HospitalInspections.org

This standard is not met as evidenced by:

During record review of the Emergency Preparedness Plan of this facility on December 3, 2018 with the Emergency Preparedness Liaison, surveyor 37694 did observe:

Documentation could not be provided to indicate that this facility has a means of providing food whether they evacuate or shelter in place.

Documentation could not be provided to indicate that this facility has a means of providing medical supplies whether they evacuate or shelter in place.

Documentation could not be provided to indicate that this facility has a means of providing pharmaceutical supplies whether they evacuate or shelter in place.

Documentation could not be provided to indicate that this facility has a means of providing fuel to operate the emergency generator whether they evacuate or shelter in place.

This standard is not met as evidenced by:

During record review of the Emergency Preparedness Plan of this facility on December 3, 2018 with the Emergency Preparedness Liaison, surveyor 37694 did observe:

Documentation could not be provided to indicate that this facility has a means of providing fuel for the emergency generator whether they evacuate or shelter in place.

On 12-3-2018 while surveying the facility with surveyor 05910 and the Physical Plant Director, it was observed:



90 minute fire rated door located near the breast care reception area shall self-close; this door is part of a required 2 hour fire barrier.


90 minute fire rated double doors located near breast care shall latch at the bottom.


Hancock Wing

90 minute doors leading to strater Wing shall latch at the bottom.




37694

This standard is not met as evidenced by:

While inspecting this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor 37694 did observe:

Missing fireproofing on the I-Beams where sprinkler hangers have been attached throughout the Shipping/Receiving area.

On 12-3-2018 while surveying the facility with the Physical Plant Director, it was observed:

One of two interior exit stairs located on the Hancock Wing level one does not meet 7.7.3. This stair serves as a required exit from the Cath Lab area and Laboratory area located on 1st floor Hancock Wing. The exit is not clearly marked and travel distance to the next available exit is beyond the allowed travel distance. At the 2nd floor Hancock level where this exit terminates, the exit door does not swing in the direction of egress as required by 7.2.1.4.2

Second interior exit stair that discharges at the lower level where Hancock and Strater Wings; the exit door at level 1 does not swing in the direction of egress as required by 7.2.1.4.2. This interior exit stair does not meet the requirements of 7.7.2 (3) Discharging at this 1st level (Hancock and Strater Wings) all doors are 90 minute fire rated and held open with magnetic hold open devices. During an emergency event people landing in this corridor would not be directed to an exit as there are no emergency exit signs shown when the 90 minute fire rated doors are closed.


The corridor to and from PT/OT which is is by hospital patients is narrower then the 8 ft. allowable width. It measured between 5 ft. and 3 ft. 9 inches.

On 12-3-2018 while surveying the facility with surveyor 05910 and the Physical Plant Director, it was observed:

In the Cardiology area on the Hancock Wing 2nd floor; Soiled linen carts and Clean linen carts stored in the corridor.


In the Cath Lab area on the 1st floor Hancock Wing; soiled linen carts, coffee carts, water cooler and recyle cans stored in the corridor.

Cath Lab storage area; storage blocking required exit.


37694

This standard is not met as evidenced by:

While inspecting this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor 37694 did observe:

Exit access corridor from Shipping/Receiving Area to exterior door is obstructed by combustible storage and reduced to 24" in some areas. This corridor shall maintain clear width of at least 44".

Patient bed stored in from of On-Call Sleeping Room outside the Emergency Department obstructing corridor door from opening.

Emergency Department has Mobile Imaging Unit being stored outside X-Ray Room.

On 12-3-2018 while surveying the facility with surveyor 34673 and the Physical Plant Director, it was observed:

The marked exit from maternity to the outside contained new chairs, tables and other items obstructing the egress path..

This REQUIREMENT is not met as evidenced by:

On 11/03/18, Based on observation of Surveyors 39983 and 33342 in the accompany of the Maintenance Worker observed:


1. Electric room located on lower level across from OR entrance is not self-closing.
2. Door to Main Storage room across from elevators near Med Gas is required to be self-closing. Self-closing device is not working properly.
3. Materials Handling main entrance door does not latch when closed.
4. FD 14 stairwell door does not latch when closed. Latching device has been disabled.




Based on observation of surveyors 34673 and 05910 while surveying the facility with the maintenance director, it was observed:

1) Panic hardware by room 207 had the latching mechanism disabled.
2) The storage room door by room 217 was not latchng.
3) The double doors by room 200 had the latching mechanism disabled.

On 12-3-2018 while surveying the facility with surveyor 05910 and 34673 and the Physical Plant Director, it was observed:

A bench and table in the corridor, by room 200, which were not secured to either the wall or the floor, as required.

On 12-3-2018 while surveying the facility with the Physical Plant Director, it was observed:


Hancock Wing Level 1

Elevator Machine room:

1. Door shall self-close and latch.
2. Conduit penetrations through the walls shall be sealed to create a one hour fire rated assembly.


Mechanical room across from the elevator machine room; Spray foam shall be removed from any all ares and all pipe penetrations shall be sealed to create a one hour fire rated assembly.


All spray foam shall be removed from Cath Lab electrical room and all pipe penetrations sealed to create a one hour fire rated assembly.




37694

This standard is not met as evidenced by:

While inspecting this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor 37694 did observe:

Wall pipe penetrations found in Electrical Room across from Overflow X-Ray Waiting Room shall be sealed to resist the passage of smoke.


Based on observations of surveyors 34673 and 05910 while walking through the facility accompanied by the maintenance director observed:

1)The electrical room across from room 214 had used spray foam for seal of the cconduit. Spray foam shall be removed from any areas and all pipe or conduit penetrations shall be sealed to create a one hour fire rated assembly.
2) The mechanical room in Bewend had spray foam which needs to be removed and sealed to create a one hour fire rating.
3) The mechanical room in Bewend had pipe penetrations and the wall ceiling joint which needs to be properly sealed with material which will maintain the one hour fire rating.
4) The room known as the OIT room was noted on the drawings as being a 2 hour fire rated space. However the conduit carrying the wires out of the space was not properly sealed to maintain the rating.

This REQUIREMENT is not met as evidenced by:

On 11/03/18, Based on observation of Surveyors 39983 and 33342 in the accompany of the Maintenance Worker observed:

1. Blue rigid foam board exposed above ceiling tiles next to main elevators on Lower Level is required to be covered or removed.

2. Med Gas room in Lower Level has structural beam missing fire stopping material.

On 12-3-2018 while surveying the facility with surveyor 05910 and surveyor 34673, and the Physical Plant Director, observed:

The lack of a fire alarm horn and strobe in the overnight physician's sleeping room.

On 12-3-2018 while surveying the facility with surveyor 05910 and 34673, and the Physical Plant Director, it was observed:

Two fire alarm pull stations near the strair exit door by room 200 and nly one pull station isrequired at this location.

On 12-3-2018 while surveying the facility with the Physical Plant Director, it was observed:


No sprinkler coverage in storage area closet near kitchen.

No sprinkler coverage in the freezer.

On 12-3-2018 while surveying the facility with the Physical Plant Director, it was observed:



Hancock Wing Level 1

Cath Lab procedure room; Sprinkler Heads are obstructed by the machinery/ rails holding up machinery.



37694

This standard is not met as evidenced by:

During record review of this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor did observe:

5 year internal inspection of the wet sprinkler system has been overdue since February 2018.

Documentation could not be provided to indicate that the following discrepancies have been remedied from 6/15/18 sprinkler contract:
1. Add four sprinklers in the Electrical Room
2. Add eight sprinklers, re-work four sprinklers in the Emergency Area Patient Rooms
3. Add seven window sprinklers near Fire Doors 6, 27, & 29


39983

This REQUIREMENT is not met as evidenced by:

On 11/03/18, Based on observation of Surveyors 39983 and 33342 in the accompany of the Maintenance Worker observed:


3 Sprinkler Heads located in OR #2 were obstructed/ loaded with foriegn matter.

This REQUIREMENT is not met as evidenced by:

On 11/03/18, Based on observation of Surveyors 39983 and 33342 in the accompany of the Maintenance Worker observed:

1. 1 hour rated corridor next to OR entrance and corridor doors has penetrations, wall does not extend to underside of ceiling. Metal caps visible (sheet rock is missing.)

2. 2 hour rated wall above corridor doors next to Getiage Group Office does not extend to underside of ceiling.

3. Wall penetrations in 2 hour rated wall above Material Handling doors.

4. Wall penetrations in 2 hour rated wall above corridor doors across from Material Handling.

5. Wall penetrations in 2 hour rated wall above FD 29 doors.

6. Wall penetrations in rated wall above ceiling tiles outside of Brest Care Reception, section of wall does not extend to underside of ceiling.

7. Wall penetrations in mechanical space across from OR entrance.

8. FD 27 fire doors are 1 hour rated. Based on record review of facility plans, these doors are required to be 90 minute rated doors.

9. FD 29 fire doors are 1 hour rated. Based on record review of facility plans, these doors are required to be 90 minute rated doors.

10. A portion of the lock assembly has been removed, altering the integrity of the 90 minute rated fire door leading to recovery, located across from McGrath waiting area.

On 12-3-2018 while surveying the facility with surveyor 05910 and the Physical Plant Director, it was observed:


Hancock Wing 2nd floor

Foot peg found attached to sleep center door.

Employee break room door near kitchen propped open with wooden wedge.


Strater Wing 2nd floor
Patient room doors are split doors; one door being larger than the other and working independently. A large majority of the patient room doors have gaps between the two door leafs greater than 1/8"


Biewend Wing 2nd floor
Patient room doors are split doors; one door being larger than the other and working independently. A large majoritty of the patient room doors have gaps between the two door leafs greater than 1/8"

Janitor closet is missing a bolt from the hinge in the door and will not resist the passage of smoke; located in the door slab.

Bed stored in the shower room located across from room 213 was to large for the room and the door could not be closed.

Storage room door across from room 210 shall latch.

Corridor door across from room 212 shall latch.

Janitor closet near elevator machine room and kichen shall close and latch.

This standard is not met as evidenced by:

During interview with the Supervisor of the Emergency Department of this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor 37694 did observe:

Wheeled items relocation is not included in the Disaster Plan kept at the Nurse's Station.

This standard is not met as evidenced by:

During record review of this facility on December 3, 2018 with the Facilities Coordinator and surveyor 37694, surveyor 00452 did observe:

Fire drills have not been conducted quarterly per shift in 2018.
2nd shift was involved in one drill in the 2nd Quarter.
3rd shift was involved in one drill in the 1st Quarter.


Third shift fire drill was not announced with a coded announcement or activation of the fire alarm system.

This standard is not met as evidenced by:

During record review of this facility on December 3, 2018 with the Facilities Coordinator and surveyor 00452, surveyor 37694 did observe:

No documentation was provided to indicate that the indivudual perforing fire door inspections posessed the knowledge, training or experience required by NFPA 80 to complete the required annual door inspections per NFPA 80.

Based on observations of surveyors 34673 and 05910 while walking through the facility accompanied by the maintenance director observed:

1)In medical records a protective plate was found missing from the wall outlet.
2) In the overnight physician's room multiple strings of decorative lights were plugged into one another.

This REQUIREMENT is not met as evidenced by:

On 11/03/18, Based on observation of Surveyors 39983 and 33342 in the accompany of the Maintenance Worker observed:

1. A power strip located on the large black cart (Eye Tower) in OR 2 is required to be hospital grade.



On 12-3-2018 while surveying the facility with 34673 and the maintenance director it was observed:

1) An extension cord being used in place of sufficient outlets to run a fan in the 1st office on the left in the administrative office.
2) An extension cord being used as permanent power in medical records.
3) A white noise machine with its power cord running through the physician's work room doorway.
4) Room 222 had a unsecrured and unprotected power strips.