HospitalInspections.org

Based on observation and staff interview the facility failed to ensure walls were smoke resistant on 1 of 7 floors. The findings were:

Observation of the fifth floor on 10/26/10 at 11:12 AM showed the gap around the electrical cable tray in communication room #5-C2-48B was not smoke resistant. The gap between the tray and wall was 3/4-inch wide. At the time of observation an engineering staff member reported all equipment rooms were inspected semi-annually to ensure they were smoke resistant. He stated he was unsure why that gap had not been identified.

Based on observation and staff interview the facility failed to ensure corridor doors had a fire resistant rating of at least 20 minutes on 1 of 7 floors. The findings were:

Observation of the fourth floor on 10/26/10 at 1:53 PM showed the corridor door to the nutrition closet #4-N2-16 was not either a solid core door or a fire rated door. The door was a non-rated, hollow core door. At the time of observation an engineering staff member reported he was aware that all corridor doors were required to have the equivalent of a 20 minute fire rating. Furthermore, he could not explain why the door had not been noticed and replaced.

Based on observation and staff interview the facility failed to ensure smoke detector were properly installed on 1 of 7 floors. The findings were:

1. Observation of the laboratory file room on 10/26/10 at 3:05 PM showed the smoke detector was installed less than 36 inches from the ventilation diffuser. The smoke detector was installed 12-inches from the diffuser. At the time of observation the safety coordinator reported the entire fire alarm system was inspected annually by an outside contractor. Furthermore, this interview revealed the last inspection conducted during May 2010 did not identify improper installation of smoke detectors.

2. Observation of the hot laboratory #1-C1-07 on 10/27/10 at 10:52 AM showed the smoke detector was installed less than 36-inches from the ventilation diffuser. The smoke detector was only 14-inches from the diffuser.

Based on observation and staff interview the facility failed to ensure temporary wiring did not replace permanent fixed wiring, failed to ensure electrical outlets in wet locations had ground fault circuit interrupter (GFCI) protection, and failed to ensure electrical equipment in operating rooms was plugged directly into a fixed electrical outlet on 3 of 7 floors. The findings were:

1. Observation of the electrical system on 10/26/10 at 10:34 AM showed the air freshener in the neuro case managers office #5-C1-12A was plugged into a 3-way electrical adapter. At the time of observation the safety coordinator reported all staff members were in-serviced on electrical adapters on an annual basis. Furthermore, he reported all electrical equipment was inspected on a semi-annual basis.

2. Observation of the electrical system on 10/26/10 at 1:21 PM showed the electrical outlet in the fourth center medical floor medication room #4-C1-23B was located less than 72 inches from a sink and did not have GFCI protection. The outlet was located 10 inches from the sink. At the time of observation the lead electrician reported outlets were only replaced when they were damaged. He also reported electrical outlets in wet locations were not routinely inspected to ensure they had GFCI protection.

3. Observation of the electrical system on 10/26/10 between 4:30 PM and 6 PM showed the patient warming fan in operating (OR) #6 was plugged into a surge protector attached to the respiratory cart. At 4:50 PM the manager of para-operative services confirmed the fan was plugged into the surge protector throughout the surgery. Furthermore, she reported the power supply was based on convenience and not clinical need. Further review showed the same electrical configuration was in OR #5 and OR #1.

Based on observation and staff interview the facility failed to ensure walls were smoke resistant on 1 of 7 floors. The findings were:

Observation of the fifth floor on 10/26/10 at 11:12 AM showed the gap around the electrical cable tray in communication room #5-C2-48B was not smoke resistant. The gap between the tray and wall was 3/4-inch wide. At the time of observation an engineering staff member reported all equipment rooms were inspected semi-annually to ensure they were smoke resistant. He stated he was unsure why that gap had not been identified.

Based on observation and staff interview the facility failed to ensure corridor doors had a fire resistant rating of at least 20 minutes on 1 of 7 floors. The findings were:

Observation of the fourth floor on 10/26/10 at 1:53 PM showed the corridor door to the nutrition closet #4-N2-16 was not either a solid core door or a fire rated door. The door was a non-rated, hollow core door. At the time of observation an engineering staff member reported he was aware that all corridor doors were required to have the equivalent of a 20 minute fire rating. Furthermore, he could not explain why the door had not been noticed and replaced.

Based on observation and staff interview the facility failed to ensure smoke detector were properly installed on 1 of 7 floors. The findings were:

1. Observation of the laboratory file room on 10/26/10 at 3:05 PM showed the smoke detector was installed less than 36 inches from the ventilation diffuser. The smoke detector was installed 12-inches from the diffuser. At the time of observation the safety coordinator reported the entire fire alarm system was inspected annually by an outside contractor. Furthermore, this interview revealed the last inspection conducted during May 2010 did not identify improper installation of smoke detectors.

2. Observation of the hot laboratory #1-C1-07 on 10/27/10 at 10:52 AM showed the smoke detector was installed less than 36-inches from the ventilation diffuser. The smoke detector was only 14-inches from the diffuser.

Based on observation and staff interview the facility failed to ensure temporary wiring did not replace permanent fixed wiring, failed to ensure electrical outlets in wet locations had ground fault circuit interrupter (GFCI) protection, and failed to ensure electrical equipment in operating rooms was plugged directly into a fixed electrical outlet on 3 of 7 floors. The findings were:

1. Observation of the electrical system on 10/26/10 at 10:34 AM showed the air freshener in the neuro case managers office #5-C1-12A was plugged into a 3-way electrical adapter. At the time of observation the safety coordinator reported all staff members were in-serviced on electrical adapters on an annual basis. Furthermore, he reported all electrical equipment was inspected on a semi-annual basis.

2. Observation of the electrical system on 10/26/10 at 1:21 PM showed the electrical outlet in the fourth center medical floor medication room #4-C1-23B was located less than 72 inches from a sink and did not have GFCI protection. The outlet was located 10 inches from the sink. At the time of observation the lead electrician reported outlets were only replaced when they were damaged. He also reported electrical outlets in wet locations were not routinely inspected to ensure they had GFCI protection.

3. Observation of the electrical system on 10/26/10 between 4:30 PM and 6 PM showed the patient warming fan in operating (OR) #6 was plugged into a surge protector attached to the respiratory cart. At 4:50 PM the manager of para-operative services confirmed the fan was plugged into the surge protector throughout the surgery. Furthermore, she reported the power supply was based on convenience and not clinical need. Further review showed the same electrical configuration was in OR #5 and OR #1.