HospitalInspections.org

Based on interview and observation, the facility failed to maintain a two hour fire wall between the facility and a medical office building. This has the potential to affect all patients, visitors, and staff at the facility.

Findings:

On 05/30/13 at 1:30 P.M. a tour of the second floor was conducted with Staff MM and AA. The tour revealed a two hour fire wall between the facility and a medical office building. Observation above the drop down ceiling observed the wall to have a heating, ventilation and cooling ductwork running through it. No observation was made of a damper within it.

During the tour Staff MM confirmed the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure that building construction type and height met the following building requirements for Type I construction.
The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observation above the ceiling tiles at room 95-3-02 revealed fire protective material was removed from the steel beam. Multiple areas of unprotected steel were visible. The fire resistant material was noted to have been removed surrounding hangers with additional areas of exposed steel approximately eight inches square.

Staff present on tour viewed and verified the observation.

Based on facility observation and staff interview and verification, the facility failed to ensure that in sprinkler buildings waiting areas and activity spaces were open to the corridor under certain conditions specified in the Code. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. The following areas were observed to be waiting or lounge areas that did not meet Code requirements.

* Located on the fifth floor was a family waiting area that had no smoke detection in place and no direct supervision of facility staff.

* Located on the fourth floor was a vending and lounge area, provided with sprinkler protection but no smoke detection of direct supervision by facility staff.

* Located on the third floor was a step down waiting area and vending area, identified as 95-3-95, was observed to have no smoke detection or direct supervision by staff.

Observations were verified by staff present on the tour.

Based on observation and interview, the facility failed to maintain the garbage chute ' s damper door on the first floor to ensure the chute was enclosed with construction having a fire resistance rating of at least two hours. This has the potential to affect all patients, visitors, and staff at the facility.

Findings:

On 05/30/13 at 11:58 A.M. observation of the trash chute room on the first floor revealed the chute had garbage in the receptacle that had backed up into the chute itself such that the bottom damper would be unable to close.

On 05/30/13 at 11:58 A.M. in an interview, Staff AA and MM confirmed the observation.

Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Use of a facility schematic showing placement of one hour fire rated barriers was provided by staff and used during the tour. Observations of the following areas above the ceiling tiles, revealed the presence of penetrations in the designated one hour fire rated barriers.

* Located on the fifth floor of the facility, at room 97-5-13, three penetrations were noted at the roof decking.

*Located on the first floor, at rooms 95-1-31, 95-1-42 and at room 95-1-44A penetrations were noted at the floor decking above and surrounding two hot water pipes. Also on the first floor at room 84-1-06, three penetrations were observed surrounding wire that went through the one hour fire rated barrier wall.

Staff present at the time of tour verified the observations

Based on facility observation, staff interview and verification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observation of the following hazardous areas revealed:

* Located on the fifth floor, the room where the trash chute was located was noted to have no closing device on the door.

* Located on the third floor, the storage room, 95-3-28 was noted to have broken ceiling tiles that would allow for the passage of smoke.

* Located on the second floor, storage area, 59-2-13, was observed to have broken ceiling tiles which would allow the passage of smoke.

Located in the basement at room 95-B-46 E penetrations were observed at the ceiling and surrounding pipe and conduit that went through the on hour fire rated wall.

Staff present on tour verified the observations

Based on facility observation, staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observation of various exits was completed. Observation of Stair D revealed the exit discharge lead to a metal grate stair. At the bottom of the stairs was an ivy garden. The ivy plants were observed to have grown up onto the lower two steps of the stair. In addition to an ivy garden there was no hard paved way, such as a sidewalk, away from the building.

Staff present on tour verified the discharge at the bottom of the stair was impeded by the ivy and lack of paved way.

Based on observation and interview, the facility failed to ensure fire drills were held at unexpected times under varying conditions at least quarterly on each shift. This has the potential to affect all patients, visitors, and staff at the facility.

Findings:

Review of the building's fire drill documentation was completed on 06/04/13. The review revealed for the last 12 months on only drill was conducted on the night shift, that being on 12/19/12 at 6:45 A.M. The review revealed for the last quarter of 2012 there wasn't any drills held on the first or second shift.

On 06/04/13 at 10:30 A.M. in an interview Staff NN confirmed the review because the building had been managed as a business occupancy.

Based on facility observation and staff interview and verification, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observations of sprinkler heads in the following areas revealed dirty or covered sprinkler heads that could affect the function of the sprinkler device.

* Located on the fifth floor, inside the trash chute, a sprinkler head was observed to be covered with a piece of plastic bag.

* Located on the third floor, inside the soiled linen chute, at room 59-3-319, the sprinkler device was observed to be covered with soil, and debris.

* Located on the second floor, inside the minor procedure room, two sprinkler devices were observed to be covered with fuzzy looking dust and debris.

* Located on the first floor, in the dietary department, sprinkler heads were observed to be covered with fuzzy looking dust and debris. Also on the first floor, within the trash chute, the sprinkler device was covered with a piece of .

Located in the basement, within the radiology storage area, the sprinkler heads were observed to be placed almost directly above the lights in the room. The large storage area contained thousands of radiology files.

Staff present on tour verified the observations.

Based on observation and interview, the facility failed to ensure fire extinguishers were not obstructed from view.

Findings:

Tour of all the floors of the facility revealed the fire extinguishers were encased in silver boxes mostly flush with the wall. The locations of the fire extinguishers were not identified with any arrows, signs or other coding. This has the potential to affect all patients, visitors, and staff at the facility.

On 05/28/13 at 1:40 P.M. a tour was conducted of the building ' s fifth floor. During the tour at 2:30 P.M., in an interview Staff OO and PP were asked where the location of the nearest fire extinguisher was. Although each found one, neither found the closest one. Staff OO was observed to walk past the nearest and not notice its location, while on the way to one further away.

Based on observation and interview, the facility failed to ensure all patient care areas were free of space heaters. This has the potential to affect all patients, visitors, and staff at the facility.

Findings:

On 05/30/13 at 8:05 A.M. a tour was conducted on the second floor with Staff MM and NN. During the tour, in room 1178, an office within a patient care area, a space heater was observed.

During the tour, Staff NN confirmed the observation.

Based on facility observation, staff interview and verification, the facility failed to ensure that any existing linen and trash chute, including pneumatic rubbish and linen systems sealed by fire resistive construction to prevent further use or was provided with a fire door assembly having a fire protection rating of 1 hour. All new chutes comply with section 9.5. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observation on the first floor, room 59-1-183 H, revealed the presence of a trash chute. The door to the room and the trash chute was noted to be unlocked and easily accessible to any person. Room 59-1-183 H was located near the entrance to the dining room which was available to patients, visitors and staff.

Staff present on tour verified the observations.

Based on facility observation, staff interview and verification, the facility failed to ensure that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were located in a room protected as a hazardous area when not attended. The facility had capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD. Observation of the first floor ultrasound sub-waiting area revealed the presence of a wheeled container, larger than 32 gallon, which contained soiled linen. The wheeled container was placed in a small area with an accordion type door in the closed postion to conceal the container.

Observation of the emergency department revealed the presence of a wheeled container, larger than 32 gallons, used to hold trash. The wheeled container was stored in an exit corridor. Located in the same corridor, in close proximity was a large red barrel, two additional smaller trash containers ( less than 32 gallons) and one soiled linen container. Staff LL present at the observation verified the containers were usually stored in the exit corridor.

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 capacity for 267 beds with a census of 139 patients at the time of survey.

Finding included:

On 05/29 and 05/30/13 between the hours of 8:00 A.M. and 5:00 P.M. tour of the facility was conducted with Staff AA, BB, CC and DD.

Observation of a medical gas storage area located on the second floor revealed the room contained 11 E size cylinders of oxygen, one E size cylinder of nitrous and two H size cylinders of carbon dioxide and nitrous. The larger, H size cylinders were placed at the wall near the light switch to the room. The light switch was noted to be less than five feet from the from the floor.

Observation of a medical gas storage area for empty cylinders, located in the basement, revealed the presence of an electrical receptacle placed just above the floor in the room. Located in another room next to the empty cylinder storage room was an area for storage of full cylinders. This room was noted to be stacked to capacity with medical gas cylinders, most of which were oxygen. The total within the room was well over 3000 cubic feet. Staff present could not verify that no electrical receptacles were placed out of view in the room.

Staff present on tour verified the observations.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing the facility.

Findings included:

Facility tour took place on 06/03/13 between 3:00 P.M.and 5:00 P.M. with staff members FF, II, and JJ. During tour of the physician office spaces, observation was made of smoke detectors located near air flow devices. Areas identified by staff present on tour were listed as C130-36, C130-38, C130-16 and C130-18. Observation of the rooms revealed small storage areas or small basic laboratory areas. The smoke detectors were about 12 to 18 inches from the air flow devices.

One smoke detector, present in the conference room of the facility, was also approximately the same distance from the air flow device.

These findings were verified by staff present during tour.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular on the third floor. This has the potential to affect all patients, visitors, and staff at the facility.

Findings:

On 05/29/13 at 11:15 A.M. a tour was conducted of the facility ' s third floor with Staff MM and NN. Observation of clean utility room 1195 revealed two power strips daisy-chained. The first was plugged into the second which was plugged into the wall. The first had one receptacle in use and the second had two receptacles in use plus the one used by the other power strip.

During the tour, in an interview Staff MM confirmed the finding.