HospitalInspections.org

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that vision panels in corridor walls were fixed window assemblies in approved frames in one location in the building (the laboratory.) This could affect all individuals utilizing the services in this and adjacent smoke compartments.

Findings include:

On 7/22/11 at 4:05 PM a tour of the laboratory was conducted with staff A1 and staff B1. During the tour the two surveyors and the accompanying staff observed a sliding glass window, approximately three feet wide by four feet, located near door C1950 that opened onto the corridor from the laboratory. This finding was confirmed by staff A1 and staff B1 at the time of the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that vision panels in corridor walls were fixed window assemblies in the corridor of the operating rooms on the second floor. This could affect all individuals utilizing the services of this and adjacent smoke compartments.

Findings include:

Tour was conducted on 7/18/11 from 1:30 PM until 4:40 PM with staff A1, B1, C1, D1, and E1. A window consisting of two sliding glass panels, measuring approximately three feet wide by four feet high, was observed in the corridor wall in surgery where the pharmacy was located. This finding was confirmed by staff B1 during the tour.

Based on observation during tour and staff verification, it was determined the facility failed to ensure the smoke barriers were constructed with at least a one hour fire rated construction according to the third floor architectural plans. This had the potential to affect all those utilizing this area of the facility.

Nationwide Children's Hospital has a capacity of 359 beds with a census of 258 patients at the time of the survey. The census at Children's Hospital NICU (Riverside Site) was 15 patients on 7/21/11.

Findings include:

Tour of the facility took place on 7/21/11 with staff # A1, R3, R7, R8 and R9. During tour of the one hour smoke barrier, observation was made of several penetrations located above the ceiling tile in the following locations:

Within the conference room at the northeast corner of the unit, observation was made of an approximate three inch by seven inch opening and one unsealed conduit.

Just outside of the conference room door observation was made of one unsealed insulated line. To the left approximately six feet, observation was made of one, one inch unsealed conduit and two four inch unsealed conduits with wires passing through.

Continuing west along the one hour fire wall approximately half the distance between the conference room door and the reception window, observation was made of an approximate two inch by three foot open area above the duct which penetrated the barrier.

Within a few feet to the right of the reception window, observation was made of an small open area above the duct and one unsealed white insulated line. Additionally, observation was made of an approximate six inch round opening in the barrier and two unsealed conduits at their ends.

Within the attending physician's office, observation was made of one unsealed curved conduit.

Near room #3249, observation was made of an approximate four inch by seven inch hole in the side of a drywall constructed box which penetrated the fire barrier.

These findings were verified by staff #R7 during tour.

Based on observation during tour of the Neonatal Intensive Care Unit (NICU) and staff verification, it was determined the facility failed to ensure the exit access was readily available in regard to one exit access door equipped with a 15 second delay latching mechanism. This had the potential to affect all personnel utilizing this area.

Nationwide Children's Hospital has a capacity of 359 beds with a census of 258 patients at the time of the survey. The census of Children's Hospital NCSU (Doctor's Hospital Site) was eight patients on 7/22/11.

Findings include:

Tour of the NICU took place on 7/22/11 with staff members A1, D2 and D3. Observation was made of the rear exit access door equipped with a 15 second delay egress locking mechanism. When staff #D2 attempted to access this door in order for this surveyor to time the delay mechanism, observation was made by this surveyor and staff members A1 and D3 of this door failing to open even after 40 seconds had elapsed. This process was repeated again and observation was made of the same results.

This surveyor then requested this door to be opened manually and staff #D2 obliged by disarming the 15 second delay, and the door was able to be accessed. It was then closed and reattempted to be accessed utilizing the 15 second delay. The third attempt was successful. Staff #A1, D2 and D3 stated they could not understand why this happened.

Later the same afternoon, staff # D3 informed this surveyor they had contacted a door company to come inspect the door and the locking mechanism.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two of two fire doors in the horizontal exit on the first floor between the JW building and the adjacent building closed properly when tested.

Findings include:

Tour was conducted on 7/18/11 from 1:30 PM until 4:40 PM with staff A1, staff B1, staff C1, staff D1, and staff E1. One of the double fire doors designated C1990 failed to close due to rubbing when it was tested during the tour. The single fire door designated G1.JW1925A caught on the flooring when it was opened, and stayed open instead of automatically swinging shut when released. These findings were confirmed by staff B1 during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that emergency lighting of at least one and one-half hour duration was provided at one of two exits from the first floor of the building.

Findings include:

Tour was conducted on 7/18/11 from 1:30 PM until 4:40 PM with staff A1, staff B1, staff C1, staff D1, and staff E1. During the tour it was observed that one of two exits on the first floor of the building was altered due to construction of an adjoining building. The temporary exit involved going through an area that was under construction. This exit pathway had lighting that was comprised of overhead fluorescent lights as well as incandescent lighting. After further research, it was confirmed by staff B1 on 7/25/11 at 10:45 AM that the lighting observed in the exit pathway did not have any kind of emergency power backup in the event of power failure.

Based on emergency battery operated light documentation review and staff verification it was determined this facility failed to ensue the emergency battery operated egress lights were tested on a monthly basis as required by the National Fire Protection Association (NFPA) 101, Chapter 7.9.3. This had the potential to affect all those utilizing this area of the facility.

Nationwide Children's Hospital has a capacity of 359 beds with a census of 258 patients at the time of the survey. The census at Children's Hospital NCSU (Doctor's Hospital Site) was eight patients on 7/22/11.

Findings include:

Documentation review for the emergency battery operated egress lights took place on 7/22/11. Observation was made of the required annual 90 minute test but no documentation was available for the 30 second monthly testing.
Interview with staff member #D2 on 7/22/11 at approximately 10:30 AM revealed the facility staff were not aware of performing the required 30 second monthly testing.

Based on review of sprinkler inspection records and staff interview, it was determined that the facility failed to ensure that the sprinkler system was inspected/tested during the second quarter of 2011. This could affect all individuals in the facility.

Nationwide Children's Hospital has a capacity of 359 beds with a census of 258 patients at the time of the survey. The census was nine patients at Grant Hospital NCSU on 7/21/11.

Findings include:

Records of sprinkler inspection and testing were reviewed on 7/21/11 with staff F1 beginning at 2:00 PM. The last inspection/testing of the sprinkler system was on 2/7/11. There was no evidence that the sprinkler system had been inspected/tested during the second quarter of 2011.

It was confirmed by staff A1 on 7/22/11 at 3:20 PM, after talking with staff F1 by telephone, that the inspection/testing had not been done.