HospitalInspections.org

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of five floors.

Findings include:

Observation on December 10, 2013 at 10:00 am revealed unsealed common wall penetrations above the common wall doors between the Southeast building and the Rehab building at the third floor level.

Interview with the Vice President of Plant Operations (VPPO) December 10, 2013 at 10:00 am confirmed the unsealed penetrations of the common wall.

K-012

Based upon observation and interview, it was determined the building construction type and height does not meet regulations in all areas of the entire building.

Findings include:

Observation on December 10, 2013 at 11:00 am revealed the facility exceeds the height requirement for a Type II (000), Unprotected Noncombustible construction building. This is acceptable per FSES conducted on September 23, 2004.

Interview with the VPPO on December 10, 2013 at 11:00 am confirmed the building does not meet the height requirement and is acceptable per an FSES.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on one of four floors.

Findings include:

Observation on December 10, 2013 at 10:35 am revealed the facility had corridor doors that lacked positive latching at the following locations:
A. Third floor Mental Health Unit room 3415.
B. Third floor Mental Health Unit room 3408.

Interview with the Vice President of Plant Operations on December 10, 2013 at 10:35 am confirmed the corridor doors lacked positive latching and subsequent correction during the survey.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of seven floors.

Findings include:

Observation on December 9, 2013 at 1:50 pm revealed the Lower Level Lab smoke barrier door self-closer prevents the the door from being open.

Interview with the VPPO on December 9, 2013 at 1:50 pm confirmed the smoke barrier door could not be re-opened after being closed.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of eleven floors.

Findings include:

1. Observation on December 9, 2013, at 12:35 pm revealed the second floor Supply Room door next to room 2231 lacked positive latching with the closure.

Interview with ET on December 9, 2013, at 12:35 pm confirmed the door lacked positive latching.

2. Observation on December 9, 2013, at 10:30 am revealed the seventh floor Hip and Joint supply room corridor door in the west hall lacks positive latching with the self-closer.

Interview with the VPPO on December 9, 2013 at 10:30 am confirmed the supply room corridor door lacked positive latching with the self-closer and subsequent correction during the survey.

Based upon observation and interview, the illumination of the means of egress failed to meet requirements on one of eleven floors.

Findings include:

Observation on December 9, 2013, at 10:50 am revealed the fourth floor stair tower N-4 exit illumination was burned out.

Interview with ET on December 9, 2013, at 10:50 am confirmed the exit illumination was burned out.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of thirteen floors.

Findings include:

Observation on December 9, 2013 at 10:20 am revealed the seventh floor mechanical room had a fluorescent light fixture suspended from fire sprinkler piping.

Interview with the VPPO on December 9, 2013 at 10:20 am confirmed the lighting fixture was suspended from sprinkler piping and subsequent correction during the survey.

Based on observation and interview portable fire extinguishers shall be provided in all health care occupancies in accordance with regulations.

Findings include:

Observation on December 10, 2013, at 1:15 pm revealed the ground floor CHF Clinic had a fire extinguisher that was not readily visible for instant use in case of fire.

Interview with Engineering Technician (ET) on December 10, 2013, at 1:15 pm confirmed the fire extinguisher was not readily visible.

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of four floors.

Findings include:

Observation on December 11, 2013 at 10:20 am revealed that a IV cart was placed in front of the emergency medical gas shut-off valves in Pre-Op obstructing immediate access.

Interview with the Engineering Coordinator on December 11, 2013 confirmed the the IV cart was placed in front of the emergency medical gas shut-off panel.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of four floors.

Findings include:

Observation on December 11, 2013 at 9:40 am revealed that a hydraulic oil cooling fan was plugged into an extension cord in the lower level elevator equipment room.

Interview with the Engineering Coordinator on December 11, 2013 at 9:40 am confirmed the unapproved application of an extension cord.