HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to prevent the passage of smoke from suite into the egress corridor. Louver allowed the transfer of air through lower part of the door at eleventh floor storage room.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility lacked an exit sign marking the exit path from the 1) Cardiac cath lab, near the soiled utility and 2) Biomed exit door and 3) second floor endoscopy corridor and 4) Reeves conference room/classroom and 5) seventh floor mental health wing.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. Cardiac cath lab soiled utility door and seventh floor west storage door positive latching hardware was not latching in the door frame. Seventh floor east ' s soiled utility room positive latching hardware was not latching in the door frame and had no closure. Seventh floor storage room had no closure. Both ninth floor 1) south clean linen and 2) east linen closet double doors did not latch. Eleventh floor ' s chute room door was missing a closure. Twelfth floor chute room door positive latching hardware was not latching in the door frame. Eleventh floor linen closet 1155 did not latch.

Based on observations during the survey walk of the facility on the afternoon of 1/08/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to assure the protection of a hazardous room. Cardiac cath lab clean linen door lacked a self-closing or automatic-closing device. Doors to hazardous areas shall be self-closing or automatic-closing.


Based on observations during the survey walk of the facility on the days of 1/08/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was either not operational or not provided at the morgue corridor door and at eighth floor soiled utility door.

Based on observations during the survey walk of the facility on the days of 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide egress direction. Exit sign ' s light was not lit near second floor angio room and sixth floor D elevator lobby.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility lacked an exit sign marking the exit path from the 1) Cardiac cath lab, near the soiled utility and 2) Biomed exit door and 3) second floor endoscopy corridor and 4) Reeves conference room/classroom and 5) seventh floor mental health wing.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the morgue ' s freezer. This room appeared to be greater than 100 square feet. The freezer door did not have a closure. This room requires either a fire sprinkler system or a fire rated door with self-closing device.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a sprinklered smoke compartment. Sublevel ' s radiation room and first floor emergency department emergency med toilet and its department ' s patient belonging room and hearing room and the mechanical room near the hearing room were all missing a sprinkler heads. Additionally sprinkler heads were missing from first floor IT room, near lab blood draw and the gift shop staff toilet.

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility, the facility failed to provide a clear and unobstructed egress corridor. Tenth floor corridor had equipment impeding into the egress path

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the medical gas room. Receptacle was located in the wall below 5 ' above finished floor at the eleventh floor ' s nitro tank medical gas room. NFPA 99; 1999: 4-5.1.1.2 ..... Electrical wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage.

Based on observations during the survey walk of the facility on the days of 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the egress corridor. Medical gas outlets are open to 1) second floor egress corridor at Recovery department and 2) large rehab area and 3) at IPCU. NFPA 101, 2000, 19.3.6.1 .....Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5(see also 19.2.5.9), unless otherwise permitted by the following:(1)Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
Also applicable is NFPA 101: 2003: 19.2.5.8 ... ... Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervenieng room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.


Based on observations during the survey walk of the facility on the afternoon of 1/09/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the egress corridor. An egress route to exterior exit access doors went through a hazardous area, which included many boxes and mattresses.

Based on review of records during the survey of facility on the afternoon of 1/9/2013, while being accompanied by Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility, the facility failed to provide accurate documentation of the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually and biannually in critical care areas. Facility must initiate a log to retain these records.

106
Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a distinctive color at the generator's emergency system electrical receptacle. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panelboard.
The existing electrical receptacle at the emergency generator was white in color.

106
Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to properly identify emergency electrical panels in the 1968 portion of the facility (panel ecSL02). The emergency electrical panels (EES) shall be readily identifiable as a component of the essential electrical system and shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to prevent the passage of smoke from suite into the egress corridor. Louver allowed the transfer of air through lower part of the door at eleventh floor storage room.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility lacked an exit sign marking the exit path from the 1) Cardiac cath lab, near the soiled utility and 2) Biomed exit door and 3) second floor endoscopy corridor and 4) Reeves conference room/classroom and 5) seventh floor mental health wing.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. Cardiac cath lab soiled utility door and seventh floor west storage door positive latching hardware was not latching in the door frame. Seventh floor east ' s soiled utility room positive latching hardware was not latching in the door frame and had no closure. Seventh floor storage room had no closure. Both ninth floor 1) south clean linen and 2) east linen closet double doors did not latch. Eleventh floor ' s chute room door was missing a closure. Twelfth floor chute room door positive latching hardware was not latching in the door frame. Eleventh floor linen closet 1155 did not latch.

Based on observations during the survey walk of the facility on the afternoon of 1/08/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to assure the protection of a hazardous room. Cardiac cath lab clean linen door lacked a self-closing or automatic-closing device. Doors to hazardous areas shall be self-closing or automatic-closing.


Based on observations during the survey walk of the facility on the days of 1/08/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was either not operational or not provided at the morgue corridor door and at eighth floor soiled utility door.

Based on observations during the survey walk of the facility on the days of 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide egress direction. Exit sign ' s light was not lit near second floor angio room and sixth floor D elevator lobby.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility lacked an exit sign marking the exit path from the 1) Cardiac cath lab, near the soiled utility and 2) Biomed exit door and 3) second floor endoscopy corridor and 4) Reeves conference room/classroom and 5) seventh floor mental health wing.
If the solution requires adding an EXIT light, provide power from the Life Safety Branch of the EES to meet the requirements of NFPA 99

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the morgue ' s freezer. This room appeared to be greater than 100 square feet. The freezer door did not have a closure. This room requires either a fire sprinkler system or a fire rated door with self-closing device.

Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a sprinklered smoke compartment. Sublevel ' s radiation room and first floor emergency department emergency med toilet and its department ' s patient belonging room and hearing room and the mechanical room near the hearing room were all missing a sprinkler heads. Additionally sprinkler heads were missing from first floor IT room, near lab blood draw and the gift shop staff toilet.

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility, the facility failed to provide a clear and unobstructed egress corridor. Tenth floor corridor had equipment impeding into the egress path

Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the medical gas room. Receptacle was located in the wall below 5 ' above finished floor at the eleventh floor ' s nitro tank medical gas room. NFPA 99; 1999: 4-5.1.1.2 ..... Electrical wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage.

Based on observations during the survey walk of the facility on the days of 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the egress corridor. Medical gas outlets are open to 1) second floor egress corridor at Recovery department and 2) large rehab area and 3) at IPCU. NFPA 101, 2000, 19.3.6.1 .....Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5(see also 19.2.5.9), unless otherwise permitted by the following:(1)Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
Also applicable is NFPA 101: 2003: 19.2.5.8 ... ... Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervenieng room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.


Based on observations during the survey walk of the facility on the afternoon of 1/09/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to protect the egress corridor. An egress route to exterior exit access doors went through a hazardous area, which included many boxes and mattresses.

Based on review of records during the survey of facility on the afternoon of 1/9/2013, while being accompanied by Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility, the facility failed to provide accurate documentation of the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually and biannually in critical care areas. Facility must initiate a log to retain these records.

106
Based on observations during the survey walk of the facility on the morning of 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to provide a distinctive color at the generator's emergency system electrical receptacle. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panelboard.
The existing electrical receptacle at the emergency generator was white in color.

106
Based on observations during the survey walk of the facility on the days of 1/08/2013, 1/9/2013 and 1/10/2013, while being accompanied by the Director of Risk Management, Facilities Director, Director of Facility Maintenance and several staff members from the facility; the facility failed to properly identify emergency electrical panels in the 1968 portion of the facility (panel ecSL02). The emergency electrical panels (EES) shall be readily identifiable as a component of the essential electrical system and shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.