations:
A. Patient room 608.
B. Patient room 325.

Interview with MT on April 29, 2014, at 1:20 pm confirmed the fire sprinkler escutcheons missing at the above listed locations.

2. Observation on April 30, 2014, at 8:30 am revealed the second floor MRI suite pre-action fire sprinkler system gauges have not been calibrated or replaced within the past five years.

Interview with MT on April 30, 2014, at 8:30 am confirmed the sprinkler system gauges have not been calibrated or replaced within the past five years.

3. Observation on April 30, 2014, at 10:05 am revealed the first floor Power Center 4 had a ceiling tile missing which may compromise fire sprinkler operation in case of fire.

Interview with MT on April 30, 2014, at 10:05 am confirmed the missing ceiling tile.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulation on one of seven floors.

Findings include:

Observation on April 30, 2014, at 9:10 am revealed the second floor pantry had a wet chemical fire extinguisher that was located behind a refrigerator and not readily accessible.

Interview with MT on April 30, 2014, at 9:10 am confirmed the fire extinguisher was not readily accessible.

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on two of seven floors.

Findings include:

Observation on April 29, 2014, between 10:10 am and 2:15 pm revealed the facility had items in the exit corridor that impede on the required clear and unobstructed corridor width at the following locations:
1. Seventh floor exit corridor (computer-on-wheels being charged in the corridor).
2. Seventh floor exit corridor (bed being stored by the exit stair tower).
3. Third floor ICU/Central Processing exit corridor (storage, beds, cribs, and total enclosure beds stored).

Interview with MT on April 29, 2014, at 2:15 pm confirmed the items in the exit corridor and the subsequent correction of Item #1 during the time of the survey.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 10:30 am and 12:40 pm revealed unsecured oxygen cylinders at the following locations:
A. Seventh floor pediatric clean prep room.
B. Fourth floor O.R. storage room.

Interview with MT on April 29, 2014, at 12:40 pm confirmed the unsecured oxygen cylinders at the above listed locations.

2. Observation on April 30, 2014, at 10:15 am revealed an unsecured Life Flight oxygen container in the first floor oxygen storage room.

Interview with MT on April 30, 2014, at 10:15 am confirmed the unsecured oxygen container.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 12:55 pm and 2:54 pm revealed the facility had unauthorized electrical configurations at the following locations:
A. Fourth floor phone room (surge protector plugged into another surge protector).
B. Utilization of a multiple outlet extension cord in the second floor x-ray reading office across from Diagnostic Service Nurse Coordinator.

Interview with MT on April 29, 2014, at 2:54 pm confirmed the unauthorized electrical configurations listed above.

2. Observation on April 30, 2014, at 8:40 am revealed the second floor MRI suite electrical panel in the closet across from dressing room 3 was blocked by storage.

Interview with MT on April 30, 2014, at 8:40 am confirmed the electrical panel was blocked by storage.

3. Observation on April 30, 2014, between 8:50 am and 10:30 am revealed the facility had unauthorized electrical devices plugged into surge protectors at the following locations:
A. Second floor radiologist reading room across from medical gas valve box (coffee pot plugged into a surge protector.
B. Second floor CENTREX (refrigerator plugged into a surge protector).
C. Second floor main lobby coffee kiosk (Extension cords and surge protectors. This area needs evaluated for proper electrical safe practices).
D. Lab waiting room (number machine plugged into a surge protector which is attached to the machine).
E. Second floor case management 1 (refrigerator plugged into a surge protector).
F. Second floor case management 2 (refrigerator plugged into a surge protector).
G. Physician lounge (refrigerator and coffee pot plugged into a surge protector).
H. Second floor medical records back area (toaster and coffee pot plugged into a surge protector).
I. Second floor medical records area next to Quality Initiatives & Resources (microwave oven plugged into a surge protector).
J. Second floor medical staff office (microwave oven plugged into a surge protector).
K. First floor materials management office (coffee pot plugged into an extension cord).
L. First floor Materials Management Director office (utilization of a multiple outlet extension cord).
M. First floor ER medical command radio room (surge protector hanging unsecured)
N. First floor operational excellence room (refrigerator and coffee pot plugged into a surge protector).

Interview with MT on April 30, 2014, at 10:30 am confirmed the electrical issues listed above.

Based upon observation and interview, it was determined the building construction type and height does not meet regulations on one of seven floors.

Findings include:

Observation on April 29, 2014, at 12:55 pm revealed the fourth floor phone room had an unsealed penetration of the rated ceiling assembly.

Interview with Maintenance Technician (MT) on April 29, 2014, at 12:55 pm confirmed the unsealed penetration.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on three of seven floors.

Findings include:

Observation on April 29, 2014, between 10:35 am and 1:45 pm revealed corridor doors lacked positive latching at the following locations:
1. Patient room 714 (potty chair blocking door from closing and latching).
2. Patient room 613 (potty chair blocking door from closing and latching).
3. Third floor corridor door to lab lacks positive latching with the closure.

Interview with MT on April 29, 2014, at 1:45 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #2 at the time of the survey.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 11:20 am and 2:50 pm revealed hazardous area doors lack positive latching at the following locations:
A. Fourth floor O.R. soiled utility room door held open with unauthorized hold-open device.
B. Second floor radiology supply closet door.

Interview with MT on April 29, 2014, at 2:50 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #A during the time of the survey.

2. Observation on April 30, 2014, at 9:12 am revealed the second floor respiratory work room storage room was held open with an unauthorized hold-open device.

Interview with MT on April 30, 2014, at 9:12 am confirmed the storage room door was held open.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination on one of seven floors.

Findings include:

Observation on April 29, 2014, at 11:30 am revealed the fourth floor cardiac cath lab exit light was burned out.

Interview with MT on April 29, 2014, at 11:30 am confirmed the exit light was burned out.

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per regulations on one of seven floors.

Findings include:

Observation on April 29, 2014, at 2:35 pm revealed the second floor ER equipment room lacks a fire sprinkler under duct that is wider than four feet.

Interview with MT on April 29, 2014, at 2:35 pm confirmed the duct lacked a fire sprinkler.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on four of seven floors.

Findings include:

1. Observation on April 29, 2014, between 10:50 am and 1:20 pm revealed fire sprinkler escutcheons missing at the following locations:
A. Patient room 608.
B. Patient room 325.

Interview with MT on April 29, 2014, at 1:20 pm confirmed the fire sprinkler escutcheons missing at the above listed locations.

2. Observation on April 30, 2014, at 8:30 am revealed the second floor MRI suite pre-action fire sprinkler system gauges have not been calibrated or replaced within the past five years.

Interview with MT on April 30, 2014, at 8:30 am confirmed the sprinkler system gauges have not been calibrated or replaced within the past five years.

3. Observation on April 30, 2014, at 10:05 am revealed the first floor Power Center 4 had a ceiling tile missing which may compromise fire sprinkler operation in case of fire.

Interview with MT on April 30, 2014, at 10:05 am confirmed the missing ceiling tile.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulation on one of seven floors.

Findings include:

Observation on April 30, 2014, at 9:10 am revealed the second floor pantry had a wet chemical fire extinguisher that was located behind a refrigerator and not readily accessible.

Interview with MT on April 30, 2014, at 9:10 am confirmed the fire extinguisher was not readily accessible.

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on two of seven floors.

Findings include:

Observation on April 29, 2014, between 10:10 am and 2:15 pm revealed the facility had items in the exit corridor that impede on the required clear and unobstructed corridor width at the following locations:
1. Seventh floor exit corridor (computer-on-wheels being charged in the corridor).
2. Seventh floor exit corridor (bed being stored by the exit stair tower).
3. Third floor ICU/Central Processing exit corridor (storage, beds, cribs, and total enclosure beds stored).

Interview with MT on April 29, 2014, at 2:15 pm confirmed the items in the exit corridor and the subsequent correction of Item #1 during the time of the survey.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 10:30 am and 12:40 pm revealed unsecured oxygen cylinders at the following locations:
A. Seventh floor pediatric clean prep room.
B. Fourth floor O.R. storage room.

Interview with MT on April 29, 2014, at 12:40 pm confirmed the unsecured oxygen cylinders at the above listed locations.

2. Observation on April 30, 2014, at 10:15 am revealed an unsecured Life Flight oxygen container in the first floor oxygen storage room.

Interview with MT on April 30, 2014, at 10:15 am confirmed the unsecured oxygen container.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on three of seven floors.

Findings include:

1. Observation on April 29, 2014, between 12:55 pm and 2:54 pm revealed the facility had unauthorized electrical configurations at the following locations:
A. Fourth floor phone room (surge protector plugged into another surge protector).
B. Utilization of a multiple outlet extension cord in the second floor x-ray reading office across from Diagnostic Service Nurse Coordinator.

Interview with MT on April 29, 2014, at 2:54 pm confirmed the unauthorized electrical configurations listed above.

2. Observation on April 30, 2014, at 8:40 am revealed the second floor MRI suite electrical panel in the closet across from dressing room 3 was blocked by storage.

Interview with MT on April 30, 2014, at 8:40 am confirmed the electrical panel was blocked by storage.

3. Observation on April 30, 2014, between 8:50 am and 10:30 am revealed the facility had unauthorized electrical devices plugged into surge protectors at the following locations:
A. Second floor radiologist reading room across from medical gas valve box (coffee pot plugged into a surge protector.
B. Second floor CENTREX (refrigerator plugged into a surge protector).
C. Second floor main lobby coffee kiosk (Extension cords and surge protectors. This area needs evaluated for proper electrical safe practices).
D. Lab waiting room (number machine plugged into a surge protector which is attached to the machine).
E. Second floor case management 1 (refrigerator plugged into a surge protector).
F. Second floor case management 2 (refrigerator plugged into a surge protector).
G. Physician lounge (refrigerator and coffee pot plugged into a surge protector).
H. Second floor medical records back area (toaster and coffee pot plugged into a surge protector).
I. Second floor medical records area next to Quality Initiatives & Resources (microwave oven plugged into a surge protector).
J. Second floor medical staff office (microwave oven plugged into a surge protector).
K. First floor materials management office (coffee pot plugged into an extension cord).
L. First floor Materials Management Director office (utilization of a multiple outlet extension cord).
M. First floor ER medical command radio room (surge protector hanging unsecured)
N. First floor operational excellence room (refrigerator and coffee pot plugged into a surge protector).

Interview with MT on April 30, 2014, at 10:30 am confirmed the electrical issues listed above.