HospitalInspections.org

Based on observation during facility tour and staff verification it was determined this facility failed to ensure patient room doors and corridor room doors were held open only by devices arranged to automatically close the door and that doors in vertical openings latched shut upon closing. This had the potential to affect all those who were utilizing these areas of this facility. The facility census was 213 at the beginning of the survey.


Findings include:


On 02/29/12 between the hours of 1:40 P.M. and 4:00 P.M., tour of the first floor medical oncology area was completed with staff BB and CC. Observation was made in a medical records storage area which housed a significant amount of combustible medical records files. Upon entrance to the area, a small portable paper shredder was noted to be holding the door to the medical record storage room in the open position. Staff BB verified the paper shredder was not to be holding the door open.

Staff BB informed a supervisor in the area the door to the medical record storage area could not be blocked in the open position with any unapproved device. On 03/01/12 between 8:40 AM and 3:10 P.M. tour of the first floor continued. When again passing through the medical oncology area, the door to the medical records storage area was observed to be held open by the portable paper shredder.


21957

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour observation was made of several doors that failed to close and latch properly, doors which were held open with unapproved devices and one door which failed to positive latch shut. They were observed in the following locations:

Third floor:
*South door of a large meeting room located within the Gero Psychiatry area was observed to be equipped with a self closing device. This door was observed to be propped open with a trash can.

*Office door within the coumadin clinic was observed to be equipped with a self closing device and was propped open with a wood wedge.

*Patient room number 366 on 3-West oncology was observed to have a door equipped with a self closing device. Observation was also made of an isolation supply kit hanging from the top of the door and a stethoscope hung over the outer door handle. This door failed to close shut properly when tested due to both the stethoscope inhibiting the latching mechanism and the metal hanger overlapping the top of the door rubbing against the top of the door frame.

*Patient room number 365 on 3-West oncology was observed to have a door equipped with a self closing device. Observation was also made of an isolation supply kit hanging from the top of the door. This door failed to close shut properly when tested due to the metal hanger overlapping the top of the door rubbing against the top of the door frame.

These findings were verified by staff members AA and DD during tour. Staff AA removed all items identified which were inhibiting the proper closing of the doors with exception of the isolation kits.


Second floor:
*Doors to room numbers 200 and 202 located between 2 North and 2 West failed to latch shut properly.

*Stairwell door which commuted to the third floor surgery locker rooms failed to latch shut.

*Two doors equipped with self closing devices within the surgery department were observed to be propped open using a chair and a wood wedge.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Potentially all patients and visitors could be affected. The facility had a census of 213 patients at the time of the survey.

Findings included:

On 03/01/12 between the hours of 8:40 A.M. and 12:00 P.M. tour of the emergency department was completed with Staff BB and CC. Observation of the emergency department revealed an area identified as rapid assessment. The rapid assessment area was observed to have an area where patients were initially assessed, then if needed, taken into another area for further treatment. The second area was observed to be a large room with private areas provided by curtains. The room had at least five doors, one of which lead to another small room in the emergency department.

While in the second area with the multiple doors it was observed that no exit signage was visible which would indicated the way out of the area. Staff BB present in the area verified there was no visible signage to indicate how to exit the area.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire rated protection. Additionally, the corridor walls were observed to have penetrations. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 213.


Findings include:


First Floor

On 03/01/12 between the hours of 8:40 A.M. and 3:10 P.M., tour of the first floor was completed with Staff BB and CC. Observation of the first floor revealed penetrations located in the radiology/emergency department corridor walls. The corridor was not provided with sprinkler system protection.

Observation above the ceiling tiles of the corridor revealed three penetrations approximately 2 to 3 inches in diameter. Staff BB and CC repaired the penetrations later in the day on 03/01/12.

Basement

On 02/28/12 between 3:10 P.M. and 5:00 P.M. and on 02/29/12 between 9:00 A.M. and 12:00 P.M. tour of the basement level of the facility was completed with Staff BB and FF. The following penetrations were observed above the ceiling tiles in fire rated barrier walls;

1. A penetration approximately 12 inches square was observed in a two hour fire rated wall located in the IT office. Unsealed areas were noted surrounding three conduits and an orange cable line which went through the fire rated walls.

2. Penetrations were observed in the one hour fire rated walls in the central sterile storage area. One fire rated wall had one penetration estimated to be approximately one inch by two inches in size. Unsealed open areas surrounded two conduits and a wire which went through the fire rated wall. In another one hour fire rated wall which surrounded the room was other unsealed areas which surrounded two pipes which went through the wall.

3. A penetration was observed in the smoke barrier wall located across from the nutritional area which surrounded a square electrical box.

Staff present on tour observed and verfied the findings.


21957


Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour observation was made of several penetrations located above the ceiling tiles within the half hour fire rated smoke barrier in the following locations:

Third floor:

*Within the group room in the Gero Psychiatry department observation was made of an open end conduit.

*Within room B-314 observation was made of eight penetrations around I-beams and conduits. Additionally, an approximate one inch hole was observed in the drywall.

*Within room B-310 observation was made of three unsealed conduits.

*Just outside and to the south of the physician's office waiting area of building B and above the one foot square tiles, observation was made of one unsealed conduit and a small hole.

*Across from room B-305, observation was made of two unsealed conduits. Additionally, near the fire extinguisher sign, observation was made of an unsealed half inch conduit.

*Across from the main lobby elevators observation was made of three unsealed conduits.



Second floor:
*Within the critical care unit (CCU) staff lounge observation was made of an unsealed pneumatic tube passing through the south wall.

*Within the CCU clean supply room observation was made of an unsealed pneumatic tube passing through the west wall.

*Within the corridor located between the Harding Center CCU and Cath Lab, observation was made of an unsealed sanitary line near the cath lab door.

*Outside of the respiratory care gas lab observation was made of an approximate four inch unsealed conduit where it passes through the drywall and also the inner diameter of the conduit was not sealed.

*Within the corridor located between the Harding Center CCU and Cath Lab and across from the electrical closet, observation was made of two unsealed I-beams and a three inch square opening.

*Within the corridor located between the Harding Center CCU and Cath Lab at the south end across from stairwell E, observation was made of an approximate 10 inch by six inch hole adjacent to the sanitary line. Additionally, a small unsealed area on the top of the duct was observed.

*Above the step down intensive care unit's (SICU) clinical manager office door observation was made of an unsealed plastic pipe. Above the double doors in the same area observation was made of a four inch unsealed conduit with wires passing through.

*At the SICU west entrance observation was made of a three inch open end conduit and a one inch open end conduit.

*Above the smoke barrier doors dividing the pre-op area from the surgery support area, observation was made of four three inch conduits which did not have the inner diameter sealed.

*At the north end of the corridor dividing the PACU from the operating rooms, observation was made of one unsealed steel support bracket.

*At the south end of the corridor dividing the surgery support from the operating rooms and near the data communication room, observation was made of an unsealed insulated line above the duct passing through the drywall.

*Within the surgery waiting area approximately 20 feet from the stairs, observation was made of one unsealed copper line.

*Within the 2 west large supply room located outside the waiting area, observation was made of one unsealed silver conduit.

*At the gross lab area within the smoke barrier, observation was made of a 24 inch square metal frame which housed a pass through sliding glass window. This window and frame lacked a fire resistance rating.



These findings were verified by staff AA and DD during tour.

21957

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous area, specifically one soiled utility room door was not closing properly and another door lacked a self-closing device. This had the potential to affect all those utilizing this area of the facility. The facility patient census was 213 at the beginning of the survey.

Findings include:

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour of the second floor sub-acute care unit, observation was made of the soiled utility room door failing to close and latch shut. This door was also located within the smoke barrier. Staff AA and DD verified this finding during tour.

On 02/29/12 between the hours of 1:40 P.M. and 4:00 P.M., tour of the first floor medical oncology area was completed with Staff BB and CC. Observation of the area revealed a soiled utility room complete with an automatic sprinkler system. The door to the soiled utility room was in the open position. Observation of the door to the room revealed there was no self-closing mechanism in place on the door. Staff BB and CC verified the door to the soiled utility room was identified as needing a self-closing device.

Based on facility observation and staff interview and verification the facility failed to ensure that patient room doors were arranged so that the patient could open the door from inside without using a key. The facility had a census of 15 patients at the time of the survey.

Findings included:

On 02/28/12 at 1:45 P.M., tour and observation of the facility was initiated with Staff BB and EE. Observation of the facility revealed the presence of two seclusion rooms utilized for acute patient conditions. Located next to the seclusion rooms was another room identified as a holding or observation room. A patient was observed to be soundly sleeping in the room with the door open.

Observation of the door to the room revealed the presence of a deadbolt type lock which required a key. Staff present on tour indicated the dead bolt type lock was only locked when the room was empty in order to prevent patients from wandering into the room. Staff demonstrated how the lock functioned which revealed anyone inside the room would not be able to exit the room when the door was locked.

Staff from the facility further verified that patients use the room if they do not wish to share a room with another patient or their condition prevents them from sharing a patient room.

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. The facility had a census of 213 patients at the time of the survey.

Findings included:

On 03/01/12 between the hours of 8:40 A.M. and 3:10 P.M., tour of the laboratory area revealed a small closet type room which housed two H sized tanks of carbon dioxide. The storage room was located within a corridor outside the laboratory of the hospital.

Observation of the inside of the closet area revealed two H sized tanks of carbon dioxide. In addition to the tanks was storage bags of Christmas decorations. Staff BB and CC present on tour verified the presence of the Christmas decorations and that the decorations were not to be stored in the medical gas storage closet.

Emergency illumination is provided in accordance with 39.2.9.1

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regard to documentation of monthly and yearly testing. The facility was an offsite location which provided outpatient therapy services, MRI testing and a community fitness facility.

Findings included:

On 02/28/12 between 10:50 A.M. and 12:00 P.M. tour of the facility and review of facility documentation was completed with Staff BB and FF. Observation of the facility revealed there was no emergency generator for provision of lighting in the event of a power outage. Battery powered emergency lighting was observed throughout the facility.

Review of facility information revealed documented evidence that battery powered emergency lighting was tested quarterly. There was no indication that testing was completed for 30 seconds per month or that testing was completed for 90 minutes per year.

Interview of Staff FF verfied that battery back-up lighting was tested quarterly and that there was no documentation to indicate the amount of time for the testing.

Based on observation and staff interview it was determined this facility failed to ensure the existing elevators conform with Firefighter's Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators and the National Fire Protection Association 101 Chapter 19.5.3, 9.4.3.2 and NFPA 72 Chapter 3-9.3.1 in regards to locating and linking smoke detectors to the fire alarm system in order to provide fire recall.

Findings include:

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour of the second and third floor main lobby elevators observation was made of no smoke detectors located near the elevators. This was also confirmed as the same on the first floor and basement levels during interview with staff BB on 03/02/12 at approximately 1:30 PM. Additionally staff BB stated these elevators have no fire recall system.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure patient room doors and corridor room doors were held open only by devices arranged to automatically close the door and that doors in vertical openings latched shut upon closing. This had the potential to affect all those who were utilizing these areas of this facility. The facility census was 213 at the beginning of the survey.


Findings include:


On 02/29/12 between the hours of 1:40 P.M. and 4:00 P.M., tour of the first floor medical oncology area was completed with staff BB and CC. Observation was made in a medical records storage area which housed a significant amount of combustible medical records files. Upon entrance to the area, a small portable paper shredder was noted to be holding the door to the medical record storage room in the open position. Staff BB verified the paper shredder was not to be holding the door open.

Staff BB informed a supervisor in the area the door to the medical record storage area could not be blocked in the open position with any unapproved device. On 03/01/12 between 8:40 AM and 3:10 P.M. tour of the first floor continued. When again passing through the medical oncology area, the door to the medical records storage area was observed to be held open by the portable paper shredder.


21957

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour observation was made of several doors that failed to close and latch properly, doors which were held open with unapproved devices and one door which failed to positive latch shut. They were observed in the following locations:

Third floor:
*South door of a large meeting room located within the Gero Psychiatry area was observed to be equipped with a self closing device. This door was observed to be propped open with a trash can.

*Office door within the coumadin clinic was observed to be equipped with a self closing device and was propped open with a wood wedge.

*Patient room number 366 on 3-West oncology was observed to have a door equipped with a self closing device. Observation was also made of an isolation supply kit hanging from the top of the door and a stethoscope hung over the outer door handle. This door failed to close shut properly when tested due to both the stethoscope inhibiting the latching mechanism and the metal hanger overlapping the top of the door rubbing against the top of the door frame.

*Patient room number 365 on 3-West oncology was observed to have a door equipped with a self closing device. Observation was also made of an isolation supply kit hanging from the top of the door. This door failed to close shut properly when tested due to the metal hanger overlapping the top of the door rubbing against the top of the door frame.

These findings were verified by staff members AA and DD during tour. Staff AA removed all items identified which were inhibiting the proper closing of the doors with exception of the isolation kits.


Second floor:
*Doors to room numbers 200 and 202 located between 2 North and 2 West failed to latch shut properly.

*Stairwell door which commuted to the third floor surgery locker rooms failed to latch shut.

*Two doors equipped with self closing devices within the surgery department were observed to be propped open using a chair and a wood wedge.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Potentially all patients and visitors could be affected. The facility had a census of 213 patients at the time of the survey.

Findings included:

On 03/01/12 between the hours of 8:40 A.M. and 12:00 P.M. tour of the emergency department was completed with Staff BB and CC. Observation of the emergency department revealed an area identified as rapid assessment. The rapid assessment area was observed to have an area where patients were initially assessed, then if needed, taken into another area for further treatment. The second area was observed to be a large room with private areas provided by curtains. The room had at least five doors, one of which lead to another small room in the emergency department.

While in the second area with the multiple doors it was observed that no exit signage was visible which would indicated the way out of the area. Staff BB present in the area verified there was no visible signage to indicate how to exit the area.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire rated protection. Additionally, the corridor walls were observed to have penetrations. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 213.


Findings include:


First Floor

On 03/01/12 between the hours of 8:40 A.M. and 3:10 P.M., tour of the first floor was completed with Staff BB and CC. Observation of the first floor revealed penetrations located in the radiology/emergency department corridor walls. The corridor was not provided with sprinkler system protection.

Observation above the ceiling tiles of the corridor revealed three penetrations approximately 2 to 3 inches in diameter. Staff BB and CC repaired the penetrations later in the day on 03/01/12.

Basement

On 02/28/12 between 3:10 P.M. and 5:00 P.M. and on 02/29/12 between 9:00 A.M. and 12:00 P.M. tour of the basement level of the facility was completed with Staff BB and FF. The following penetrations were observed above the ceiling tiles in fire rated barrier walls;

1. A penetration approximately 12 inches square was observed in a two hour fire rated wall located in the IT office. Unsealed areas were noted surrounding three conduits and an orange cable line which went through the fire rated walls.

2. Penetrations were observed in the one hour fire rated walls in the central sterile storage area. One fire rated wall had one penetration estimated to be approximately one inch by two inches in size. Unsealed open areas surrounded two conduits and a wire which went through the fire rated wall. In another one hour fire rated wall which surrounded the room was other unsealed areas which surrounded two pipes which went through the wall.

3. A penetration was observed in the smoke barrier wall located across from the nutritional area which surrounded a square electrical box.

Staff present on tour observed and verfied the findings.


21957


Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour observation was made of several penetrations located above the ceiling tiles within the half hour fire rated smoke barrier in the following locations:

Third floor:

*Within the group room in the Gero Psychiatry department observation was made of an open end conduit.

*Within room B-314 observation was made of eight penetrations around I-beams and conduits. Additionally, an approximate one inch hole was observed in the drywall.

*Within room B-310 observation was made of three unsealed conduits.

*Just outside and to the south of the physician's office waiting area of building B and above the one foot square tiles, observation was made of one unsealed conduit and a small hole.

*Across from room B-305, observation was made of two unsealed conduits. Additionally, near the fire extinguisher sign, observation was made of an unsealed half inch conduit.

*Across from the main lobby elevators observation was made of three unsealed conduits.



Second floor:
*Within the critical care unit (CCU) staff lounge observation was made of an unsealed pneumatic tube passing through the south wall.

*Within the CCU clean supply room observation was made of an unsealed pneumatic tube passing through the west wall.

*Within the corridor located between the Harding Center CCU and Cath Lab, observation was made of an unsealed sanitary line near the cath lab door.

*Outside of the respiratory care gas lab observation was made of an approximate four inch unsealed conduit where it passes through the drywall and also the inner diameter of the conduit was not sealed.

*Within the corridor located between the Harding Center CCU and Cath Lab and across from the electrical closet, observation was made of two unsealed I-beams and a three inch square opening.

*Within the corridor located between the Harding Center CCU and Cath Lab at the south end across from stairwell E, observation was made of an approximate 10 inch by six inch hole adjacent to the sanitary line. Additionally, a small unsealed area on the top of the duct was observed.

*Above the step down intensive care unit's (SICU) clinical manager office door observation was made of an unsealed plastic pipe. Above the double doors in the same area observation was made of a four inch unsealed conduit with wires passing through.

*At the SICU west entrance observation was made of a three inch open end conduit and a one inch open end conduit.

*Above the smoke barrier doors dividing the pre-op area from the surgery support area, observation was made of four three inch conduits which did not have the inner diameter sealed.

*At the north end of the corridor dividing the PACU from the operating rooms, observation was made of one unsealed steel support bracket.

*At the south end of the corridor dividing the surgery support from the operating rooms and near the data communication room, observation was made of an unsealed insulated line above the duct passing through the drywall.

*Within the surgery waiting area approximately 20 feet from the stairs, observation was made of one unsealed copper line.

*Within the 2 west large supply room located outside the waiting area, observation was made of one unsealed silver conduit.

*At the gross lab area within the smoke barrier, observation was made of a 24 inch square metal frame which housed a pass through sliding glass window. This window and frame lacked a fire resistance rating.



These findings were verified by staff AA and DD during tour.

21957

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous area, specifically one soiled utility room door was not closing properly and another door lacked a self-closing device. This had the potential to affect all those utilizing this area of the facility. The facility patient census was 213 at the beginning of the survey.

Findings include:

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour of the second floor sub-acute care unit, observation was made of the soiled utility room door failing to close and latch shut. This door was also located within the smoke barrier. Staff AA and DD verified this finding during tour.

On 02/29/12 between the hours of 1:40 P.M. and 4:00 P.M., tour of the first floor medical oncology area was completed with Staff BB and CC. Observation of the area revealed a soiled utility room complete with an automatic sprinkler system. The door to the soiled utility room was in the open position. Observation of the door to the room revealed there was no self-closing mechanism in place on the door. Staff BB and CC verified the door to the soiled utility room was identified as needing a self-closing device.

Based on facility observation and staff interview and verification the facility failed to ensure that patient room doors were arranged so that the patient could open the door from inside without using a key. The facility had a census of 15 patients at the time of the survey.

Findings included:

On 02/28/12 at 1:45 P.M., tour and observation of the facility was initiated with Staff BB and EE. Observation of the facility revealed the presence of two seclusion rooms utilized for acute patient conditions. Located next to the seclusion rooms was another room identified as a holding or observation room. A patient was observed to be soundly sleeping in the room with the door open.

Observation of the door to the room revealed the presence of a deadbolt type lock which required a key. Staff present on tour indicated the dead bolt type lock was only locked when the room was empty in order to prevent patients from wandering into the room. Staff demonstrated how the lock functioned which revealed anyone inside the room would not be able to exit the room when the door was locked.

Staff from the facility further verified that patients use the room if they do not wish to share a room with another patient or their condition prevents them from sharing a patient room.

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. The facility had a census of 213 patients at the time of the survey.

Findings included:

On 03/01/12 between the hours of 8:40 A.M. and 3:10 P.M., tour of the laboratory area revealed a small closet type room which housed two H sized tanks of carbon dioxide. The storage room was located within a corridor outside the laboratory of the hospital.

Observation of the inside of the closet area revealed two H sized tanks of carbon dioxide. In addition to the tanks was storage bags of Christmas decorations. Staff BB and CC present on tour verified the presence of the Christmas decorations and that the decorations were not to be stored in the medical gas storage closet.

Emergency illumination is provided in accordance with 39.2.9.1

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regard to documentation of monthly and yearly testing. The facility was an offsite location which provided outpatient therapy services, MRI testing and a community fitness facility.

Findings included:

On 02/28/12 between 10:50 A.M. and 12:00 P.M. tour of the facility and review of facility documentation was completed with Staff BB and FF. Observation of the facility revealed there was no emergency generator for provision of lighting in the event of a power outage. Battery powered emergency lighting was observed throughout the facility.

Review of facility information revealed documented evidence that battery powered emergency lighting was tested quarterly. There was no indication that testing was completed for 30 seconds per month or that testing was completed for 90 minutes per year.

Interview of Staff FF verfied that battery back-up lighting was tested quarterly and that there was no documentation to indicate the amount of time for the testing.

Based on observation and staff interview it was determined this facility failed to ensure the existing elevators conform with Firefighter's Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators and the National Fire Protection Association 101 Chapter 19.5.3, 9.4.3.2 and NFPA 72 Chapter 3-9.3.1 in regards to locating and linking smoke detectors to the fire alarm system in order to provide fire recall.

Findings include:

Facility tour began on 02/29/12 at approximately 8:00 AM with staff members AA and DD. During tour of the second and third floor main lobby elevators observation was made of no smoke detectors located near the elevators. This was also confirmed as the same on the first floor and basement levels during interview with staff BB on 03/02/12 at approximately 1:30 PM. Additionally staff BB stated these elevators have no fire recall system.