HospitalInspections.org

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the 2 hour separation wall located outside room 184 has penetrations above the door that are not sealed properly to maintain the integrity of the assembly.

2) It was also observed that the 2 hour separation wall located above the door to the CT corridor on the first floor will need to be evaluated to determined if the wall meets the required 2 hour separation. There are penetrations in the area it could not be determined if the penetrations are in the 2 hour assembly or not.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Penetrations in 2 hr. wall located in CT suite area adjacent to room # 155.
Penetrations should be sealed using a listed system that maintains continuity of the two hr. fire separation.

2. Maintenance shop 2 hr wall (shared with exit corridor) has penetrations that were not properly sealed.
Penetrations should be sealed using a listed system that maintains continuity of the two hour fire wall.

3. Main electrical room 2 hr wall (shared w/ med library) has penetrations with no fire stopping material present.
-Wall shared with exit corridor has penetrations with no fire stopping material present.
- Door and frame for this room does not have tags to indicate the rating of the assembly
Penetrations should be sealed using a listed system that maintains continuity of the two hour fire wall.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the door going into the OB Delivery room 267 had a door stop attached to the bottom of the door preventing the door from being closed.

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Smoke barrier wall located on second floor medical surgical area had pipe penetrations that were not properly sealed and would not prevent the passage of smoke.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the following doors to hazardous areas require closure devices; the storage room door outside of surgical area, the ICU storage room, and the storage room door for the Behavioral Health Department. It was also observed that the doors of room G44, G39, G06, and the door to Central Supply needs to close and automatically latch.

2) It was observed that the ceiling of the IT Room located outside of room 141 had holes in the ceiling that need to be sealed to maintain the rating of the ceiling.

3) It was observed that in room G47, Soiled Utility, there are several holes in the ceiling that are required to be sealed to maintain the required fire separation.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. O/R office-storage room did not have a self closing device on the door

2. Soiled Linen room #365 has gaps between the left side of door frame and door that were larger than 1/2" and would not prevent the passage of smoke/fire

3. Storage room next to room 361 did not have a self closing device.

4. Second floor med-surg storage room (across from stairwell A) did not have a self closing device on the door

5. Storage room # 254 did not have a self closing device

6. Surgical specialties storage room had tape across the door latch which prevented it from properly latching

7. Maintenance shop door #G49 would not properly close and latch.

8. Soiled utility room door # G47 would not properly close and latch

9. Laundry room door # G48 would not properly close and latch

10. ER storage room # 168 had penetrations in the 1 hour wall (above ceiling) that were not properly sealed. There are pipe penetrations that were either not sealed or were sealed with spray foam insulation and no documentation was provided that verified the material used were listed for commercial use and/or that it has a fire rating for penetrations.
Penetration need to be sealed with a listed system that maintains continuity of the 1 hr fire rating

11. Central storage room #B08 has penetrations in the walls and ceiling that are not properly sealed.
Penetration need to be sealed with a listed system that maintains continuity of the 1 hour fire wall.

12. Data rooms located on each level have penetrations in the 1 hour wall that did not have fire stopping present to maintain the enclosure rating.

13. The electrcial closet located in the 1970's wing had penetrations that did not have fire stopping present.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the Exit door in stairwell "A" at ground level did not latch properly.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the exit sign located in the stairwell at ground level was obscured from view and needs to be relocated to show the clear direction of egress.





35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Corridor and elevator lobby area in the basement level had multiple carts being stored within exit corridor. Carts were in the same location for a period of time exceeding 1 hour.

2. OB floor has two delayed egress doors;no more than one delayed egress lock is allowed in means of egress.
-The delayed egress device located near stair F is located more than 48" from the floor and requires more than one operation to open the door, which is prohibited

3. The motion activated bifold doors located near x-ray do not have the proper sized sign required for emergency operations of the doors.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that when the nursing staff on the 2nd floor were interviewed concerning the facility fire plan it was discovered that the plan was only accessible through the facility computer system. A written plan for the protection of all patients and for their evacuation in the event of an emergency is required.

2) It was observed when interviewing the charge nurse for the Children's Wing on the second floor that he/she was unaware of or the location of the key that is used to unlock the fire alarm pull station located at all exits on that wing.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that during records review of the fire alarm inspection/tests for the last two years did not indicate that the sensitivity testing for the fire alarm smoke detectors has been done as required.

2)It was also observed through an interview with the Director of Facilities Management that the fire alarm system dialer that communicates an alarm to a central receiving station only has one dedicated phone line for emergency communications of an alarm. NFPA 72, paragraph 8.3.6.1.6* requires that two independent means shall be provided to retransmit a fire alarm signal to the designated public fire service communications center.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the ER on-call sleeping rooms on the on the first and second floor require a single station smoke detector.

Based on records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. There was no documentation provided that the magnetic door hold open devices that are connected to the fire alarm system had been tested/inspected annually.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the following sprinkler system deficiencies were noted during the survey:
1) Same Day Surgery Recovery closet is not sprinkler protected;
2) The Behavioral Health Department storage room, kitchenette and an alcove do not have sprinkler coverage;
3)The sprinkler head located outside room 184 was missing the escutcheon plate.


35163

Based on observation and records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Pharmacy had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

2 Attic storage was located within less than 18" of sprinkler heads (entire length of half of the attic space) which would not allow for proper sprinkler pattern development.

3. Sprinkler heads (2) on ceiling near room #230 are missing escutcheon plates

4. Sprinkler head located in the kitchen walk-in cooler had a light fixture within 2" of the sprinkler head which would not allow for proper sprinkler pattern development.

5. Fire department hose connections located on each level near the exits have not been tested or inspected and no documentation could be provided.

The following additional deficiencies were observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) Several fire extinguishers throughout the facility were not properly marked as required by NFPA 10. When the extinguisher is obscured from view or not readily visible the extinguisher shall be identified as to it's location. Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.

2) In the kitchen are what appears to be controls for a CO2 fire extinguishing system. The system has been removed. The controls must be removed so as not to confuse personnel in thinking that there is still an active system available.

Based on observation and interviews by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Children's psychiatric wing had decorations/combustible materials throughout the exit corridor walls, that were not flame retardant. Maintenance staff verified they had not been treated with any spray flame retardant chemical.

Based on observation and records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. The last medical gas system inspection report (2015) indicated several deficiencies throughout the facility. No documentation could be provided that the deficiencies have been corrected and interview with maintenance staff indicated there was no plan/timeline when the items that were identified would be corrected

2. The housekeeping closet on the O/B floor has a medical gas zone valve box located inside the room(not visible from corridor). The piping is labeled oxygen and nitrous oxide, but does not indicate what area/rooms it serves.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the "New" generator does not have the required annunciator located in a normally occupied area that is required by NFPA 99, (2000 edition).

2) It was observed that the "Old" generator annunciation does not include all of the required systems monitored. When tested the annunciator did not have indicators for "When the battery charger is malfunctioning or when the main fuel storage tank contains less that a 3 hour operating supply".

Based on interviews by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. It was found that is was a regular practice to use the dryer to dry rags and mop heads from the kitchen and cleaning staff.
Even if the linens, rags or mop heads have been laundered, they can still hold enough contaminate traces to add fuel to the oxidation process that causes spontaneous ignition.
There is a warning label from the manufacturers located on the dryers that addresses the potential fire risk associated with this practice.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that in the Nuclear Med room on the first floor the outlet located near the sink is not GFCI protected as required.

2) It was observed that tin the Nuclear Med room on the first floor an electrical extension was being used improperly as permanent wiring.

3) It was observed that in the OR Clean Room located on the 3rd floor an electrical outlet located near the sink was not GFCI protected.

4) It was observed that in the General Surgery Room located on the ground floor a micro wave oven and coffee pot were plugged into an extension cord and power strip.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. There was a exposed electrical junction box that was missing a cover, located above the dumbwaiter shaft in the area of the operating rooms.

2. On the ceiling of the attic space there was a exposed electrical box that was missing a cover.

3. Attic space had a extension cord that was being used as a permanent power source for a ceiling mounted light fixture.

4. Children's psychiatric wing-medication room, had two multi outlet devices interconnected and one was located directly below a sink/water source.

5. On ceiling of maintenance shop there was a exposed electrical box that was missing a cover.

6. Soiled linen room # G47 has a open electrical box that was missing a cover, located on the ceiling.

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Near linen storage area in the 70's wing there was a alcohol based hand sanitizing station that was installed above a electrical night light which could be a ignition source

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the 2 hour separation wall located outside room 184 has penetrations above the door that are not sealed properly to maintain the integrity of the assembly.

2) It was also observed that the 2 hour separation wall located above the door to the CT corridor on the first floor will need to be evaluated to determined if the wall meets the required 2 hour separation. There are penetrations in the area it could not be determined if the penetrations are in the 2 hour assembly or not.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Penetrations in 2 hr. wall located in CT suite area adjacent to room # 155.
Penetrations should be sealed using a listed system that maintains continuity of the two hr. fire separation.

2. Maintenance shop 2 hr wall (shared with exit corridor) has penetrations that were not properly sealed.
Penetrations should be sealed using a listed system that maintains continuity of the two hour fire wall.

3. Main electrical room 2 hr wall (shared w/ med library) has penetrations with no fire stopping material present.
-Wall shared with exit corridor has penetrations with no fire stopping material present.
- Door and frame for this room does not have tags to indicate the rating of the assembly
Penetrations should be sealed using a listed system that maintains continuity of the two hour fire wall.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the door going into the OB Delivery room 267 had a door stop attached to the bottom of the door preventing the door from being closed.

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Smoke barrier wall located on second floor medical surgical area had pipe penetrations that were not properly sealed and would not prevent the passage of smoke.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the following doors to hazardous areas require closure devices; the storage room door outside of surgical area, the ICU storage room, and the storage room door for the Behavioral Health Department. It was also observed that the doors of room G44, G39, G06, and the door to Central Supply needs to close and automatically latch.

2) It was observed that the ceiling of the IT Room located outside of room 141 had holes in the ceiling that need to be sealed to maintain the rating of the ceiling.

3) It was observed that in room G47, Soiled Utility, there are several holes in the ceiling that are required to be sealed to maintain the required fire separation.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. O/R office-storage room did not have a self closing device on the door

2. Soiled Linen room #365 has gaps between the left side of door frame and door that were larger than 1/2" and would not prevent the passage of smoke/fire

3. Storage room next to room 361 did not have a self closing device.

4. Second floor med-surg storage room (across from stairwell A) did not have a self closing device on the door

5. Storage room # 254 did not have a self closing device

6. Surgical specialties storage room had tape across the door latch which prevented it from properly latching

7. Maintenance shop door #G49 would not properly close and latch.

8. Soiled utility room door # G47 would not properly close and latch

9. Laundry room door # G48 would not properly close and latch

10. ER storage room # 168 had penetrations in the 1 hour wall (above ceiling) that were not properly sealed. There are pipe penetrations that were either not sealed or were sealed with spray foam insulation and no documentation was provided that verified the material used were listed for commercial use and/or that it has a fire rating for penetrations.
Penetration need to be sealed with a listed system that maintains continuity of the 1 hr fire rating

11. Central storage room #B08 has penetrations in the walls and ceiling that are not properly sealed.
Penetration need to be sealed with a listed system that maintains continuity of the 1 hour fire wall.

12. Data rooms located on each level have penetrations in the 1 hour wall that did not have fire stopping present to maintain the enclosure rating.

13. The electrcial closet located in the 1970's wing had penetrations that did not have fire stopping present.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the Exit door in stairwell "A" at ground level did not latch properly.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the exit sign located in the stairwell at ground level was obscured from view and needs to be relocated to show the clear direction of egress.





35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Corridor and elevator lobby area in the basement level had multiple carts being stored within exit corridor. Carts were in the same location for a period of time exceeding 1 hour.

2. OB floor has two delayed egress doors;no more than one delayed egress lock is allowed in means of egress.
-The delayed egress device located near stair F is located more than 48" from the floor and requires more than one operation to open the door, which is prohibited

3. The motion activated bifold doors located near x-ray do not have the proper sized sign required for emergency operations of the doors.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that when the nursing staff on the 2nd floor were interviewed concerning the facility fire plan it was discovered that the plan was only accessible through the facility computer system. A written plan for the protection of all patients and for their evacuation in the event of an emergency is required.

2) It was observed when interviewing the charge nurse for the Children's Wing on the second floor that he/she was unaware of or the location of the key that is used to unlock the fire alarm pull station located at all exits on that wing.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that during records review of the fire alarm inspection/tests for the last two years did not indicate that the sensitivity testing for the fire alarm smoke detectors has been done as required.

2)It was also observed through an interview with the Director of Facilities Management that the fire alarm system dialer that communicates an alarm to a central receiving station only has one dedicated phone line for emergency communications of an alarm. NFPA 72, paragraph 8.3.6.1.6* requires that two independent means shall be provided to retransmit a fire alarm signal to the designated public fire service communications center.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the ER on-call sleeping rooms on the on the first and second floor require a single station smoke detector.

Based on records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. There was no documentation provided that the magnetic door hold open devices that are connected to the fire alarm system had been tested/inspected annually.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management. It was observed that the following sprinkler system deficiencies were noted during the survey:
1) Same Day Surgery Recovery closet is not sprinkler protected;
2) The Behavioral Health Department storage room, kitchenette and an alcove do not have sprinkler coverage;
3)The sprinkler head located outside room 184 was missing the escutcheon plate.


35163

Based on observation and records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Pharmacy had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

2 Attic storage was located within less than 18" of sprinkler heads (entire length of half of the attic space) which would not allow for proper sprinkler pattern development.

3. Sprinkler heads (2) on ceiling near room #230 are missing escutcheon plates

4. Sprinkler head located in the kitchen walk-in cooler had a light fixture within 2" of the sprinkler head which would not allow for proper sprinkler pattern development.

5. Fire department hose connections located on each level near the exits have not been tested or inspected and no documentation could be provided.

The following additional deficiencies were observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) Several fire extinguishers throughout the facility were not properly marked as required by NFPA 10. When the extinguisher is obscured from view or not readily visible the extinguisher shall be identified as to it's location. Acceptable means of identifying the fire extinguisher locations could include arrows, lights, signs, or coding of the wall or column.

2) In the kitchen are what appears to be controls for a CO2 fire extinguishing system. The system has been removed. The controls must be removed so as not to confuse personnel in thinking that there is still an active system available.

Based on observation and interviews by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. Children's psychiatric wing had decorations/combustible materials throughout the exit corridor walls, that were not flame retardant. Maintenance staff verified they had not been treated with any spray flame retardant chemical.

Based on observation and records review by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. The last medical gas system inspection report (2015) indicated several deficiencies throughout the facility. No documentation could be provided that the deficiencies have been corrected and interview with maintenance staff indicated there was no plan/timeline when the items that were identified would be corrected

2. The housekeeping closet on the O/B floor has a medical gas zone valve box located inside the room(not visible from corridor). The piping is labeled oxygen and nitrous oxide, but does not indicate what area/rooms it serves.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that the "New" generator does not have the required annunciator located in a normally occupied area that is required by NFPA 99, (2000 edition).

2) It was observed that the "Old" generator annunciation does not include all of the required systems monitored. When tested the annunciator did not have indicators for "When the battery charger is malfunctioning or when the main fuel storage tank contains less that a 3 hour operating supply".

Based on interviews by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. It was found that is was a regular practice to use the dryer to dry rags and mop heads from the kitchen and cleaning staff.
Even if the linens, rags or mop heads have been laundered, they can still hold enough contaminate traces to add fuel to the oxidation process that causes spontaneous ignition.
There is a warning label from the manufacturers located on the dryers that addresses the potential fire risk associated with this practice.

This tag not met as observed by surveyors 20980 & 35163 and the Director of Facilities Management.

1) It was observed that in the Nuclear Med room on the first floor the outlet located near the sink is not GFCI protected as required.

2) It was observed that tin the Nuclear Med room on the first floor an electrical extension was being used improperly as permanent wiring.

3) It was observed that in the OR Clean Room located on the 3rd floor an electrical outlet located near the sink was not GFCI protected.

4) It was observed that in the General Surgery Room located on the ground floor a micro wave oven and coffee pot were plugged into an extension cord and power strip.



35163

Based on observation by the surveyor 20980 and 35163 on 4/4/16 and 4/5/16, accompanied by the maintenance director the following was found;

1. There was a exposed electrical junction box that was missing a cover, located above the dumbwaiter shaft in the area of the operating rooms.

2. On the ceiling of the attic space there was a exposed electrical box that was missing a cover.

3. Attic space had a extension cord that was being used as a permanent power source for a ceiling mounted light fixture.

4. Children's psychiatric wing-medication room, had two multi outlet devices interconnected and one was located directly below a sink/water source.

5. On ceiling of maintenance shop there was a exposed electrical box that was missing a cover.

6. Soiled linen room # G47 has a open electrical box that was missing a cover, located on the ceiling.