HospitalInspections.org

Based on observations and staff interview, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames, which could endanger the patients, staff, and other building occupants.

The findings include:

On April 7, 2015 from 1:00 PM to 4:30 PM while on tour with facility staff, it was observed throughout the facility, multiple ceiling tiles which have become damaged and badly stained for the dropped ceiling grid, which maintains the smoke tight enclosure of the corridor. It was acknowledged during the observations by the Facility Plant Operations Director, that the ceiling grid tiles that are part of the corridor smoke barriers were damaged and in need of repair.

The following locations were observed, but are not limited to:

3rd floor Computer Classroom A
3rd floor Housekeeping across from Nurses' Station
3rd floor in Corridor outside Rm 3207
3rd floor in Corridor outside Rm 3401
3rd floor in Corridor outside Rm 3505
3rd floor in Corridor outside Rm 3511
2nd floor in Corridor outside Rm 2208
2nd floor in Corridor outside Rm 2108
2nd floor in Corridor outside Rm 2112
2nd floor in Corridor outside Rm 2116
2nd floor in Janitors Closet by Rm 2416
1st floor in Laboratory Waiting Lobby South
1st floor in Cafe Employee's Northeast Seating Area

Damaged ceiling grid tiles can lead to the failure of the smoke barrier assembly to properly resist passage of smoke or heat and allow for the accumulation of fire/smoke gases in an unprotected space, resulting in a possible smoke explosion, which is not in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.3, 19.7.6.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.

Based on observations, the facility failed to properly utilize a listed appliance in accordance with the terms of their listings and the manufacturer's instructions to protect a patient care area from cooking equipment, and which can result in a fire endangering the patients, staff, or other building occupants.

The findings include:

On April 7, 2015 at 3:11 PM while on tour with facility staff, it was observed, in the Occupational Therapy Kitchen, utilized for teaching rehabilitation skills for patients in cooking operations, multiple flammable and combustible items were stored on top of the residential range cooking surfaces including plastics and towels. The cooking top was observed to be electrically energized and operable. Per the manufacturer's safety instructions regarding storage in or on appliances, flammable materials should not be stored in an oven, warmer drawer, near surface units or in the storage drawer. This includes paper, plastic and cloth items, such as cookbooks, plasticware and towels, as well as flammable liquids. Do not store explosives, such as aerosol cans, on or near the range. Failure of the facility staff to follow the manufacturer's Owner's operating instructions, which can allow for a fire to develop quickly, endangering the patients or staff utilizing the space, or allow for an unwitnessed fire if the room is not occupied, which can spread to other parts of the facility. All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer's instructions in accordance with NFPA 96 (1998) 9-1.1, 9-1.2.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 4.6.12.3, 9.2.3, 19.3.2.6, 19.7.6.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.

Based on observations and staff interview, the facility failed to maintain proper testing of patient care medical equipment, which is used in patient care areas, and which allows for the use of anesthetizing piped-in medical gas, and which can lead to failure of the equipment and endanger the patients, staff, or other building occupants.

The findings include:

On April 7, 2015 from 1:00 PM to 4:30 PM while on tour with facility staff, it was observed, patient care medical equipment, stored in clean equipment rooms ready for use in patient care areas, which utilize a piped-in medical gas system, and which had bio-medical department inspection stickers that were out-of-date. Upon discovery, the Facility Plant Operations Director acknowledged that the equipment was out of compliance per the sticker date, and had the equipment removed and taken to the Bio-medical Services Department immediately.

The following equipment was observed:

3rd floor Clean Equipment Storage by Rm 3415 equipment service date due 2/2015
2nd floor Clean Equipment Storage by Rm 2215 equipment service date due 5/2014

During exit conference, Facility Plant Operations Director advised that the equipment found was on the Bio-medical services missing equipment list. All patient care medical electrical equipment capable of being utilized in anesthetizing locations shall be tested, inspected, and maintained in accordance with NFPA 99 (1999) 7-5.1.3, 9-2.1.7.3, 9-2.1.13, 12-3.7.1, 12-4.1, 12-4.1.2, 12-4.1.2.4, 12-4.1.2.9.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.

Based on observations and staff interview, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames, which could endanger the patients, staff, and other building occupants.

The findings include:

On April 7, 2015 from 1:00 PM to 4:30 PM while on tour with facility staff, it was observed throughout the facility, multiple ceiling tiles which have become damaged and badly stained for the dropped ceiling grid, which maintains the smoke tight enclosure of the corridor. It was acknowledged during the observations by the Facility Plant Operations Director, that the ceiling grid tiles that are part of the corridor smoke barriers were damaged and in need of repair.

The following locations were observed, but are not limited to:

3rd floor Computer Classroom A
3rd floor Housekeeping across from Nurses' Station
3rd floor in Corridor outside Rm 3207
3rd floor in Corridor outside Rm 3401
3rd floor in Corridor outside Rm 3505
3rd floor in Corridor outside Rm 3511
2nd floor in Corridor outside Rm 2208
2nd floor in Corridor outside Rm 2108
2nd floor in Corridor outside Rm 2112
2nd floor in Corridor outside Rm 2116
2nd floor in Janitors Closet by Rm 2416
1st floor in Laboratory Waiting Lobby South
1st floor in Cafe Employee's Northeast Seating Area

Damaged ceiling grid tiles can lead to the failure of the smoke barrier assembly to properly resist passage of smoke or heat and allow for the accumulation of fire/smoke gases in an unprotected space, resulting in a possible smoke explosion, which is not in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.3, 19.7.6.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.

Based on observations, the facility failed to properly utilize a listed appliance in accordance with the terms of their listings and the manufacturer's instructions to protect a patient care area from cooking equipment, and which can result in a fire endangering the patients, staff, or other building occupants.

The findings include:

On April 7, 2015 at 3:11 PM while on tour with facility staff, it was observed, in the Occupational Therapy Kitchen, utilized for teaching rehabilitation skills for patients in cooking operations, multiple flammable and combustible items were stored on top of the residential range cooking surfaces including plastics and towels. The cooking top was observed to be electrically energized and operable. Per the manufacturer's safety instructions regarding storage in or on appliances, flammable materials should not be stored in an oven, warmer drawer, near surface units or in the storage drawer. This includes paper, plastic and cloth items, such as cookbooks, plasticware and towels, as well as flammable liquids. Do not store explosives, such as aerosol cans, on or near the range. Failure of the facility staff to follow the manufacturer's Owner's operating instructions, which can allow for a fire to develop quickly, endangering the patients or staff utilizing the space, or allow for an unwitnessed fire if the room is not occupied, which can spread to other parts of the facility. All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer's instructions in accordance with NFPA 96 (1998) 9-1.1, 9-1.2.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 4.6.12.3, 9.2.3, 19.3.2.6, 19.7.6.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.

Based on observations and staff interview, the facility failed to maintain proper testing of patient care medical equipment, which is used in patient care areas, and which allows for the use of anesthetizing piped-in medical gas, and which can lead to failure of the equipment and endanger the patients, staff, or other building occupants.

The findings include:

On April 7, 2015 from 1:00 PM to 4:30 PM while on tour with facility staff, it was observed, patient care medical equipment, stored in clean equipment rooms ready for use in patient care areas, which utilize a piped-in medical gas system, and which had bio-medical department inspection stickers that were out-of-date. Upon discovery, the Facility Plant Operations Director acknowledged that the equipment was out of compliance per the sticker date, and had the equipment removed and taken to the Bio-medical Services Department immediately.

The following equipment was observed:

3rd floor Clean Equipment Storage by Rm 3415 equipment service date due 2/2015
2nd floor Clean Equipment Storage by Rm 2215 equipment service date due 5/2014

During exit conference, Facility Plant Operations Director advised that the equipment found was on the Bio-medical services missing equipment list. All patient care medical electrical equipment capable of being utilized in anesthetizing locations shall be tested, inspected, and maintained in accordance with NFPA 99 (1999) 7-5.1.3, 9-2.1.7.3, 9-2.1.13, 12-3.7.1, 12-4.1, 12-4.1.2, 12-4.1.2.4, 12-4.1.2.9.

These findings were confirmed with the Facility Plant Operations Director and Facility Maintenance Director during the exit conference on April 7, 2015 at 4:50 PM.