HospitalInspections.org

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K114/K115 of CMS-2786U
a. Occupancy separation and smoke barrier, respectively are incomplete, the one hour fire barrier doesn't separate other tenant spaces from the hospital based facility; and smoke barrier lacks smoke damper duct penetration, and self- closing device on storage room door in barrier.

b. there is unsealed holes in the one hour barrier located near the rear exit.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the sprinkler system is noncompliant with Business Occupancy requirements due to the following:

1. K12 of CMS-2786U - there is no sprinkler coverage in the following areas:
a. nurse's medication room located in Infusion Center

b. closet in surgical wait loss room 003.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there is an unsealed conduit penetration in corridor wall above ceiling - beside elevator on second floor north.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, doors protecting egress corridors are incomplete due to the following:

1. Lack of positive latching hardware on cross corridor doors to main Operating Suite.

2. Lack of positive latching hardware on double doors to recovery suite - located near suite doors to main operating suite.

3. Lack of positive latching hardware on door to kitchen - located near front elevator lobby.

4. Lack of positive latching hardware on double doors to kitchen, inactive leaf is not latched in the closed position. Doors could be pulled open due to lack of automatic latches on inactive leaf - located beside medical gas storage area.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, fire door to elevator shaft is not self-closing and latching - located in mechanical room on second floor.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there are unsealed penetrations in smoke barrier wall near EMT room - located on first floor.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, hazardous areas are incomplete due to the following:

1. Rehabilitation nursing supply storage room contains alcohol based hand sanitizers - room is not designed as a severe hazardous area storage room with forty-five minute rated fire door.(located on sixth floor)

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there is no solid and slip-resistant surface from exit discharge gate to publicway - enclosed exterior courtyard near first floor dining room.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, exit access is incomplete due to the following:

1. OT storage room is equipped with a manual deadbolt, in addition to the positive latching hardware, that creates greater than a single hand motion to exit the room. The additional hardware is mounted greater than forty-eight inches above the floor.(located on sixth floor)

Note: This door hardware arrangement consist throughout the facility on door openings in corridor walls.

2. Dictation room is equipped with a manual deadbolt, in addition to the positive latching hardware, that creates greater than a single hand motion to exit the room. The additional hardware is mounted greater than forty-eight inches above the floor.(located on the sixth floor)

3. Lack of guardrails protecting exit discharge boundary near loading dock - located near exit discharge adjacent to kitchen area.

4. The use of delayed egress special locking arrangement on cross corridor doors near room 304 - locks at this location create more than one delayed egress locking arrangement in the same egress path.

Note: The facility has no documentation supporting the use of categorical waiver permitted by CMS.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, emergency lighting is incomplete due to the following:

1. Lack of emergency lighting connected to the Life Safety Branch of the essential electrical system - first floor medical records area, north exit vestibule and lobby.

2. Lack of unswitched emergency light circuit, connected to Life Safety Branch of essential electrical system, in corridor located on 8-West.(second floor)

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, exit and directional signs are incomplete due to the following:

1. Lack of exit directional sign at operating suite corridor near sterile processing entrance - located on second floor.

2. Lack of exit sign in corridor near EKG back entrance.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the fire alarm system is incomplete due to the following:

1. there is no remote annunciator for the facility fire alarm system within the infusion care or wound care center - facilities are located on the same floor within the Medical Office Building.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, sprinkler coverage is incomplete due to the following:

1. Lack of sprinkler in walk-in cooler - located in main kitchen area on first floor.

2. Lack of sprinkler coverage for workroom behind IMCU nurse's station on first floor.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, sprinkler system valve supervision is incomplete due to the following:

1. There is no electrical supervision of valves located upstream of sprinkler system low air pressure, and alarm pressure switches - located in mechanical room near kitchen.

2. Use of unacceptable valve monitoring device for sprinkler system component located in boiler room on first floor - cord connected tamper switch device is not listed for use on NFPA approved systems.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, sprinkler system maintenance is incomplete due to the following:

1. different types of pendent sprinklers located in the same compartment - located in administrative corridor near switchboard room, and information desk on first floor.

2. paint on heat sensitive element of sprinkler - located in IT closet beside medical records.

3. paint on heat sensitive element of sprinkler - located in storage room beside IT closet in medical records area.

4. paint on sprinkler near EMT entrance on first floor.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, HVAC systems are incomplete due to the following:

1. Combination fire and smoke damper did not close with activation of duct smoke detectors serving area - located behind access panel, beside elevator lobby at entrance #1, to Same Day Surgery.

2. Lack of air handler manual emergency stop switch for unit serving Medical Records - located on first floor.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there is no baffle between the deep fryer and the range -located in first floor kitchen area.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, means of egress clearance is incomplete due to the following:

1. wall mounted charting station does not self-close - located on corridor wall beside room 504.

2. door to shower rooms does not open 180 degrees against corridor wall - located in Neon Unit, and across corridor from room 503. Doors protrude greater than seven inches into corridor width in fully opened position.

3. closet door protrudes greater than seven inches into corridor width in fully open position - located across corridor from room 239.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, medical gas cylinders are stored improperly due to the following:


1. Clean storage room in Labor/Delivery - oxygen cylinders are stored less than five feet from combustible supplies.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there are no gauges installed on medical gas piping located in zone valve enclosure box - located in Adult Care section near room 364.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the relative humidity is 18% in OR #1; and 15% in OR #2.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the essential electrical system is incomplete due to the following:

1. The emergency power system failed to restore power in not greater than ten seconds during loss of normal power to the automatic transfer switch #4.

2. lack of generator annunciator panel for emergency power system serving south campus hospital - panel must be located in a supervised area were signals can be heard and observed.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, the electrical systems are incomplete due to the following:

1. Lack of identification label on Life Safety panelboard - located in switchboard room on first floor.

2. Lack of complete labeling of all circuit breakers in electrical panel - emergecny panel located in sixth floor electrical equipment room near south nurse's station.

3. Lack of label on snap switch identifying device to be shut-off - located behind nurse's station on sixth floor south wing.

4. Lack of cover on exposed incandescent light bulb located above storage space - janitor's closet near north tower elevators.

5. Lack of junction box covers on live electrical equipment - located in the Edgegard Units in the pharmacy on third floor.

6. Lack of documentation to demonstrate that all electrical circuit breakers are maintained and tested in accordance with the manufacturer's instructions.

7. Ground-fault circuit interrupters did not trip during test - located in bathrroms of rooms 415, and 238.

8. Lack of knockout cover for electrical junction box - located behind main sprinkler piping in boiler room near exterior ramp, and loading dock.

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, elevator operation is incomplete due to the following:

1. during test of corridor smoke detector near smoke barrier, it was observed that elevator returned to the level of exit discharge; however, the doors to elevator did not open.(elevator #1)

Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, there is an ABHR located above an electrical device located in the dining room near kitchen area.