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.

Based upon observation and interview, it was determined that the facility's common wall with a non-conforming building failed to be maintained per regulations on one of four floors.

Findings include:

Observation on December 10, 2013 at 12:45 pm revealed the facility had unsealed penetrations of the common wall on the Skybridge side of the common wall above the suspended ceiling on the first floor level.

Interview with the VPPO on December 10, 2013 at 12:45 pm confirmed the unsealed penetrations of the common wall.

Based upon observation and interview, it was determined the facility failed to ensure the two (2) hour common wall and/or doors were in accordance with regulations on one of five floors.

Findings include:

Observation on December 10, 2013, at 10:00 am revealed the common wall doors S0G015 in Radiology lacked positive latching with the closure.

Interview with Engineering Technician (ET) on December 10, 2013, at 10:00 am confirmed the doors lacked positive latching.

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 building construction type and height does not meet regulations in all areas of the entire building.

Findings include:

Observation on December 9, 2013, at 9:30 am revealed the facility exceeds the height requirement for a Type II (000), Unprotected Noncombustible building. This is acceptable per FSES conducted on September 4, 2004.

Interview with Engineering Technician (ET) on December 9, 2013, at 9:30 am confirmed the building does not meet the height requirement and is acceptable per 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, 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 seven floors.

Findings include:

Observation on December 09, 2013 at 1:35 pm revealed the double corridor doors to the McGarvey multi-purpose lacked positive latching with the self-closer.

Interview with the Vice President of Plant Operations (VPPO) on December 9, 2013 at 1:35 pm confirmed the corridors lacked positive with the self-closer.

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 two of eleven floors.

Findings include:

1. Observation on December 9, 2013, between 11:20 am and 1:07 pm revealed the facility had corridor doors that were blocked open preventing the door from closing and latching at the following locations:
A. Fourth floor Employee Break Room (Computer on Wheels blocking door).
B. Second floor Social Worker's office (wooden wedge holding door open).
C. Second floor patient room 2206 (isolation cart blocking door).
D. Second floor patient room 2201 (isolation cart blocking door).

Interview with ET on December 9, 2013, at 1:07 pm confirmed the above listed doors were blocked preventing the doors from closing and latching.

2. Observation on December 9, 2013 at 2:15 pm revealed the lower level Central Processing corridor door lacked positive latching with the self-closer.

Interview with the Vice President of Operations (VPPO) on December 9, 2013 at 2:15 pm confirmed the corridor door 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, the smoke barrier door assemblies do not comply with regulations on one of eleven floors.

Findings include:

Observation on December 9, 2013, at 9:50 am revealed the eighth floor smoke barrier doors were blocked by an I-Vac machine preventing the doors from closing.

Interview with ET on December 9, 2013, at 9:50 am confirmed the smoke barrier doors were blocked from closing.

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, the piped in medical gas system does not comply with regulations on one of eleven floors.

Findings include:

Observation on December 9, 2013, at 12:40 pm revealed the medical gas shut-off valves on the second floor entrance to Surgical Suite locker room area had metal tags covering the location description of the area that the valves serviced.

Interview with ET on December 9, 2013, at 12:40 pm confirmed the location description of area serviced by shut-off valves was covered.

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.

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 two of seven floors.

Findings include:

Observation on December 9, 2013 between 1:00 pm and 1:55 pm revealed the facility was utilizing surge protectors in unapproved applications at the following locations:
A. The first floor Admitting Office had three surge protectors plugged into an other surge protector.
B. The lower level Med Tech School room had a surge plugged into an other surge protector.

Interview with the VPPO on December 9, 2013 at 1:55 pm confirmed the facility was utilizing unapproved surge protector applications at the above listed locations.



16143

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 five floors.

Findings include:

Observation on December 10, 2013, at 9:50 am revealed Radiology office S0G015 had a coffee pot plugged into a surge protector.

Interview with ET on December 10, 2013, at 9:50 am confirmed the coffee pot plugged into a surge protector.

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 10, 2013, between 12:40 pm and 1:10 pm revealed the facility had unauthorized electrical devices plugged into surge protectors at the following locations:
1. Second floor Dr. Bidwell's office (refrigerator plugged into a surge protector).
2. Second floor OBGYN suite Staff Lounge (microwave oven plugged into a surge protector).

Interview with ET on December 10, 2013, at 1:10 pm confirmed the above listed electrical devices were plugged into a surge protector.

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 two of eleven floors.

Findings include:

Observation on December 9, 2013, between 12:55 pm and 1:45 pm revealed the facility had unauthorized electrical appliances plugged into surge protectors at the following locations:
1. Second floor Staff Accountant office (refrigerator plugged into a surge protector).
2. Second floor O.R. Lounge (microwave oven plugged into a surge protector).
3. Ground floor Valet office (refrigerator plugged into a surge protector).
4. Ground floor Security office (toaster oven and coffee pot plugged into a surge protector).

Interview with ET on December 9, 2013, confirmed the above listed electrical devices were plugged into a surge protector.

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.

Based upon observation and interview, it was determined that the facility's common wall with a non-conforming building failed to be maintained per regulations on one of four floors.

Findings include:

Observation on December 10, 2013 at 12:45 pm revealed the facility had unsealed penetrations of the common wall on the Skybridge side of the common wall above the suspended ceiling on the first floor level.

Interview with the VPPO on December 10, 2013 at 12:45 pm confirmed the unsealed penetrations of the common wall.

Based upon observation and interview, it was determined the facility failed to ensure the two (2) hour common wall and/or doors were in accordance with regulations on one of five floors.

Findings include:

Observation on December 10, 2013, at 10:00 am revealed the common wall doors S0G015 in Radiology lacked positive latching with the closure.

Interview with Engineering Technician (ET) on December 10, 2013, at 10:00 am confirmed the doors lacked positive latching.

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 building construction type and height does not meet regulations in all areas of the entire building.

Findings include:

Observation on December 9, 2013, at 9:30 am revealed the facility exceeds the height requirement for a Type II (000), Unprotected Noncombustible building. This is acceptable per FSES conducted on September 4, 2004.

Interview with Engineering Technician (ET) on December 9, 2013, at 9:30 am confirmed the building does not meet the height requirement and is acceptable per 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, 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 seven floors.

Findings include:

Observation on December 09, 2013 at 1:35 pm revealed the double corridor doors to the McGarvey multi-purpose lacked positive latching with the self-closer.

Interview with the Vice President of Plant Operations (VPPO) on December 9, 2013 at 1:35 pm confirmed the corridors lacked positive with the self-closer.

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 two of eleven floors.

Findings include:

1. Observation on December 9, 2013, between 11:20 am and 1:07 pm revealed the facility had corridor doors that were blocked open preventing the door from closing and latching at the following locations:
A. Fourth floor Employee Break Room (Computer on Wheels blocking door).
B. Second floor Social Worker's office (wooden wedge holding door open).
C. Second floor patient room 2206 (isolation cart blocking door).
D. Second floor patient room 2201 (isolation cart blocking door).

Interview with ET on December 9, 2013, at 1:07 pm confirmed the above listed doors were blocked preventing the doors from closing and latching.

2. Observation on December 9, 2013 at 2:15 pm revealed the lower level Central Processing corridor door lacked positive latching with the self-closer.

Interview with the Vice President of Operations (VPPO) on December 9, 2013 at 2:15 pm confirmed the corridor door 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, the smoke barrier door assemblies do not comply with regulations on one of eleven floors.

Findings include:

Observation on December 9, 2013, at 9:50 am revealed the eighth floor smoke barrier doors were blocked by an I-Vac machine preventing the doors from closing.

Interview with ET on December 9, 2013, at 9:50 am confirmed the smoke barrier doors were blocked from closing.

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, the piped in medical gas system does not comply with regulations on one of eleven floors.

Findings include:

Observation on December 9, 2013, at 12:40 pm revealed the medical gas shut-off valves on the second floor entrance to Surgical Suite locker room area had metal tags covering the location description of the area that the valves serviced.

Interview with ET on December 9, 2013, at 12:40 pm confirmed the location description of area serviced by shut-off valves was covered.

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.

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 two of seven floors.

Findings include:

Observation on December 9, 2013 between 1:00 pm and 1:55 pm revealed the facility was utilizing surge protectors in unapproved applications at the following locations:
A. The first floor Admitting Office had three surge protectors plugged into an other surge protector.
B. The lower level Med Tech School room had a surge plugged into an other surge protector.

Interview with the VPPO on December 9, 2013 at 1:55 pm confirmed the facility was utilizing unapproved surge protector applications at the above listed locations.



16143

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 five floors.

Findings include:

Observation on December 10, 2013, at 9:50 am revealed Radiology office S0G015 had a coffee pot plugged into a surge protector.

Interview with ET on December 10, 2013, at 9:50 am confirmed the coffee pot plugged into a surge protector.

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 10, 2013, between 12:40 pm and 1:10 pm revealed the facility had unauthorized electrical devices plugged into surge protectors at the following locations:
1. Second floor Dr. Bidwell's office (refrigerator plugged into a surge protector).
2. Second floor OBGYN suite Staff Lounge (microwave oven plugged into a surge protector).

Interview with ET on December 10, 2013, at 1:10 pm confirmed the above listed electrical devices were plugged into a surge protector.

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 two of eleven floors.

Findings include:

Observation on December 9, 2013, between 12:55 pm and 1:45 pm revealed the facility had unauthorized electrical appliances plugged into surge protectors at the following locations:
1. Second floor Staff Accountant office (refrigerator plugged into a surge protector).
2. Second floor O.R. Lounge (microwave oven plugged into a surge protector).
3. Ground floor Valet office (refrigerator plugged into a surge protector).
4. Ground floor Security office (toaster oven and coffee pot plugged into a surge protector).

Interview with ET on December 9, 2013, confirmed the above listed electrical devices were plugged into a surge protector.