HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to maintain corridor doors in 2 of 20 smoke compartments observed during the survey. Findings include:

1. Observation on 4/26/2016 at 1:43 PM revealed the door to the CT (computerized tomography) control room had a kick down door stop installed impeding the closing of the door. This finding was confirmed by Safety Manager A at the time of discovery.

2. Observation on 4/26/2016 at 1:50 PM revealed the doors to room 1313B1 had a gapping more than 1/8 inch between the double doors. This finding was confirmed by Safety Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain 4 of 14 fire/smoke barriers observed during the survey in resisting the passage of smoke. Findings include:

1. On 4/25/2016 at 1:03 PM, observation above the suspended ceiling at the fire doors, by the 4th floor elevator 2, revealed approximately a 1" (inch) by 1" tubing penetration not properly sealed. This finding was confirmed by Master Plumber A at the time of discovery.

2. On 4/25/2016 at 1:55 PM, observation above the suspended ceiling at the fire doors FCS-B1-4-7-W revealed penetrations had been sealed with material not approved for use in fire/smoke barriers. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/27/2016 at 11:00 AM, observation above the suspended ceiling between rooms 344 and 346 revealed penetrations not properly sealed. This finding was confirmed by Safety Manager A at the time of discovery.

4. On 4/27/2016 at 11:07 AM, observation above the suspended ceiling in room 340, staff lounge, revealed penetrations not properly sealed. This finding was confirmed by Safety Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility did not maintain hazardous areas on 1 of 4 floors. Findings include:

1. On 4/25/2016 at 1:05 PM, observation revealed the soiled utility room on the 4th floor by elevator 2 had ceiling tiles that were damaged and were in need of replacing. This finding was confirmed by Master Plumber A at the time of discovery.

2. On 4/25/2016 at 1:55 PM, observation revealed room 365 was being used as a storage room over 50 square feet and did not have properly rated partitions and door closing hardware. This finding was confirmed by MEP Supervisor A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure doors to exit in 5 of 30 3rd floor rooms observed during the survey had approved releasing devices. Findings include:

Observations on 4/25/2016 between 1:45 PM and 2:15 PM, revealed rooms 349, 356, 363, 366 and 368 were equipped with a door lever and a key operated deadbolt on the corridor side of the door. In order to open the door, if the latches for both were engaged, two motions were required to open the door to exit the room. These findings were confirmed by MEP Supervisor A at the time of discovery.

Based on document review and staff interview, it was determined that the facility failed to conduct fire drills under varied times and conditions. Findings include:

Review of fire drill documentation with MEP Supervisor A on 4/28/2016 between 10:00 AM and 11:30 AM revealed:

- Two of four 1st shift fire drills conducted on 4/26/15 and 8/3/15 were conducted between 1:00 PM and 1:45 PM
- Three of four 2nd shift fire drills conducted on 8/26/15, 11/19/15 and 2/24/16 were conducted between 7:30 PM and 8:00 PM

Based on observation and staff interview, it was determined that the facility did not maintain and ensure that the sprinkler pipes were free from external loads in 1 of 1 automatic sprinkler systems. Findings include:

1. On 4/25/2016 at 1:10 PM, observation revealed wires being tied to and draped over the sprinkler piping above the suspended ceiling in Corridor 406. This finding was confirmed by MEP Supervisor A at the time of discovery.

2. On 4/26/2016 at 1:40 PM, observation in the telecommunication closet by Volunteer Services, revealed missing and damaged ceiling tiles. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/26/2016 at 1:42 PM, observation in the telecommunication closet by Volunteer Services, revealed storage within 18 inches of the sprinkler deflector. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility did not ensure that the exit corridors were clear and unobstructed in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/25/2016 at 12:47 PM, observation revealed wheelchairs and patient beds which were not in use, being stored in the lobby of elevators 6 and 7 on the 4th floor. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure oxygen cylinders were secured and stored in a safe manner in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/27/2016 at 10:40 AM, observation in room 2029 revealed two "E" style oxygen cylinders not properly secured. This finding was confirmed by Safety Manager A at the time of discovery.

I. Based on observation and staff interview, it was determined that the facility failed to maintain 6 of 16 fire doors observed during the survey. Findings include:

1. On 4/25/2016 at 1:00 PM, observation revealed Fire Doors FCS-B1-4-7-W, in corridor 406, framing was missing the fire rating label. This finding was confirmed by MEP Supervisor A at the time of discovery.

2. On 4/25/2016 at 1:00 PM, observation revealed Fire Doors, by elevator 2 in corridor 402, framing was missing the fire rating label. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/26/2016 at 1:30 PM, observation revealed Fire Doors FCS-B1-1-8-E, by room 1403C, framing was missing the fire rating label. This finding was confirmed by Safety Manager A at the time of discovery.

4. Observations revealed the following fire doors did not latch properly when released from the open position:

a) On 4/25/2016 at 1:05 PM, Fire Doors FCS-B1-4-7-W, in corridor 406, right side door from pull side bottom latch did not latch properly. This finding was confirmed by MEP Supervisor A at the time of discovery.

b) On 4/25/2016 at 1:05 PM, Fire Doors by elevator 2 in corridor 402, bottom latches did not latch properly. This finding was confirmed by Master Plumber A at the time of discovery.

c) On 4/25/2016 at 1:25 PM, Fire Doors FCS-B1-4-5-W, in corridor 406, did not latch properly at the bottom of the doors. This finding was confirmed by MEP Supervisor A at the time of discovery.

d) On 4/25/2016 at 1:55 PM, Fire Doors FCS-B1-3-8-W, in corridor 406, did not latch properly at the bottom of the doors. This finding was confirmed by Master Plumber A at the time of discovery.

e) On 4/26/2016 at 1:30 PM, Fire Doors FCS-B1-1-8-E, by first floor 1403C, did not latch properly at the bottom of the doors. This finding was confirmed by Safety Manager A at the time of discovery.

5. On 4/28/2016 at 2:00 PM, observation revealed the fire doors by room 342 had the fire rating label painted over. This finding was confirmed by Safety Manager A at the time of discovery.

6. On 4/28/2016 at 2:00 PM, observation revealed the fire doors at the main entrance had a gapping more than 1/8 inch between the double doors. This finding was confirmed by Safety Manager A at the time of discovery.

II. Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 2 fire suppression systems. Findings include:

Observations on 4/26/2016 at 1:35 PM revealed penetrations in the suspended ceiling in the 1st floor telephone closet, by the laundry, which was protected by a FM-200 (Trademark) fire suppression system. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain electrical installations in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/25/2016 at 1:47 PM, observation revealed room 368 had a microwave plugged into a power strip, plugged into a duplex outlet. This finding was confirmed by MEP Supervisor A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain corridor doors in 2 of 20 smoke compartments observed during the survey. Findings include:

1. Observation on 4/26/2016 at 1:43 PM revealed the door to the CT (computerized tomography) control room had a kick down door stop installed impeding the closing of the door. This finding was confirmed by Safety Manager A at the time of discovery.

2. Observation on 4/26/2016 at 1:50 PM revealed the doors to room 1313B1 had a gapping more than 1/8 inch between the double doors. This finding was confirmed by Safety Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain 4 of 14 fire/smoke barriers observed during the survey in resisting the passage of smoke. Findings include:

1. On 4/25/2016 at 1:03 PM, observation above the suspended ceiling at the fire doors, by the 4th floor elevator 2, revealed approximately a 1" (inch) by 1" tubing penetration not properly sealed. This finding was confirmed by Master Plumber A at the time of discovery.

2. On 4/25/2016 at 1:55 PM, observation above the suspended ceiling at the fire doors FCS-B1-4-7-W revealed penetrations had been sealed with material not approved for use in fire/smoke barriers. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/27/2016 at 11:00 AM, observation above the suspended ceiling between rooms 344 and 346 revealed penetrations not properly sealed. This finding was confirmed by Safety Manager A at the time of discovery.

4. On 4/27/2016 at 11:07 AM, observation above the suspended ceiling in room 340, staff lounge, revealed penetrations not properly sealed. This finding was confirmed by Safety Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility did not maintain hazardous areas on 1 of 4 floors. Findings include:

1. On 4/25/2016 at 1:05 PM, observation revealed the soiled utility room on the 4th floor by elevator 2 had ceiling tiles that were damaged and were in need of replacing. This finding was confirmed by Master Plumber A at the time of discovery.

2. On 4/25/2016 at 1:55 PM, observation revealed room 365 was being used as a storage room over 50 square feet and did not have properly rated partitions and door closing hardware. This finding was confirmed by MEP Supervisor A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure doors to exit in 5 of 30 3rd floor rooms observed during the survey had approved releasing devices. Findings include:

Observations on 4/25/2016 between 1:45 PM and 2:15 PM, revealed rooms 349, 356, 363, 366 and 368 were equipped with a door lever and a key operated deadbolt on the corridor side of the door. In order to open the door, if the latches for both were engaged, two motions were required to open the door to exit the room. These findings were confirmed by MEP Supervisor A at the time of discovery.

Based on document review and staff interview, it was determined that the facility failed to conduct fire drills under varied times and conditions. Findings include:

Review of fire drill documentation with MEP Supervisor A on 4/28/2016 between 10:00 AM and 11:30 AM revealed:

- Two of four 1st shift fire drills conducted on 4/26/15 and 8/3/15 were conducted between 1:00 PM and 1:45 PM
- Three of four 2nd shift fire drills conducted on 8/26/15, 11/19/15 and 2/24/16 were conducted between 7:30 PM and 8:00 PM

Based on observation and staff interview, it was determined that the facility did not maintain and ensure that the sprinkler pipes were free from external loads in 1 of 1 automatic sprinkler systems. Findings include:

1. On 4/25/2016 at 1:10 PM, observation revealed wires being tied to and draped over the sprinkler piping above the suspended ceiling in Corridor 406. This finding was confirmed by MEP Supervisor A at the time of discovery.

2. On 4/26/2016 at 1:40 PM, observation in the telecommunication closet by Volunteer Services, revealed missing and damaged ceiling tiles. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/26/2016 at 1:42 PM, observation in the telecommunication closet by Volunteer Services, revealed storage within 18 inches of the sprinkler deflector. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility did not ensure that the exit corridors were clear and unobstructed in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/25/2016 at 12:47 PM, observation revealed wheelchairs and patient beds which were not in use, being stored in the lobby of elevators 6 and 7 on the 4th floor. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure oxygen cylinders were secured and stored in a safe manner in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/27/2016 at 10:40 AM, observation in room 2029 revealed two "E" style oxygen cylinders not properly secured. This finding was confirmed by Safety Manager A at the time of discovery.

I. Based on observation and staff interview, it was determined that the facility failed to maintain 6 of 16 fire doors observed during the survey. Findings include:

1. On 4/25/2016 at 1:00 PM, observation revealed Fire Doors FCS-B1-4-7-W, in corridor 406, framing was missing the fire rating label. This finding was confirmed by MEP Supervisor A at the time of discovery.

2. On 4/25/2016 at 1:00 PM, observation revealed Fire Doors, by elevator 2 in corridor 402, framing was missing the fire rating label. This finding was confirmed by Master Plumber A at the time of discovery.

3. On 4/26/2016 at 1:30 PM, observation revealed Fire Doors FCS-B1-1-8-E, by room 1403C, framing was missing the fire rating label. This finding was confirmed by Safety Manager A at the time of discovery.

4. Observations revealed the following fire doors did not latch properly when released from the open position:

a) On 4/25/2016 at 1:05 PM, Fire Doors FCS-B1-4-7-W, in corridor 406, right side door from pull side bottom latch did not latch properly. This finding was confirmed by MEP Supervisor A at the time of discovery.

b) On 4/25/2016 at 1:05 PM, Fire Doors by elevator 2 in corridor 402, bottom latches did not latch properly. This finding was confirmed by Master Plumber A at the time of discovery.

c) On 4/25/2016 at 1:25 PM, Fire Doors FCS-B1-4-5-W, in corridor 406, did not latch properly at the bottom of the doors. This finding was confirmed by MEP Supervisor A at the time of discovery.

d) On 4/25/2016 at 1:55 PM, Fire Doors FCS-B1-3-8-W, in corridor 406, did not latch properly at the bottom of the doors. This finding was confirmed by Master Plumber A at the time of discovery.

e) On 4/26/2016 at 1:30 PM, Fire Doors FCS-B1-1-8-E, by first floor 1403C, did not latch properly at the bottom of the doors. This finding was confirmed by Safety Manager A at the time of discovery.

5. On 4/28/2016 at 2:00 PM, observation revealed the fire doors by room 342 had the fire rating label painted over. This finding was confirmed by Safety Manager A at the time of discovery.

6. On 4/28/2016 at 2:00 PM, observation revealed the fire doors at the main entrance had a gapping more than 1/8 inch between the double doors. This finding was confirmed by Safety Manager A at the time of discovery.

II. Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 2 fire suppression systems. Findings include:

Observations on 4/26/2016 at 1:35 PM revealed penetrations in the suspended ceiling in the 1st floor telephone closet, by the laundry, which was protected by a FM-200 (Trademark) fire suppression system. This finding was confirmed by Master Plumber A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain electrical installations in 1 of 20 smoke compartments observed during the survey. Findings include:

On 4/25/2016 at 1:47 PM, observation revealed room 368 had a microwave plugged into a power strip, plugged into a duplex outlet. This finding was confirmed by MEP Supervisor A at the time of discovery.