HospitalInspections.org

Based upon observation and interview, it was determined that the facility failed to maintain common wall doors in one instance in accordance with regulations.

Findings include:
Observation on September 14, 2011, at 2:06 pm, revealed the common wall cross corridor door located at the Silverstein side of the " link " had its self-closure detached.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the detached component of the barrier door.

Based on observation and interview, it was determined that the facility failed to maintain protection of structural members in one instance with the component.

Findings Include:

Observation made on September 13, 2011, at 9:00 am, revealed the rear area of the mechanical penthouse lacks protection of structural steel beams and bar joists consistent with penthouses within each building, Dulles Building, penthouse.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the unprotected structural members.

Based upon observation and interview, it was determined that the facility failed to provide interior surface documentation in one instance within this component.

Findings include

Observation made on September 13, 2011, at 9:55 am, revealed documentation was unavailable to verify the exposed interior surface flame spread rating of the fourth floor movable wall.

Interview with the Maintenance Supervisor at the exit conference on September 13, 2011, at 1:00 pm, confirmed the unavailable documentation.

Based on observation and interview, it was determined that the facility failed to maintain positive latching on corridor doors along the means of egress in three instances within the component.

Findings Include:

1. Observation made on September 12, at 12:05 pm, revealed there were roller latch on linen closet corridor doors at rooms 1280 (3x2' feet) and 1285 (41/2x2' feet), Founders Building, 12th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the use of roller latches.

2. Observation made on September 14, 2011, at 8:40 am, revealed there was a corridor dutch door across from OR's 34 - 37 next to the telephone closet, the upper leaf does not self-latch into the lower leaf (manual flush bolt currently installed). In addition, the doors lack an astragal between the upper and lower meeting edges, Ravdin Building, 4th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridor dutch door hardware was incomplete.

3. Observation made on September 14, 2011, at 1:15 pm, revealed the corridor double doors at the Inpatient Pharmacy require an automatic flush bolt on the inactive leaf. A manual flush bolt is currently installed and was not secured at the time of inspection, Silverstein Building, basement.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridors double doors require latching adjustment.

Based on observation and interview, it was determined that the facility failed to maintain protection of vertical openings in one instance within the component.

Findings Include:

Observation made on September 13, 2011, at 10:05 am, revealed the mechanical room, which houses the vacuum pumps and air compressors, serves as the enclosures for the bottom of shafts leading through the building. The mechanical room is currently used for strecther storage, Silverstein Building, 6th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the vertical opening was used for storage.

Based on observation and interview, it was determined that the facility failed to maintain testing of fire alarm components in two instances within the component.

Findings Include:

1. Observation made on September 13, 2011, at 9:55 am, revealed there were two roll-down windows at the Blood Bank that are tied into the building fire alarm system. The facility must provide verification that the devices have been tested and operational, Dulles Building, 3rd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the roll-down doors were electrically interconnected.


2. Observation made on September 13, 2011, at 9:56 am, revealed the smoke detector was secured on an angle outside the Blood Bank, Dulles Building, 3rd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the smoke detector was not secured properly.

Based upon observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls three of seven levels within this component.

Findings include:
Observations on September 14, 2011, between 9:19 am and 11:06 am, revealed there were unsealed penetrations in the smoke barrier walls in the following locations:
a. 9:19 am, fourth floor north, above the cross corridor double smoke doors, by the physical therapy suite, four inch sprinkler main pipe lacked fire proofing material where it penetrated the smoke barrier wall.
b. 9:55 am, fifth floor south, above the cross corridor double smoke doors, blue/gray wire penetration.
c. 9:59 am, fifth floor south, above the pharmacy entrance double smoke doors, red/white wire penetration.

d. 10:25 am, fifth floor above the rear entrance door to the rehab gym, blue and white wire penetration above the duct. The doors are located near the service elevator.
e. 11:06 am, third floor core area, inside the telecom room, four inch white pipe penetrating the smoke barrier wall that routes behind and around the telecom room.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the unsealed penetrations.

Based upon observation and interview, it was determined that the facility failed to ensure the smoke barrier doors remain smoke tight in the closet position in order to impede the transfer of smoke in five instances within this component.

Findings Include:

1.Observation made on September 13, 2011, revealed that between 11:30 am and 12:00 pm, the following smoke barrier doors have openings between doors at the meeting edges, when the doors are in the closed position, of more than eighth of an inch and require an astragal.

a. 11:30 am, level three smoke barrier doors labeled 3-029W.
b. 11:45 am, level three smoke barrier doors by environmental closet labeled 3-216W
c. 11:47 am, level three smoke barrier doors at ophthalmology staff room.
d. 11:50 am, level three smoke barrier doors at Urology entrance doors.
e. 12:00 pm, level two smoke barrier doors at environmental closet labeled 2-120W.

Interview with the Maintenance Supervisor at the exit conference on September 13, 2011, at 1:00 pm, confirmed smoke barrier doors were not maintained properly.

Based on observation and interview, it was determined that the facility failed to maintain protection of hazardous areas in one instance within the component.

Findings Include:

Observation made on September 13, 2011, at 11:40 am, revealed the mechanical room doors behind the elevators do not latch and the undercut of the door exceeds 1" inch, Dulles Building, ground floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the hazardous area door requires adjustment.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the stair tower doors with positive latching into the door frame on one of three levels.

Findings include:

Observation made on September 13, 2011 at 11:35 am, revealed level three stair tower eleven labeled (TRC-STO-1) corridor door would not close and latch in the frame.

Interview with the Maintenance Supervisor at the exit conference on September 13, 2011, at 1:00 pm, confirm door failed to latch.

Based on observation and interview, it was determined that exit passeways were not maintained clear and unobstructed in one location whithin the component.

Findings Include:

Observation made on September 13, 2011, at 2:08 pm, revealed that stairtower 6 leads onto a corridor which housed a large trash cart, wheelchair, and a medical gas (oxygen, vacuum, air) shut-off valve for Ultrasound. The exit passage is a continuation of the stair tower, White Building, 7th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the exit passageway was used for other purposes.

Based on observation and interview, it was determined that the facility failed to maintain the corridor means of egress free of obstructions in eleven instances within the component.

Findings Include:

1. Observation made on September 12, 2011, between 11:30 am and 12:20 pm, revealed there were items stored along the corridor means of egress (soiled linen carts, trash cans (approximately 13 gallons each), eg., outside room 1273, Founders Building, 12th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridors are used for storage.

2. Observation made on September 12, 2011, at 12:30 pm, revealed there were pull down desk units in the open position along the corridor, Founders Building, 10th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed there were obstructions to egress.

3. Observation made on September 13, 2011, at 11:42 am, revealed the exit sign leads through a large storage room which houses pallets and boxes and storage of red needle containers, leading from Dulles through the White Building, basement.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the exit leads through a hazardous area.

4. Observation made on September 13, 2011, at 1:45 pm, revealed there was a monitor being charged in the corridor and the manual pull station was not clearly visible, Ravdin Building, 8th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridor was used for charging equipment and storage.

5. Observation made on September 13, 2011, at 2:30 pm, revealed stair tower 6 headroom clearance between the 6th and 7th floors, is less than the 6' 8"inch minimum requirement. The measurement at the shortest projection is 5' 8" inches, Ravdin White Building.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the minimum headroom clearance was not maintained.

6. Observation made on September 14, 2011, at 9:20 am, revealed there were fixed chairs and/or an ottoman housed inside the corridor at the Family Waiting Area, Silverstein Building, 11th and 12th floors.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed there were obstructions to corridor egress.

7. Observation made on September 14, 2011, at 9:58 am, revealed the exit is not readily visible as you exit onto the rear corridor from the bed shop area. In addition, the door blocks the exit sign when in the open position, Silverstein Building, 6th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the location of the current exit sign.

8. Observation made on September 14, 2011, at 10:10 am, revealed there was a bed housed inside the exit passageway of stairtower 1out the mechanical room, Silverstein Building 6th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the exit passage was used for storage.

9. Observation made on September 14, 2011, at 11:50 am, revealed there were beds, linen carts, trash cans stored in the corridor means of egress at the Orthopedics Unit outside stair 3, Silverstein Building, 2nd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridors were used for storage.

10. Observation made on September 14, 2011, at 11:55 am, revealed the breakaway doors at the emergency department lacks signs that indicate "push in the event of an emergency," Silverstein Building ground floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the emegency exit was not readily identifiable in the event of an emergency.

11. Observation made on September 14, 2011, at 11:35 am, revealed there were boxes with ceiling tiles housed in the corridor leading to Silverstein, Ravdin Building 3rd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the corridor was usesd for storage.

Based on observation and interview, it was determined that the facility failed to maintain illumination along the means of egress in one instance with the component.

Findings Include:

Observation made on September 13, 2011, at 11:24 am, revealed the light was inoperable inside stairtower 12, Donner Buidling, 1st floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed exit illumination was inoperable.

Based on observation and interview, it was determined that the facility failed to maintain installation of exit signs

Findings Include:

1. Observation made on September 13, 2011, at 2:07 pm, revealed the exit sign was not illuminated at stair 6, White Building, 7th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the exit sign was not illuminated.

2. Observation made on September 14, 2011, at 9:00 am, revealed the facility lacks an exit sign at the Ravdin Building, penthouse.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed exiting was not readily visible.

3. Observation made on September 14, 2011, at 11:35 am, revealed the facility lacks an exit sign above the cross corridor double doors at the Pulmonary Medicine corridor, Ravdin Building, 3rd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed exit was not readily visible.

Based on observation and interview, it was determined that the facility failed to maintain manual pull stations readily observable in one instance within the facility.

Findings Include:

Observation made on September 13, 2011, at 9:30 am, revealed there was a crash cart housed in the corridor across from room 922, near the stairtower. The manual pull station was not clearly visible, Silverstein Building, 10th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the manual pull station was not readily visible.

Based upon observation and interview , it was determined that the facility failed to ensure that duct mounted smoke detectors are being maintained in one instance within this component.

Findings include:

Observation made on September 14, 2011 at 10:12 am revealed that in the fourth floor southwing unoccupied space in the ceiling space, there was a duct mounted smoke detector assembly that was missing its protective cover plate.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the missing protective cover plate.

Based on observation and interview, it was determined that the facility failed to provide complete automatic sprinkler protection in one instance within the component.

Findings Include:

Observation made on September 13, 2011, at 1:00 pm, revealed ductwork which extends approximately 5' feet lacks automatic sprinkler protection, outside elevator contacts 142 and 136, Ravdin Building, penhouse.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed complete sprinkler protection was not provided.

Based upon observation and interview, it was determined that the facility failed to maintain ceiling components, sprinklers escutcheons, and dry sprinkler system components in ten instances in accordance with regulations.

Findings include
1. Observation made on September 14, 2011, at 2:40 pm, revealed the inside the Rhoades Building electrical closet (rp1020) the entire ceiling assembly was removed, which may delay operation of the sprinkler system.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the location of the sprinkler system.

2. Observation made on September 14, 2011, between am and am, revealed the following locations had missing sprinkler escutcheons:

a. 1:17 pm, Rhoades penthouse mechanical area document room has six sprinkler heads which are missing escutcheons.
b. 1:29 pm, Rhoades family business center across from 3026 missing escutcheon
c. 2:43 pm, Rhoades first floor exit stairway discharge corridor missing escutcheon
Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the missing escutcheons.

3. Observation made on September 15, 2011, between 6:54 am and 8:19 am, revealed the following locations had incomplete or damaged ceiling component which may delay sprinkler operation:

a. 7:00 am, O.R. area staff bathrooms lack sprinkler coverage.
b. 7:37 am, Rhoades wood shop, ceiling tile holes from relocated ceiling mounted electrical junction boxes in two areas.
c. 8:05 am, Rhoades basement laundry chute discharge room has an incomplete unobstructed ceiling assembly with partial above ceiling coverage.
d. 8:19 am, Rhoades basement mechanical room ceiling, near column, above air handling unit, has a sprinkler covered with spray applied fire proofing. The sprinkler head must be replaced.
Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the above noted conditions which affect performance of the sprinkler system.

4. Observation made on September 15, 2011, between 6:54 am and 8:19 am, revealed the following locations had missing sprinkler escutcheons:

a. 6:54 am, O.R. #35 missing sprinkler escutcheon
b. 7: 33 am, Rhoades basement paint shop office missing escutcheon
Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the missing sprinkler escutcheons

5. Observation made on September 15, 2011, at 10: 00 am, revealed the loading dock dry pipe system trip test connection is not installed at the end of the most distant sprinkler pipe.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the lack of verification of the inspectors test outlet.

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Based upon observation and interview, it was determined that the facility failed to install ducts and protect inlet/outlet openings with a grille or screen in three instances in accordance with regulations.

Findings include

1. Observation on September 14, 2011, at 2:40 pm, revealed the Rhoades first floor electrical closet rp1020 supply duct lacks a grille or screen.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the lack of grille protection.

2. Observation on September 15, 2011, at 7:38 am, revealed the Rhoades basement janitors closet, located right of the laundry discharge room, has an exhaust duct without a grille or screen.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the lack of grille protection.

3.Observation on September 15, 2011, at 7:40 am, revealed the Rhoades basement laundry chute discharge room has a supply duct which discharges above the ceiling assembly.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the current ventilation of the exhaust system.

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Based on observation and interview, it was determined that the facility failed to maintain the two hour fire resistance rating of the linen chute discharge enclosures in two instances within the component.

Findings Include:

1. Observation made on September 12, 2011, at 11:55 am, revealed there were small holes in the linen chute access door where the door handle had been removed, Founders Building, 14th floor. In addition, the linen chute wash out door self-closure was inoperable.

InterviewInterview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the integrity of the linen chute was not maintained.


2. Observation made on September 12, 2011, at 11:58 am, revealed there were small holes in the linen chute access door and the self-closure was inoperable, Founders Building, 12th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the integrity of the linen chute was not maintained.

Based on observation and interview, it was determined that the facility failed to maintain protection of medical gas cylinders in four instances within the component.

Findings Include:

1. Observation made on September 12, 2011, at 11:50 am, revealed one oxygen E cylinders was housed near the heating, air conditioning, and ventilating unit behind the nurses station, Founders Building, 14th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the oxygen cylinder was not stored properly.

2. Observation made on September 14, 2011, at 9:15 am, revealed oxygen E cylinders housed inside an equipment room. The electrical outlets were not installed a minimum of 60-inches above the floor, Silverstein Building, 11th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the electrical compnents were not installed properly.

3. Observation made on September 14, 2011, at 9:50 am, revealed the nitrous oxide manifold system for the Dental Suite light fixtures were not installed a minimum of 60-inches from the floor. In addition, the door was held open by an unauthorized means, Silverstein Building, 6th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the electrical components were not installed properly.

4. Observation made on September 14, 2011, at 11:42 am, revealed there were beds housed along the corridor means of egress, an oxygen E cylinder was not housed in it's cradle and was unsecured, Silverstein Building, 3rd floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the oxygen cylinder was not secured properly.

Based on observation and interview, it was determined the facility failed to ensure the emergency generator room maintained a minimum two hour fire resistive rating in one instance within the facility.

Findings include:

Observation on September 14, 2011, at 11:50 am, in the basement revealed inside the generator enclosure, there was an unsealed penetration of a structural beam above electrical panel CDPH 480Y/277V and unsealed wire penetrations of the enclosure above the entrance doors.

Interview at the exit conference with the Assistant Hospital Director Support Services and Assistant Director Physical Plant on September 15, 2011, at 11:00 am, confirmed the unsealed penetrations of the generator room.

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical equipment in one instance within the component.

Findings Include:

Observation made on September 13, 2011, at 9:55 am, revealed the automatic transfer switch room door was tied open by an unauthorized means, Silverstein Building, 6th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the electrical room enclosure was not protected.

Based on observation and interview, it was determined that the facility failed to maintain installation of Alcohol Based Hand Rubs (ABHRs) devices in three instances within the component.

Findings Include:

1. Observation made on September 12, 2011, between 11:40 am and 12:00 pm, revealed AHBRs were installed above or adjacent to electrical outlets/switches at the following locations:

a. 11:40 am, above the electrical outlet inside room 1485, Founders Building, 14th floor
(this deficiency was corrected while on-site)
b. 12:00 pm, adjacent to the electrical outside inside rooms 1284 and 1285, Founders Building, 12th floor

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the ABHRs were not installed properly.

2. Observation made on September 13, 2011, at 9:40 am, revealed ABHRs was storage above soiled linen carts, Dulles Building, 7th floor.

Interview with Facility Personnel on September 14, 2011, at 2:00 pm, confirmed the ABHRs are installed above hazardous containers.