HospitalInspections.org

Based on observations and testing, the facility failed to maintain doors protecting the corridors.

The findings included:

1. Observation on 3/8/16 at 9:32 AM, revealed penetrations above the fire door 0535. NFPA 101, 8.2.3.2.4.2 (2000 Edition)

2. Observation on 3/8/16 at 1:17 PM, revealed fire rated doors not latching within the frame in the following locations:
a. The West hall stairwell fire doors (top held down by nurses tape) removed by maintenance staff on sight.
b. The GI lab door
c. The GI waiting room door and (propped open with wastecan)
d. The South stair well fire doors (missing hardware and not latching bottom)
e. The North hall fire doors (missing hardware and not latching bottom)
f. One of two GI storage closet doors missing a self-closing device.
g. Fire door 0540 Does not properly latch
NFPA 80, 15-1.2 (1999 Edition), NFPA 80, 15-2.3 (1999 Edition), NFPA 80, 15-2.4.1 (1999 Edition), and NFPA 80, 3-4.3 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the doors protecting the corridors.

The finding included:

Observation on 3/8/16 at 11:33 AM, revealed penetrations in the electrical room door. NFPA 80, 15-2.5.4 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the doors protecting the corridors.

The findings included:

1. Observation on 3/9/16 at 9:11 AM, revealed the smoke doors next to the Cardio hall had penetrations. NFPA 80, 15-2.5.4 (1999 Edition)

2. Observation on 3/9/16 at 10:10 AM, revealed the fire doors by the Little kitchen did not latch within the frame (bottoms). NFPA 80, 15.1.2 (1999 Edition)

3. Observation on 3/9/16 at 10:25 AM, revealed the fire doors by room 16 did not latch within the frame (bottoms). NFPA 80, 15.1.2 (1999 Edition)

4. Observation on 3/9/16 at 10:35 AM, revealed the fire doors by the Lab contained improper fire caulk. NFPA 80, 15-2.5.4 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the sprinkler system.

The finding included:

Observation on 3/9/16 at 9:40 AM, revealed corroded sprinklers in the walk in cooler and freezer. NFPA 25, 2-2.1.1 (1998 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the sprinkler system.

The findings included:

1. Observation on 3/8/16 at 12:53 AM, revealed 14 corroded sprinklers under the main entrance canopy. NFPA 25, 2-2.1.1 (1998 Edition)

2. Observation on 3/8/16 at 1:07 PM, revealed a sprinkler covered with foreign material (lint) in the following locations:
a. Room 216
b. ICU room 6
c. PAC U area
d. ER Observation room 9
e. ER Observation room 10
f. Room 329
g. Staff lounge hall
h. Room 317
NFPA 25, 2-2.1.1 (1998 Edition)

3. Observation on 3/8/16 at 1:12 PM, revealed an escutcheon plate missing in room 208 and inside the narcotics room. NFPA 13, 3-2.7.2 (1999 Edition)

4. Observation on 3/8/16 at 1:44 PM, revealed mixed sprinklers (quick and standard) response in the following areas:
a. ICU storage room
b.(Old) 2nd nurses station
c. Dishwashing room/Dietitian room
NFPA 13, 5-3.1.5.2 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 11:30 AM, revealed the soiled utility closet had no negative air pressure. NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 1:26 PM, negative air pressure was not maintained in the following areas:
a. GI chemical closet
b. Pharmacy Bathroom
c. Laboratory Bathroom
NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 2:09 PM, revealed the janitor ' s closet had no negative air pressure. NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observation and staff interview, the facility failed to properly train kitchen staff on fire suppression activity's.

The findings included:

Instructions for manually operating the kitchen's hood fire-extinguishing system posted conspicuously in the kitchen. Interview with kitchen staff member #1 at 8:51 AM, revealed that staff member #1 did not know how to manually operate the kitchen's hood fire-extinguishing system. The instructions shall be reviewed periodically by the employees. NFPA 96, 8-1.4 (1998 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/8/16.

Based on observations, the facility failed to maintain the emergency exits.

The finding included:

Observation on 3/8/16 at 2:11 PM, revealed the conference room exit blocked by furniture. NFPA 101, 7.5.1.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the piped medical gas lines as required.

The finding included:

Observation on 3/8/16 at 1:56 PM, revealed medical gas lines touching dissimilar metals throughout the basement (material management), 1st, 2nd and 3rd floors. NFPA 99, 4-3.1.2.9 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the piped medical gas lines as required.

The finding included:

Observation on 3/9/16 at 10:10 AM, revealed medical gas lines touching dissimilar metals throughout the facility. NFPA 99, 4-3.1.2.9 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the electrical system.

The finding included:

1. Observation on 3/8/16 at 9:18 AM, revealed a light fixture inside the janitors closet across from the dishwashing room in the basement was charred.

2. Observation on 3/8/16 at 10:32 AM, revealed an exposed junction box inside the storage room across from the psychiatric room. NFPA 70, 370-28(c) (1999 Edition)

3. Observation on 3/8/16 at 1:10 PM, revealed a junction box missing the cover behind the tv inside the womens physican sleeping room.

4. Observation on 3/8/16 at 2:13 PM, revealed a junction box plate missing the cover above the ceiling at the ICU entrance. NFPA 70, 370-28(c) (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the electrical system.

The finding included:

Observation on 3/9/16 at 9:42 AM, revealed a junction box plate missing in the dietitian office. NFPA 70, 370-28(c) (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain doors protecting the corridors.

The findings included:

1. Observation on 3/8/16 at 9:32 AM, revealed penetrations above the fire door 0535. NFPA 101, 8.2.3.2.4.2 (2000 Edition)

2. Observation on 3/8/16 at 1:17 PM, revealed fire rated doors not latching within the frame in the following locations:
a. The West hall stairwell fire doors (top held down by nurses tape) removed by maintenance staff on sight.
b. The GI lab door
c. The GI waiting room door and (propped open with wastecan)
d. The South stair well fire doors (missing hardware and not latching bottom)
e. The North hall fire doors (missing hardware and not latching bottom)
f. One of two GI storage closet doors missing a self-closing device.
g. Fire door 0540 Does not properly latch
NFPA 80, 15-1.2 (1999 Edition), NFPA 80, 15-2.3 (1999 Edition), NFPA 80, 15-2.4.1 (1999 Edition), and NFPA 80, 3-4.3 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the doors protecting the corridors.

The finding included:

Observation on 3/8/16 at 11:33 AM, revealed penetrations in the electrical room door. NFPA 80, 15-2.5.4 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the doors protecting the corridors.

The findings included:

1. Observation on 3/9/16 at 9:11 AM, revealed the smoke doors next to the Cardio hall had penetrations. NFPA 80, 15-2.5.4 (1999 Edition)

2. Observation on 3/9/16 at 10:10 AM, revealed the fire doors by the Little kitchen did not latch within the frame (bottoms). NFPA 80, 15.1.2 (1999 Edition)

3. Observation on 3/9/16 at 10:25 AM, revealed the fire doors by room 16 did not latch within the frame (bottoms). NFPA 80, 15.1.2 (1999 Edition)

4. Observation on 3/9/16 at 10:35 AM, revealed the fire doors by the Lab contained improper fire caulk. NFPA 80, 15-2.5.4 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the sprinkler system.

The finding included:

Observation on 3/9/16 at 9:40 AM, revealed corroded sprinklers in the walk in cooler and freezer. NFPA 25, 2-2.1.1 (1998 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the sprinkler system.

The findings included:

1. Observation on 3/8/16 at 12:53 AM, revealed 14 corroded sprinklers under the main entrance canopy. NFPA 25, 2-2.1.1 (1998 Edition)

2. Observation on 3/8/16 at 1:07 PM, revealed a sprinkler covered with foreign material (lint) in the following locations:
a. Room 216
b. ICU room 6
c. PAC U area
d. ER Observation room 9
e. ER Observation room 10
f. Room 329
g. Staff lounge hall
h. Room 317
NFPA 25, 2-2.1.1 (1998 Edition)

3. Observation on 3/8/16 at 1:12 PM, revealed an escutcheon plate missing in room 208 and inside the narcotics room. NFPA 13, 3-2.7.2 (1999 Edition)

4. Observation on 3/8/16 at 1:44 PM, revealed mixed sprinklers (quick and standard) response in the following areas:
a. ICU storage room
b.(Old) 2nd nurses station
c. Dishwashing room/Dietitian room
NFPA 13, 5-3.1.5.2 (1999 Edition)

These findings were verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 11:30 AM, revealed the soiled utility closet had no negative air pressure. NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 1:26 PM, negative air pressure was not maintained in the following areas:
a. GI chemical closet
b. Pharmacy Bathroom
c. Laboratory Bathroom
NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations and testing, the facility failed to maintain negative air pressure where required.

The finding included:

Observation on 3/8/16 at 2:09 PM, revealed the janitor ' s closet had no negative air pressure. NFPA 101, 19.5.2.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observation and staff interview, the facility failed to properly train kitchen staff on fire suppression activity's.

The findings included:

Instructions for manually operating the kitchen's hood fire-extinguishing system posted conspicuously in the kitchen. Interview with kitchen staff member #1 at 8:51 AM, revealed that staff member #1 did not know how to manually operate the kitchen's hood fire-extinguishing system. The instructions shall be reviewed periodically by the employees. NFPA 96, 8-1.4 (1998 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/8/16.

Based on observations, the facility failed to maintain the emergency exits.

The finding included:

Observation on 3/8/16 at 2:11 PM, revealed the conference room exit blocked by furniture. NFPA 101, 7.5.1.1 (2000 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the piped medical gas lines as required.

The finding included:

Observation on 3/8/16 at 1:56 PM, revealed medical gas lines touching dissimilar metals throughout the basement (material management), 1st, 2nd and 3rd floors. NFPA 99, 4-3.1.2.9 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the piped medical gas lines as required.

The finding included:

Observation on 3/9/16 at 10:10 AM, revealed medical gas lines touching dissimilar metals throughout the facility. NFPA 99, 4-3.1.2.9 (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the electrical system.

The finding included:

1. Observation on 3/8/16 at 9:18 AM, revealed a light fixture inside the janitors closet across from the dishwashing room in the basement was charred.

2. Observation on 3/8/16 at 10:32 AM, revealed an exposed junction box inside the storage room across from the psychiatric room. NFPA 70, 370-28(c) (1999 Edition)

3. Observation on 3/8/16 at 1:10 PM, revealed a junction box missing the cover behind the tv inside the womens physican sleeping room.

4. Observation on 3/8/16 at 2:13 PM, revealed a junction box plate missing the cover above the ceiling at the ICU entrance. NFPA 70, 370-28(c) (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.

Based on observations, the facility failed to maintain the electrical system.

The finding included:

Observation on 3/9/16 at 9:42 AM, revealed a junction box plate missing in the dietitian office. NFPA 70, 370-28(c) (1999 Edition)

This finding was verified by maintenance staff and acknowledged by the CEO during the exit conference on 3/9/16.