HospitalInspections.org

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or door on one of seven floors.

Findings include:

1. Observation on September 04, 2013 at 1:45 pm revealed that there is no clear building separation on the third floor between the Operating rooms going into the Maternity area. The area I was told had double doors that did not latch, no visible ratings on the door but glass did have 90 minute rated glass.

Interview with Maintenance Man 1 on September 04, 2013 at 1:45 pm confirmed the situation did occur.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and doors on two of six floors.

Findings include:

1. Observation on September 04, 2013 at 9:57 am revealed the double doors (building separation) from main patient registration 2 to tower lobby did not latch in their frames.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:57 am confirmed this condition exists.

2. Observation on September 04, 2013 at 1:45 pm revealed that there is no clear building separation on the third floor between the Operating rooms going into the Maternity area. The area I was told had double doors that did not latch, no visible ratings on the door but glass did have 90 minute rated glass.

Interview with Maintenance Man 1 on September 04, 2013 at 1:45 pm confirmed the situation did occur.

Based on observation and interview it was determined the facility failed to maintain building construction in one of one areas.

Findings include:

Observation on September 4, 2013 at 9:30 am, revealed that facility has a canopy attached to the building of noncombustible material that hangs over four feet from the building and lacks sprinkler protection.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:30 am, confirmed the type and length of the overhang.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant of four of six floors.

Findings include:

1. Observation on September 03, 2013 at 10:39 am revealed that the following doors did not latch in the frames, sixth floor Maintenance Paint room back corridor door.

Interview with the Maintenance Man 1 on September 03, 2013 at 10:39 am confirmed this condition exists.

2. Observation on September 03, 2013 at 10:46 am Old Operating room 6 door does not latch in its frame.

Interview with the Maintenance Man 1 on September 03, 2013 at 10:46 am confirmed this condition exists.

3. Observation on September 03, 2013 at 1:15 pm revealed that there was a penetration in the corridor wall above the fire bell, this building is only partially sprinklered.

Interview with MM1 on September 03, 2013 at 1:15 pm confirmed the hole in the corridor wall.

4. Observation on September 03, 2013 at 1:33 pm revealed that door S3412D and S3411 D corridor doors do not latch in their frame.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:33 pm confirmed this condition exists.

5. Observation on September 03, 2013 at 1:49 pm revealed that the 3B back Physicians office was wedged open with an unauthorized device door has a self closing device.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:49 pm confirmed this condition exists.

6. Observation on September 04, 2013 at 9:49 am revealed that the Nourishment door in Emergency room does not latch in its frame.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:49 am confirmed this condition exists.

Based on observation and interview, it was determined that the doors protecting the corridor opening in other than hazardous areas are not substantial doors or smoke resistant doors on three of seven floors.

Findings include:

1. Observation on September 04, 2013 at 1:53 pm revealed that Tower 7213 patient room door does not latch in its frame.

Interview with Maintenance Man 1 on September 04, 2013 at 1:53 pm confirmed the door did not latch.

2. Observation on September 05, 2013 between the hours of 9:00 am and 10:30 am revealed the following issues with the corridor doors.
a. T6224 door does not latch in its frame at 9:39 am.
b. T5202 ICU corridor door was extremely hard to close it was opened in the break away mode and took more than a two step operation to close the door. There was also a curtain draped in front of the door preventing the door being placed back in its non break away position.
c. On all ICU doors on the fifth floor the interior buttons are extremely difficult to open from the inside of the room if the door is latched to get out, tested at 10:00 am.

Interview with Maintenance Man 1 confirmed on September 05, 2013 at 10:30 am the doors did not function easily or as designed.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one (1) hour on two of six floors.

Findings include:

Observation on September 03, 2013 at 12:30 pm revealed the following, the interior trash chute door on 4X was blocked open because garbage (hose) was preventing it from closing.

Interview with the Maintenance Man 1 on September 03, 2012 confirmed this trash chute door was not self closing.

Observation on September 04, 2013 the soiled linen chute termination room, had linen bags blocking the chute door from closing.

Interview with Maintenance Man 1 confirmed on September 04, 2013 that the chute door was blocked open.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas on one of six floors.

Findings include:

Observation on September 04, 2013 at 10:44 am revealed that the Store room in the Lab department did not latch in its frame with a self closing device.

Interview with Maintenance Man 1 on September 04, 2013 at 10:45 am confirmed this condition exists.

Based on observation and interview the exit access is not readily accessible at all times on three of six floors but not limited to these floors.

1. Observation on September 03, 2013 at 9:42 am revealed that the clean utility room across from M6110W has a deadbolt installed on the door.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 9:42 am that the deadbolt is active on the door.

2. Observation on September 03, 2013 at 9:52 am patient room door has a working deadbolt on the door.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 9:52 am the deadbolt on the door.

3. Observation on September 03, 2013 at 10:30 am revealed the double exit/entrance doors for UPMC oncology has a working deadbolt.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 10:30 am confirmed the deadbolt.

4. Observation on September 03, 2013 at 11:17 am revealed that patient room M5122 and Clean Utility room on the fifth floor have working deadbolts.

Interview with the Maintenance Man 1 confirmed the working deadbolts on September 3, 2013 at 11:20 am.

5. Observation on September 03, 2013 at 1:26 pm revealed that M3116 D has a working dead bolt on the door.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:26 pm confirmed the working dead bolt.

6. Observation on September 04, 2013 at 9:37 am revealed the exit access door out of 2b has an active deadbolt.

Interview with Maintenance Man 1 on September 04, 2013 at 9:37 am confirmed the working deadbolt.

7. Observation on September 04, 2013 at 10:06 revealed multiple doors in the radiology department have active deadbolts on corridor doors.
A. Imaging support office
B. Radiology Assessment Office
C. Treatment in Radiology department

Interview with Maintenance Man 1 confirmed there were active deadbolts on the above doors.

Based upon document review and interview, the facility failed to provide a written plan for the protection of all patients in the event of an emergency on one of six floors.

Findings include:

Observation on September 03, 2013 at 1:30 pm revealed that two staff in the Geriatric Behavioral Unit did not know what keys unlocked the fire extinguishers. Interview with one staff about keys, she walked away to retrieve them two to three minutes later a different staff person approached with keys and none of those opened the fire extinguisher.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:35 pm confirmed that a couple of employees of this floor were unfamiliar with the written plan of protection for patients on this floor.

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

Findings include:

Observation on September 04, 2013 at 9:00 am revealed that the soiled utility linen chute room has a sprinkler pipe not capped off and a penetration around the sprinkler head itself. The pipe also had a shut off valve after the head, but this valve was not secured or electronically supervised.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:00 am confirmed the open sprinkler pipe.

Based on interview, it was determined the cooking equipment/facilities staff failed to know the emergency procedures on one of six floors.

Findings include:

Interview with kitchen staff on September 04, 2013 at 1:05 pm revealed that one staff was unfamiliar with procedures for manual activation of the extinguishing system over the cooking surface in the 2 Your Health Cafe.

Interview with the Maintenance Man 1 on September 04, 2013 at 1:05 pm confirmed the staff was unfamiliar with the ansul system.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas on one of six floors.

Findings include:

Observation on September 03, 2013 at 9:46 am in the sixth floor main soiled utility room there is an unsecured oxygen tank.

Interview with the Maintenance Man 1 on September 03, 2013 at 9:46 am confirmed that there is an unsecured oxygen tank.

Based upon observation and interview, it was determined the electrical wiring and/or equipment does not comply with NFPA 70, the National Electrical Code on one of six floors.

Findings include:

1. Observation on September 03, 2013 at 9:36 am, revealed that the wires for the computer in the drop down work stations were being frayed near room M6106W.

Interview with Maintenance Man 1 on September 03, 2013 at 9:36 am confirmed the wires being frayed by the drop down station.

2. Observation on September 03, 2013 at 9:40 am on the sixth floor across from the main nurses station there is an open 4x4 electrical box near the medical gas lines above the double smoke doors.

Interview with Maintenance Man 1 on September 03, 2013 at 9:40 am confirmed the missing cover plate.

3. Observation on September 03, 2013 at 10:06 am sixth floor main IS closet is missing two cover plates exposing the back wall.

Interview with the Maintenance Man 1 on September 03, 2013 confirmed the missing cover plates.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or door on one of seven floors.

Findings include:

1. Observation on September 04, 2013 at 1:45 pm revealed that there is no clear building separation on the third floor between the Operating rooms going into the Maternity area. The area I was told had double doors that did not latch, no visible ratings on the door but glass did have 90 minute rated glass.

Interview with Maintenance Man 1 on September 04, 2013 at 1:45 pm confirmed the situation did occur.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and doors on two of six floors.

Findings include:

1. Observation on September 04, 2013 at 9:57 am revealed the double doors (building separation) from main patient registration 2 to tower lobby did not latch in their frames.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:57 am confirmed this condition exists.

2. Observation on September 04, 2013 at 1:45 pm revealed that there is no clear building separation on the third floor between the Operating rooms going into the Maternity area. The area I was told had double doors that did not latch, no visible ratings on the door but glass did have 90 minute rated glass.

Interview with Maintenance Man 1 on September 04, 2013 at 1:45 pm confirmed the situation did occur.

Based on observation and interview it was determined the facility failed to maintain building construction in one of one areas.

Findings include:

Observation on September 4, 2013 at 9:30 am, revealed that facility has a canopy attached to the building of noncombustible material that hangs over four feet from the building and lacks sprinkler protection.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:30 am, confirmed the type and length of the overhang.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant of four of six floors.

Findings include:

1. Observation on September 03, 2013 at 10:39 am revealed that the following doors did not latch in the frames, sixth floor Maintenance Paint room back corridor door.

Interview with the Maintenance Man 1 on September 03, 2013 at 10:39 am confirmed this condition exists.

2. Observation on September 03, 2013 at 10:46 am Old Operating room 6 door does not latch in its frame.

Interview with the Maintenance Man 1 on September 03, 2013 at 10:46 am confirmed this condition exists.

3. Observation on September 03, 2013 at 1:15 pm revealed that there was a penetration in the corridor wall above the fire bell, this building is only partially sprinklered.

Interview with MM1 on September 03, 2013 at 1:15 pm confirmed the hole in the corridor wall.

4. Observation on September 03, 2013 at 1:33 pm revealed that door S3412D and S3411 D corridor doors do not latch in their frame.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:33 pm confirmed this condition exists.

5. Observation on September 03, 2013 at 1:49 pm revealed that the 3B back Physicians office was wedged open with an unauthorized device door has a self closing device.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:49 pm confirmed this condition exists.

6. Observation on September 04, 2013 at 9:49 am revealed that the Nourishment door in Emergency room does not latch in its frame.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:49 am confirmed this condition exists.

Based on observation and interview, it was determined that the doors protecting the corridor opening in other than hazardous areas are not substantial doors or smoke resistant doors on three of seven floors.

Findings include:

1. Observation on September 04, 2013 at 1:53 pm revealed that Tower 7213 patient room door does not latch in its frame.

Interview with Maintenance Man 1 on September 04, 2013 at 1:53 pm confirmed the door did not latch.

2. Observation on September 05, 2013 between the hours of 9:00 am and 10:30 am revealed the following issues with the corridor doors.
a. T6224 door does not latch in its frame at 9:39 am.
b. T5202 ICU corridor door was extremely hard to close it was opened in the break away mode and took more than a two step operation to close the door. There was also a curtain draped in front of the door preventing the door being placed back in its non break away position.
c. On all ICU doors on the fifth floor the interior buttons are extremely difficult to open from the inside of the room if the door is latched to get out, tested at 10:00 am.

Interview with Maintenance Man 1 confirmed on September 05, 2013 at 10:30 am the doors did not function easily or as designed.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one (1) hour on two of six floors.

Findings include:

Observation on September 03, 2013 at 12:30 pm revealed the following, the interior trash chute door on 4X was blocked open because garbage (hose) was preventing it from closing.

Interview with the Maintenance Man 1 on September 03, 2012 confirmed this trash chute door was not self closing.

Observation on September 04, 2013 the soiled linen chute termination room, had linen bags blocking the chute door from closing.

Interview with Maintenance Man 1 confirmed on September 04, 2013 that the chute door was blocked open.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas on one of six floors.

Findings include:

Observation on September 04, 2013 at 10:44 am revealed that the Store room in the Lab department did not latch in its frame with a self closing device.

Interview with Maintenance Man 1 on September 04, 2013 at 10:45 am confirmed this condition exists.

Based on observation and interview the exit access is not readily accessible at all times on three of six floors but not limited to these floors.

1. Observation on September 03, 2013 at 9:42 am revealed that the clean utility room across from M6110W has a deadbolt installed on the door.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 9:42 am that the deadbolt is active on the door.

2. Observation on September 03, 2013 at 9:52 am patient room door has a working deadbolt on the door.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 9:52 am the deadbolt on the door.

3. Observation on September 03, 2013 at 10:30 am revealed the double exit/entrance doors for UPMC oncology has a working deadbolt.

Interview with Maintenance Man 1 confirmed on September 03, 2013 at 10:30 am confirmed the deadbolt.

4. Observation on September 03, 2013 at 11:17 am revealed that patient room M5122 and Clean Utility room on the fifth floor have working deadbolts.

Interview with the Maintenance Man 1 confirmed the working deadbolts on September 3, 2013 at 11:20 am.

5. Observation on September 03, 2013 at 1:26 pm revealed that M3116 D has a working dead bolt on the door.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:26 pm confirmed the working dead bolt.

6. Observation on September 04, 2013 at 9:37 am revealed the exit access door out of 2b has an active deadbolt.

Interview with Maintenance Man 1 on September 04, 2013 at 9:37 am confirmed the working deadbolt.

7. Observation on September 04, 2013 at 10:06 revealed multiple doors in the radiology department have active deadbolts on corridor doors.
A. Imaging support office
B. Radiology Assessment Office
C. Treatment in Radiology department

Interview with Maintenance Man 1 confirmed there were active deadbolts on the above doors.

Based upon document review and interview, the facility failed to provide a written plan for the protection of all patients in the event of an emergency on one of six floors.

Findings include:

Observation on September 03, 2013 at 1:30 pm revealed that two staff in the Geriatric Behavioral Unit did not know what keys unlocked the fire extinguishers. Interview with one staff about keys, she walked away to retrieve them two to three minutes later a different staff person approached with keys and none of those opened the fire extinguisher.

Interview with the Maintenance Man 1 on September 03, 2013 at 1:35 pm confirmed that a couple of employees of this floor were unfamiliar with the written plan of protection for patients on this floor.

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

Findings include:

Observation on September 04, 2013 at 9:00 am revealed that the soiled utility linen chute room has a sprinkler pipe not capped off and a penetration around the sprinkler head itself. The pipe also had a shut off valve after the head, but this valve was not secured or electronically supervised.

Interview with the Maintenance Man 1 on September 04, 2013 at 9:00 am confirmed the open sprinkler pipe.

Based on interview, it was determined the cooking equipment/facilities staff failed to know the emergency procedures on one of six floors.

Findings include:

Interview with kitchen staff on September 04, 2013 at 1:05 pm revealed that one staff was unfamiliar with procedures for manual activation of the extinguishing system over the cooking surface in the 2 Your Health Cafe.

Interview with the Maintenance Man 1 on September 04, 2013 at 1:05 pm confirmed the staff was unfamiliar with the ansul system.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas on one of six floors.

Findings include:

Observation on September 03, 2013 at 9:46 am in the sixth floor main soiled utility room there is an unsecured oxygen tank.

Interview with the Maintenance Man 1 on September 03, 2013 at 9:46 am confirmed that there is an unsecured oxygen tank.

Based upon observation and interview, it was determined the electrical wiring and/or equipment does not comply with NFPA 70, the National Electrical Code on one of six floors.

Findings include:

1. Observation on September 03, 2013 at 9:36 am, revealed that the wires for the computer in the drop down work stations were being frayed near room M6106W.

Interview with Maintenance Man 1 on September 03, 2013 at 9:36 am confirmed the wires being frayed by the drop down station.

2. Observation on September 03, 2013 at 9:40 am on the sixth floor across from the main nurses station there is an open 4x4 electrical box near the medical gas lines above the double smoke doors.

Interview with Maintenance Man 1 on September 03, 2013 at 9:40 am confirmed the missing cover plate.

3. Observation on September 03, 2013 at 10:06 am sixth floor main IS closet is missing two cover plates exposing the back wall.

Interview with the Maintenance Man 1 on September 03, 2013 confirmed the missing cover plates.