HospitalInspections.org

A. Based on observations, the facility has wall four (4) of 12 penetrations.

The findings include:

During observations made May 2, 2016 through May 6, 2016 between 10:00 AM and 2:00 PM, the following areas have wall penetrations:

1. Elevator machine room inside of the mechanical room next to motor #4
2. Room 51010
3. Room 41096

These penetrations pose a potential hazard in an event of an emergency.

B. Based on observation, the facility has six (6) of 20 ceiling tile missing.

The findings include:

During observations on May 2, 2016 through May 6, 2016 at approximately 10:00 am through 2:00 pm, the following areas have ceiling tile penetrations:

1. Room 51096
2. Room 41096
3. Room 41086
4. Room 41084

These ceiling penetrations created a potential hazard for staff and patients in an event of an emergency.

C. Based on observation, the facility has twenty-two (22) of 30 ceiling tile missing.

The findings include:

During observations on May 2, 2016 through May 6, 2016 at approximately 10:00 AM through 2:00 PM, the following areas have missing ceiling tiles:

1. North side offices (former school section)
2. Room 6130
3. Room 61120

The missing ceiling tiles create a potential hazard for staff and patients in an event of an emergency.

A. Based on observations, the facility staff failed to ensure that two (2) of 300 doors closed flush and latched into the frame to prevent the passage of smoke.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the doors in the following areas failed to close flush and latch into the frame:

1. Stairway 3 exit door on 6th floor
2. 6th floor Northside Men's restroom

The failure of the doors to close flush and properly latch into the frame creates a potential fire hazard for staff and patients, in the event of an emergency.

B. Based on observation, the facility staff failed to ensure that approved doors were utilized in one (1) of 300 observations to resist fire, for at least 20 minutes and the spread of smoke.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the conference room door on 6 South was changed from the previously approved door.

The unapproved door creates a potential fire hazard for staff and patients, in the event of an emergency.

C. Based on observations, the facility staff failed to ensure that one (1) of 300 facility doors did not have a gap greater than 1/8th inch to prevent the passage of smoke. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the door leading to the Psychiatry Unit on the 6th floor had a gap greater than 1/8th inch.

A gap around the door greater than 1/8th inch creates a potential fire hazard for staff and patients.

D. Based on observations, the facility staff failed to ensure that proper hold open devices were used in three (3) of 300 observations to ensure the release of doors, when pushed or pulled. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the doors were observed being held open with an improper hold open device in the following areas:

1. Room 81072
2. Room B1113
3. Room 81039

The improper hold open devices create a potential hazard for staff and patients, in the event of an emergency.

Based on observations, the facility staff failed to ensure that two (2) of 300 facility smoke detectors were maintained.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, facility smoke detectors were missing in the following areas:

1. Room 41176
2. Room 41184

The missing smoke detectors create a potential fire hazard for staff and patients, in the event of an emergency.

A. Based on observation, the facility staff failed to ensure that one (1) of 20 standpipe caps were maintained in a manner to facilitate easy removal, in the event of a fire emergency.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) standpipe cap, located on the rooftop beside Stairwell 3 exit door, was tightened at a level that prevented easy removal, in the event of a fire.

The standpipe cap creates a potential fire hazard for staff and patients, in the event of an emergency.

B. Based on observations, the facility staff failed to ensure that two (2) of five (5) facility sprinkler head caps were maintained in reliable operating condition.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, two (2) sprinkler caps on 6 South, in the large room, were missing.

The failure to maintain the sprinkler caps in reliable operating condition pose a potential fire hazard, in an event of an emergency.

C. Based on observation, the facility staff failed to ensure one (1) of 300 facility sprinkler heads was inspected and maintained in reliable opening condition. The observation was made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the sprinkler head on 6 South was observed not mounted flush with the ceiling.

The failure to properly maintain the sprinkler head poses a potential fire hazard, in the event of an emergency.

D. Based on observations, the facility staff failed to ensure that thirty-two (32) of 500 facility sprinkler heads were free from dust. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, sprinkler heads were observed dust laden in the following areas:

Main Hospital
1. Stairwell 2 exit on the 6th floor.
2. Kitchen production area
3. Kitchen freezer 4

George Washington University-Outpatient Rehabilitation Center 6th floor
4. Office areas, and treatment areas at GW-Pain Management
5. Exam room 7
6. Inside physician's office
7. Inside exam room 5 at GW-Cardiac Surgery Center
8. Front lobby
9. Inside of supply closet
10. Inside restroom
11. Director of cardiac surgery office
12. Inside of administrative cubicles at George Washington University-Surgery Center
13. Exit coming from nourishment
14. Inside of sit-up and nourishment
15. Inside of consultation area
16. In front of housekeeping by nourishment

The dust laden sprinkler heads pose as a potential fire hazard, in an event of an emergency.

E. Based on observations, the facility failed to ensure that three (3) of 500 facility escutcheon plates were properly installed around the sprinkler heads.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, escutcheon plates were observed missing in the following areas:

1. NICU equipment room at George Washington University-Outpatient Rehabilitation Center
2. Near mechanical room at George Washington University -Cardiac Surgery Center
3. Elevator lobby outside of main entry door

The missing escutcheon plates create a potential fire hazard for staff and patients, in the event of an emergency.

F. Based on observation, the facility staff failed to ensure that one (1) of 500 facility sprinkler heads was free from corrosion.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the sprinkler head, located in the nourishment area at the George Washington University -Surgery Center, in front of the clean work station was observed with corrosion.

The corroded sprinkler head creates a potential fire hazard for staff and patients, in the event of an emergency.

Based on observations, the facility staff failed to ensure that five (5) of five (5) decorations displayed were flame retardant for use in the hospital.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the facility displayed decorations that were not flame retardant, in the following areas:

1. Room 51204
2. Room 41186 B
3. Room 42010
4. Room 32042
5. Room B 2002
6. Cafeteria

The decorations created a potential fire hazard for staff and patients.

A. Based on observations, the facility staff failed to ensure 20 of 20 surge protectors were mounted to prevent tripping. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the unmounted surge protectors were located in the following areas:


1. Room 61120
2. Room 61106
3. Nurse station south side
4. Room 51074
5. Room 51170
6. Room 51172
7. Room 51082
8. Room 51024
9. Room 52032
10. Room 41092
11. Room 41184
12. Room 41180
13. Room 42006
14. Room 31174
15. Room 31176
16. Room 31184

George Washington University -Cardiac Surgery Center

17. Across from administrative cubicles George Washington University-Pain Management Center
18. Administer corner
19. Office 3
20. Physician's office

Surge protectors that are not mounted pose a potential tripping hazard.

B. Based on observations, the facility staff failed to ensure storage was maintained at least 6 inches off the floor, in eleven (11) of 11 areas.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM storage was maintained less than 6 inches off the floor in the following areas:

1. North side offices (former school section)
2. Room 41098
3. Room B1054
4. Room B2064
5. Room B1109
6. Room 81039
7. Room G1092
8. Room G1048
9. Room 22019
10. Gift Shop
11. Room 81118

The storage located less than 6 inches off the floor poses a potential fire hazard, in the event of an emergency.

C. Based on observations, the facility staff failed to ensure two (2) of two (2) surge protectors were used in approved conditions. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM at the George Washington University Pain Management Center, two (2) surge protectors were used in unapproved conditions as follows:

1. Microwave plugged into surge protector
2. X-ray monitors plugged into a surge protector

The unapproved use of surge protectors pose a potential fire hazard.

D. Based on observations, the facility staff failed to ensure that five (5) of (5) corridors were not used for storage. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, storage was observed in the following corridors:

1. Room next to 81078
2. Room across from B2038
3. Room B1CO2
4. Room 2090
5. Bio Med next to elevator lobby

The improper storage in corridors create a potential fire hazard for staff and patients, in the event of an emergency.

E. Based on observations, the facility staff failed to ensure that storage was not blocking the exit in two (2) of two (2) observations. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, storage was observed blocking the exit in the following areas:

1. Ambulance entry door
2. Room 22036

Storage blocking exits create a potential hazard for staff and patients, in the event of an emergency.

A. Based on observation, the facility staff failed to ensure that one (1) of one (1) junction box was covered. The observation was made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the junction box in room 21011 was observed without a cover.

The uncovered junction box creates a potential fire hazard for staff.

B. Based on observations, the facility failed to ensure that six (6) of 6 extension cords were not used as permanent wiring. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, extension cords were observed being used as permanent wiring in the following areas:

1. Room G2018
2. Room 11102
3. 6th floor conference room
4. Room 61120
5. Room 51170
6. Room 41084

Extensions cords used as permanent wiring pose a fire potential hazard.

A. Based on observations, the facility has wall four (4) of 12 penetrations.

The findings include:

During observations made May 2, 2016 through May 6, 2016 between 10:00 AM and 2:00 PM, the following areas have wall penetrations:

1. Elevator machine room inside of the mechanical room next to motor #4
2. Room 51010
3. Room 41096

These penetrations pose a potential hazard in an event of an emergency.

B. Based on observation, the facility has six (6) of 20 ceiling tile missing.

The findings include:

During observations on May 2, 2016 through May 6, 2016 at approximately 10:00 am through 2:00 pm, the following areas have ceiling tile penetrations:

1. Room 51096
2. Room 41096
3. Room 41086
4. Room 41084

These ceiling penetrations created a potential hazard for staff and patients in an event of an emergency.

C. Based on observation, the facility has twenty-two (22) of 30 ceiling tile missing.

The findings include:

During observations on May 2, 2016 through May 6, 2016 at approximately 10:00 AM through 2:00 PM, the following areas have missing ceiling tiles:

1. North side offices (former school section)
2. Room 6130
3. Room 61120

The missing ceiling tiles create a potential hazard for staff and patients in an event of an emergency.

A. Based on observations, the facility staff failed to ensure that two (2) of 300 doors closed flush and latched into the frame to prevent the passage of smoke.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the doors in the following areas failed to close flush and latch into the frame:

1. Stairway 3 exit door on 6th floor
2. 6th floor Northside Men's restroom

The failure of the doors to close flush and properly latch into the frame creates a potential fire hazard for staff and patients, in the event of an emergency.

B. Based on observation, the facility staff failed to ensure that approved doors were utilized in one (1) of 300 observations to resist fire, for at least 20 minutes and the spread of smoke.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the conference room door on 6 South was changed from the previously approved door.

The unapproved door creates a potential fire hazard for staff and patients, in the event of an emergency.

C. Based on observations, the facility staff failed to ensure that one (1) of 300 facility doors did not have a gap greater than 1/8th inch to prevent the passage of smoke. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the door leading to the Psychiatry Unit on the 6th floor had a gap greater than 1/8th inch.

A gap around the door greater than 1/8th inch creates a potential fire hazard for staff and patients.

D. Based on observations, the facility staff failed to ensure that proper hold open devices were used in three (3) of 300 observations to ensure the release of doors, when pushed or pulled. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the doors were observed being held open with an improper hold open device in the following areas:

1. Room 81072
2. Room B1113
3. Room 81039

The improper hold open devices create a potential hazard for staff and patients, in the event of an emergency.

Based on observations, the facility staff failed to ensure that two (2) of 300 facility smoke detectors were maintained.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, facility smoke detectors were missing in the following areas:

1. Room 41176
2. Room 41184

The missing smoke detectors create a potential fire hazard for staff and patients, in the event of an emergency.

A. Based on observation, the facility staff failed to ensure that one (1) of 20 standpipe caps were maintained in a manner to facilitate easy removal, in the event of a fire emergency.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) standpipe cap, located on the rooftop beside Stairwell 3 exit door, was tightened at a level that prevented easy removal, in the event of a fire.

The standpipe cap creates a potential fire hazard for staff and patients, in the event of an emergency.

B. Based on observations, the facility staff failed to ensure that two (2) of five (5) facility sprinkler head caps were maintained in reliable operating condition.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, two (2) sprinkler caps on 6 South, in the large room, were missing.

The failure to maintain the sprinkler caps in reliable operating condition pose a potential fire hazard, in an event of an emergency.

C. Based on observation, the facility staff failed to ensure one (1) of 300 facility sprinkler heads was inspected and maintained in reliable opening condition. The observation was made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the sprinkler head on 6 South was observed not mounted flush with the ceiling.

The failure to properly maintain the sprinkler head poses a potential fire hazard, in the event of an emergency.

D. Based on observations, the facility staff failed to ensure that thirty-two (32) of 500 facility sprinkler heads were free from dust. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, sprinkler heads were observed dust laden in the following areas:

Main Hospital
1. Stairwell 2 exit on the 6th floor.
2. Kitchen production area
3. Kitchen freezer 4

George Washington University-Outpatient Rehabilitation Center 6th floor
4. Office areas, and treatment areas at GW-Pain Management
5. Exam room 7
6. Inside physician's office
7. Inside exam room 5 at GW-Cardiac Surgery Center
8. Front lobby
9. Inside of supply closet
10. Inside restroom
11. Director of cardiac surgery office
12. Inside of administrative cubicles at George Washington University-Surgery Center
13. Exit coming from nourishment
14. Inside of sit-up and nourishment
15. Inside of consultation area
16. In front of housekeeping by nourishment

The dust laden sprinkler heads pose as a potential fire hazard, in an event of an emergency.

E. Based on observations, the facility failed to ensure that three (3) of 500 facility escutcheon plates were properly installed around the sprinkler heads.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, escutcheon plates were observed missing in the following areas:

1. NICU equipment room at George Washington University-Outpatient Rehabilitation Center
2. Near mechanical room at George Washington University -Cardiac Surgery Center
3. Elevator lobby outside of main entry door

The missing escutcheon plates create a potential fire hazard for staff and patients, in the event of an emergency.

F. Based on observation, the facility staff failed to ensure that one (1) of 500 facility sprinkler heads was free from corrosion.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the sprinkler head, located in the nourishment area at the George Washington University -Surgery Center, in front of the clean work station was observed with corrosion.

The corroded sprinkler head creates a potential fire hazard for staff and patients, in the event of an emergency.

Based on observations, the facility staff failed to ensure that five (5) of five (5) decorations displayed were flame retardant for use in the hospital.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the facility displayed decorations that were not flame retardant, in the following areas:

1. Room 51204
2. Room 41186 B
3. Room 42010
4. Room 32042
5. Room B 2002
6. Cafeteria

The decorations created a potential fire hazard for staff and patients.

A. Based on observations, the facility staff failed to ensure 20 of 20 surge protectors were mounted to prevent tripping. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the unmounted surge protectors were located in the following areas:


1. Room 61120
2. Room 61106
3. Nurse station south side
4. Room 51074
5. Room 51170
6. Room 51172
7. Room 51082
8. Room 51024
9. Room 52032
10. Room 41092
11. Room 41184
12. Room 41180
13. Room 42006
14. Room 31174
15. Room 31176
16. Room 31184

George Washington University -Cardiac Surgery Center

17. Across from administrative cubicles George Washington University-Pain Management Center
18. Administer corner
19. Office 3
20. Physician's office

Surge protectors that are not mounted pose a potential tripping hazard.

B. Based on observations, the facility staff failed to ensure storage was maintained at least 6 inches off the floor, in eleven (11) of 11 areas.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM storage was maintained less than 6 inches off the floor in the following areas:

1. North side offices (former school section)
2. Room 41098
3. Room B1054
4. Room B2064
5. Room B1109
6. Room 81039
7. Room G1092
8. Room G1048
9. Room 22019
10. Gift Shop
11. Room 81118

The storage located less than 6 inches off the floor poses a potential fire hazard, in the event of an emergency.

C. Based on observations, the facility staff failed to ensure two (2) of two (2) surge protectors were used in approved conditions. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM at the George Washington University Pain Management Center, two (2) surge protectors were used in unapproved conditions as follows:

1. Microwave plugged into surge protector
2. X-ray monitors plugged into a surge protector

The unapproved use of surge protectors pose a potential fire hazard.

D. Based on observations, the facility staff failed to ensure that five (5) of (5) corridors were not used for storage. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, storage was observed in the following corridors:

1. Room next to 81078
2. Room across from B2038
3. Room B1CO2
4. Room 2090
5. Bio Med next to elevator lobby

The improper storage in corridors create a potential fire hazard for staff and patients, in the event of an emergency.

E. Based on observations, the facility staff failed to ensure that storage was not blocking the exit in two (2) of two (2) observations. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, storage was observed blocking the exit in the following areas:

1. Ambulance entry door
2. Room 22036

Storage blocking exits create a potential hazard for staff and patients, in the event of an emergency.

A. Based on observation, the facility staff failed to ensure that one (1) of one (1) junction box was covered. The observation was made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, the junction box in room 21011 was observed without a cover.

The uncovered junction box creates a potential fire hazard for staff.

B. Based on observations, the facility failed to ensure that six (6) of 6 extension cords were not used as permanent wiring. The observations were made in the presence of the facility staff.

The findings include:

During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, extension cords were observed being used as permanent wiring in the following areas:

1. Room G2018
2. Room 11102
3. 6th floor conference room
4. Room 61120
5. Room 51170
6. Room 41084

Extensions cords used as permanent wiring pose a fire potential hazard.