HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to ensure the integrity of the building construction in three of three floors and the lower ground floor. Findings include:

A hospital tour on 02/04/15 revealed the following:

a. 10:35 AM - Patient suite 3A was no longer being used for patient care and was being used by staff as office space. Review of documents revealed, and interview with Associate Administrator A at the time of discovery confirmed, that a change of use for that area was not submitted to the State Fire Marshal Office for review and approval.

Based on observation and staff interview, it was determined that the facility failed to maintain the integrity of interior finishes in one of five floors. Findings include:

A hospital tour revealed the following:

02/11/15 at 09:20 AM - missing ceiling tile was observed in the Patient Access Office closet. This finding was confirmed by Operations Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the integrity of interior finishes in one of one sub-level floor. Findings include:

During a hospital tour with Associate Administrator A on 02/05/15, the following was observed and acknowledged at the time of discovery:

a. 1:39 PM - missing ceiling tiles were observed in gas storage room GD-05A

Based on observation and staff interview, it was determined that the facility failed to maintain the smoke resistive properties of fire/smoke barriers in one of five floors. Findings include:

A hospital tour revealed the following:

02/09/15 at 1:01 PM - an approximately 1" data sleeve was not properly filled above the suspended ceiling by door 2K809A. This finding was confirmed by Environmental Safety Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the smoke resistive properties of fire/smoke barriers in two of three floors. Findings include:

1. A hospital tour on 02/04/15 revealed the following:

a. 1:57 PM - an approximately 1" by 1" unsealed penetration and a 1" data sleeve were not properly sealed and were observed above the suspended ceiling by door 2K821A. This finding was confirmed by Project Manager A at the time of discovery.

2. During a hospital tour with Associate Administrator A on 02/05/15, the following was observed and acknowledged at the time of discovery:

a. 11:10 AM - an approximately 1" by 1" unsealed penetration was observed above the suspended ceiling by door 1D-174

Based on observation and staff interview, it was determined that the facility failed to maintain cross-corridor barrier doors in one of three floors and the ground floor. Findings include:

1. A hospital tour on 02/04/15 revealed the following:

a. 12:40 PM - door 2K-806 door position switch knockout plugs were missing. This finding was confirmed by Project Manager A at the time of discovery.

b. 1:13 PM - door 2E60B did not latch properly in its frame when released from the open position. This finding was confirmed by Operations Manager A at the time of discovery.

2. During a hospital tour with Associate Administrator A on 02/05/15, the following was observed and acknowledged at the time of discovery:

a. 1:45 PM - door GG01A was missing fire exit hardware.

Based on observation and staff interview, it was determined that the facility failed to ensure hazardous areas were properly protected and maintained in one of three floors and the lower ground floor. Findings include:

1. A hospital tour on 02/04/15 revealed the following:

a. 09:22 AM - flooring material was being stored in room 3F14 and the ante room which were non-rated rooms. These findings were confirmed by Associate Administrator A at the time of discovery.

b. 09:30 AM - room 3F17 (non-rated room) was being used as a work shop. This finding was confirmed by Associate Administrator A at the time of discovery.

c. 11:05 AM - soiled utility room 3A-70 door did not close and positively latch in its frame. This finding was confirmed by Project Manager A at the time of discovery.

2. During a hospital tour with Operations Manager A on 02/10/15, the following was observed and acknowledged at the time of discovery:

a. 10:00 AM - the non-sprinklered sub-basement was being used to store combustible material (items included: cardboard boxes and paper).

Based on observation and staff interview, it was determined that the facility failed to maintain the fire alarm system in one of three floors. Findings include:

During a hospital tour with Operations Manager A on 02/04/15 at 2:01 PM, the following was observed and acknowledged at the time of discovery:

a. In the vestibule to the healing garden - a smoke detector was observed to be covered with blue tape

Based on observation and staff interview, it was determined that the facility failed to maintain the automatic sprinkler system in three of three floors and the lower ground floor. Findings include:

1. During a hospital tour with Operations Manager A on 02/04/15, the following was observed and acknowledged at the time of discovery:

a. 10:31 AM - several wires resting upon the sprinkler piping above the suspended ceiling by 3F115A.

b. 1:37 PM - an escutcheon for the sprinkler head was missing in room 2E54.

c. 1:40 PM - an escutcheon for the sprinkler head was dislodged in the room next to room 2E54.

2. During a hospital tour with Associate Administrator A on 02/05/15, the following was observed and acknowledged at the time of discovery:

a. 10:31 AM - several wires resting upon the sprinkler piping above the suspended ceiling by 1B60B.

b. 10:47 AM - an escutcheon for the sprinkler head was missing outside of Exam Room 3 - Orthopedic Radiology/X-Ray.

c. 10:51 AM - an escutcheon for the sprinkler head was missing outside of room 1E09 - Orthopedic Radiology/X-Ray.

d. 11:10 AM - several wires resting upon the sprinkler piping above the suspended ceiling by 1D174.

e. 2:37 PM - an escutcheon for the sprinkler head was missing in room GB42C.

f. 2:41 PM - an escutcheon for the sprinkler head was missing in room GD 105 DPS assembly area.

Based on observation and staff interview, it was determined that the facility failed to maintain the automatic sprinkler system in two of five floors. Findings include:

During a hospital tour with Environmental Safety Manager A on 02/09/15 at 12:48 PM, the following was observed and confirmed at the time of discovery:

1. An escutcheon for the sprinkler head was missing at 2K806A.

Based on observation and staff interview, it was determined that the facility failed to ensure that corridors in one of three floors remained clear of obstructions. Findings include:

During a tour with Operations Manager A on 02/04/15, the following was observed and confirmed at the time of discovery:

1. 10:04 AM - the corridor outside of the Child Life Suite was partially obstructed by carts.

Based on observation and staff interview, it was determined that the facility did not ensure to keep one of five randomly selected vertical shafts free of storage. Findings include:

A hospital tour revealed the following:

02/10/15 at 12:45 PM - the mechanical shaft in room 1K327 was being used to store housekeeping tools. This finding was confirmed by Project Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain the electrical equipment in three of three floors and the lower ground floor. Findings include:

1. A hospital tour on 02/04/15 revealed the following open electrical junction boxes:

a. 09:57 AM - above the suspended ceiling at 3K316. This finding was confirmed by Operations Manager A at the time of discovery.

b. 10:31 AM - above the suspended ceiling at 3F115A. This finding was confirmed by Operations Manager A at the time of discovery.

c. 1:57 PM - (Low Voltage) above the suspended ceiling at 2K821A. This finding was confirmed by Project Manager A at the time of discovery.

2. During a hospital tour with Associate Administrator A on 02/05/15, the following open electrical junction boxes were observed and confirmed at the time of discovery:

a. 09:53 AM - above the suspended ceiling at 1B-63

b. 10:00 AM - above the suspended ceiling at 1B-160

Based on observation and staff interview, it was determined that the facility failed to maintain the electrical equipment in two of five floors. Findings include:

1. During a hospital tour with Environmental Safety Manager A on 02/09/15, the following was observed and confirmed at the time of discovery:

a. 12:48 PM - open electrical (low voltage) junction box was above the suspended ceiling at 2K806A.

b. 1:28 PM - in the Kitchen's Housekeeping closet, a bulb shield was in place on the sprinkler head.

c. 1:30 PM - in the Kitchen, the electrical breaker panels were being blocked by a service cart.

d. 1:32 PM - in the Kitchen, an extension cord was being used to power food warmers under Hood 3.

2. During a hospital tour with Associate Administrator A on 02/09/15, the following was observed and confirmed at the time of discovery:

a. 1:35 PM - in the Kitchen Office, a power strip was plugged into another power strip (daisy chained) powering computer equipment.

b. 1:36 PM - in the Kitchen Office, an extension cord was powering a power strip.

c. 1:40 PM - in the Pizza and Panini preparation area, several extension cords were powering warming and cooking devices.

Based on observation and staff interview, it was determined that alcohol based hand rub (ABHR) dispensers were installed adjacent to an ignition source. This affected one of six smoke compartments on the third floor. Findings include:

During a hospital tour with Operations Manager A at 10:01 AM on 02/04/15, the following was observed and acknowledged at the time of discovery:

1. An ABHR stand was adjacent to an electrical plug.