HospitalInspections.org

On 1-14-2019 while surveying the facility with the Physical Director of operations, it was observed:

Soiled linen room located near the loading dock area has several pipe penetrations through the floor/ceiling assembly. Mineral wool was observed from the soiled linen room area, but the penetration could not be verified that it was sealed at the second floor level. Floor/ceiling penetrations shall be sealed with a fire stopping material that provides a UL listed assembly for a minimum of 2 hours.

On 01-14-2019, Based on Observations, Surveyor 16776 and 39983 along with the Maintenance Supervisor:


1. Found on the 3rd floor and 2nd Floor Janitor Closets from the Corridors had Non approved slid locks on the doors.
Non approved locks for doors; LSC Chapter 7 Section 7.2.1.5.3. Remove locks from doors.

On 1-14-2019 while surveying the facility with the Physical Director of operations, it was observed:


Egress path to the Exit stair across from X-Ray #1 blocked by chairs and a privacy curtain.



37694

This standard is not met as evidenced by:

While inspecting this facility on January 14, 2019 with the Safety Specialist/Emergency Preparedness Coordinator and surveyor 05910, surveyor 37694 did observe:

Four cabinets in the 2nd Floor Short Wing across from Room 207 did not positively latch.

ICU-3 corridor door shall not be propped open with unapproved kickstop.

On 1-14-2019 while surveying the facility with the Physical Director of operations, it was observed:

Required exit stair across from X-ray room #1 not marked as an exit.

On 1-14-2019 while surveying the facility with the Physical Director of operations, it was observed:

Ceiling tiles missing from the I.T. Room on the first floor.

The Core Data Room requires a ceiling membrane that resists the passage of smoke the door to this area also requires a self-closing device; room is larger than fifty square feet.


Soiled utility room located near loading dock area shall resist the passage of smoke. Penetrations and voids in the walls and at the top of wall are unprotected or only filled with mineral wool.

Across from room 016 there is a 3/4" hole located near the top of the storage room door on the latch side..

Elevator machine room loacated on the 3rd floor in the mechanical area has a non-compliant vent opening in the wall.

On 1-14-2019 while surveying the facility with the Director of operations, it was observed:

Sprinkler head placement in the C.T. area and in the Stress testing area on the first floor are installed to close together.

No sprinkler coverage in the alcove/storage area located across from the medical directors office.

Linen room located near the loading dock area is missing sprinkler coverage in the back area where trash cans are stored.


On 1-14-2019 while surveying the facility with maintenance personal, it was observed:

One pendant style sprinkler head located on the 3rd floor mechanical area and one pendant style sprinkler head located on the first floor area near the maintenance shop area not installed to their correct listing. Both heads need to be replaced with upright sprinkler heads and correctly installed.

On 1-14-2019 while surveying the facility with the Physical Director of operations, it was observed:

Ceiling tile not fitting tightly around the sprinkler head escutcheon cap located on the ceiling outside the stress test room.


37694

This standard is not met as evidenced by:

While inspecting this facility on January 14, 2019 with the Safety Specialist/Emergency Preparedness Coordinator and surveyor 05910, surveyor 37694 did observe:

Sprinkler head in the far back of the 2nd Floor IT Closet 125 obstructed by tall black shelving. Maintain 18 inches of clearance around all heads.

On 01-14-2019, Based on Observations, Surveyor 16776 and 39983 along with the Maintenance Supervisor:


3rd Floor:


1. Corridor, Ceiling above the Mailroom Door Hole Penetrations in 1 hr. rated wall.

2. In O.B. Clean Supply Room Hole Penetrations above the double doors.


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Basement:



1. Soiled Linen Room; Hole Penetrations in the Drop Ceiling from plumbing.

2. Clean Utility Room: Hole Penetration found at the top of the Door. ( Smoke door.).

3. Clean Utility Room; Hole Penetrations found in Ceiling Tiles from the Sprinkler Pipes, Hole penetrations from sprinkler pipes to back wall.

On 1-14-2019 while surveying the facility with the maintenance, it was observed:

In the OB area, two corridor doors removed near the I.T. office.

3rd floor I.T. server room door with a vent installed in the door.

Dutch style door located in the Gym area does not have latching hardware on the upper leaf and the meeting edges of the door shall be equipped to resist the passage of smoke.

On 01-14-2019, Based on Observations by Surveyor 16776 and 39983 along with with the Maintenance Supervisor:


On the 3rd floor:

1. Corridor Fire doors to O.B. above the ceiling, Hole Penetrations through the 2 hr. Rated Wall.

2. Wellness Treatment Room, In side the treatment room, the Wall to the corridor by the time clock, 2 Hr Rated Wall above the the drop ceiling large Hole Penetrations, Found exposed 2 x 6 wood joists construction to the roof deck. Hole and Non Rated Joists Not Rated for the Wall assembly.

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1 Floor:


1. Corridor outside the Laboratory, Found Hole Penetrations above the ceiling in the 2 Hr. Rated Wall .

2. In the Laboratory, Exit door from the laboratory to Stair E, and to include the Exit Stair Tower showed on the Life Safety Plans that the wall assembly are list as 2 hr. Rated. Found Hole Penetrations and Wall Assembly that failed to meet 2 hr Rating listed on the Plans. Exit Door from the laboratory Not rated for the 2 hr. Assembly.

3. Main Floor, Main Entrance Corridor going to Elevator A; Wall assembly has Hole Penetrations for a Rated 2 hr Wall Assembly that are list on the Life Safety Plan are 2 Hr. listed. Founded wall assembly failed to meet the 2 Hr. Rating listed on the Plans.

This standard is not met as evidenced by:

While inspecting this facility on January 14, 2019 with the Safety Specialist/Emergency Preparedness Coordinator and surveyor 05910, surveyor 37694 did observe:

Left smoke barrier door from ASU to the Med Surg wing did not positively latch when released from magnetic hold open device.

This standard is not met as evidenced by:

During record review of this facility on January 14, 2019 with the Safety Specialist/Emergency Preparedness Coordinator and surveyor 05910, surveyor 37694 did observe:

The following discrepancies on the Medical Gas Inspection from July 2018 have not been remedied:

Maintenance Discrepancy
1. Medical Air Compressor - When the high alarm pressure set point for the master alarm system is reached, both the high and low alarms sound at the master alarm panels.

Compliance Discrepancies
1. Surgical Services - The vacuum inlets in Operating Room 3 are not supplied through a zone valve.
2. Surgical Services - The vacuum inlets in the Steris Room, Soiled Utility, Decontamination, and Central Sterile are not being used for patient care.
3. Surgical Services - There inspector was unable to locate the zone valves controlling the flow of oxygen and vacuum to the following rooms, Surgical Personnel Only, Surgical Services Nurse Manager, Anesthesiology, Pre-Op Teaching, and the Female Staff Locker Room.
4. ASU - The area alarm panel located right of the Nurses' Station does not have separate visual indicators for each condition monitored.
5. ICU/Telemetry - The area alarm panel located right of the Nurses' Station does not have separate visual indicators for each condition monitored.
6. Vacuum Pumps - All turns, offsets, and other changes in direction to the exhaust piping are not brazed.
7. Vacuum Pumps - Vacuum exhaust needs to be turned down and screened or otherwise be protected against the entry of vermin, debris, or precipitation by screening fabricated or composed of a non-corroding material.
8. Vacuum Pumps - Vacuum exhaust is located less than 25 feet from any door, window, air intake, or other openings in buildings or places of public assembly.
9. Vacuum Pumps - The current dual use medical vacuum/WAGD system located in the mechanical room by Facilities is not designed of materials using lubricants and sealants that are inert in the presence of oxygen, nitrous oxide, and halogenated anesthetics.
10. Medical Air Compressor - All turns, offsets, and other changes in direction to the intake piping are not brazed.
11. Medical Air Compressor - Medical air intake is not located a minimum of 25 feet from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes.
12. EOSC - Pressure relief vent line's discharge terminal needs to be turned down and screened to prevent the entry or rain, snow or vermin.
13. EOSC - The oxygen check valve located on the EOSC line has threaded connections.
14. Oxygen Bulk System - Bulk tank enclosure does not have two points of entry/exit.

General Comments
1. The bulk oxygen signals were not tested during the annual medical gas inspection and evaluation. These signals are tested by your bulk oxygen supplier and should be reported with their annual preventative maintenance program. These signals include the following: a) Oxygen Main Liquid Level Low, b) Oxygen Reserve in Use, c) Oxygen Reserve Liquid Level Low, and d) Oxygen Reserve Low Pressure
2. William G Frank Medical Gas Testing and Consulting, LLC recommends that the current vacuum system located in the Mechanical Room by Facilities that is a dual use medical vacuum/WAGD system, be replaced. The dual use medical vacuum/WAGD system currently in use consists of oil lubricated pumps which is a major fire risk in the presence of halogenated anesthetics.

This standard is not met as evidenced by:

While inspecting this facility on January 14, 2019 with the Safety Specialist/Emergency Preparedness Coordinator and surveyor 05910, surveyor 37694 did observe:

Unapproved electric air purifiers plugged into ICU and ASU corridor outlets.