HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the egress corridor may have been compromised.
Surgical suite ' s operating room doors did not latch and appeared to be opening onto an egress corridor. This group of rooms did not appear to be in a suite. If this is a suite, define the suite. If the doors open onto an egress corridor, the doors shall latch.


Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the egress corridor may have been compromised.
In the emergency department, all exam treatment bays are open via cubicle curtains to what appears an egress pathway. These bays did not appear to be in a suite. If this is a suite, define the suite. The bays can not open onto an egress corridor and may require doors that latch.

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the integrity of the corridor. An astragal was not present on the suite ' s/room ' s double doors at 1) second floor physical therapy and 2) emergency department double swinging doors and 3) X-ray doors.
Smoke could penetrate into the egress corridor.

It could not be determined if the nursery door is a fire rated or smoke door. This door A3-11 was labeled fire smoke door but did not latch.

Doors did not latch at 1) operating room 11; 2) kitchen door near dry ingredients room; 3) patient door C424 and 4) emergency department ' s sliding exam room doors.



Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at linen storage door

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the protection of a hazardous room. Delivery suite ' s equioment storage door and mail room door and fourth floor soiled utility room door (near the service elevators) did not latch.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain a rated door. Stair door F on lower level did not latch.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the egress path.
At lower level Stair F, the exit stair continued beyond the floor of discharge and was not interrupted at the floor of discharge. Stairs that continue beyond the floor of discharge shall be interrupted at the floor of discharge by partitions, doors, or other effective means.

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain a clear and unobstructed egress path. Outside the exterior of stairwell 2 at the loading dock, equipment blocked the opening of the stairwell door. Inside the emergency department stairwell, janitor cart was blocking the exit

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist at 1) ultrasound suite and 2) ortho storage and 3) in egress corridor near lower level IT and 4) inside IT suite and 5) medical records department. Signs would indicate the direction of egress either out of the suite or through the egress corridor.



Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist near the plant engineer department, which would indicate the direction of egress.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the FACP panel and subpanels were not labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breaker shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the fire alarm was not maintained.
Fire alarm control panel ' s trouble signal was lit at the second floor C tower ' s electrical room.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the smoke detector was not maintained. The smoke detector was not operational at third floor north labor and delivery lobby.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain safety in the kitchen. NFPA 96 states that all deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain safety in the kitchen. The caps were off of the auxiliary nozzels above the range and fryers.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the electrical room was cluttered with furniture, supplies, and boxes. They are considered of combustible material. Electrical room should never be used as backup storage for combustible supplies.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one;
the facility failed to maintain a safe egress path. The basement egress corridor contained full laundry bins (both soiled and clean).

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to protect the egress corridor. Medical gas outlets are open to 1) second floor special procedure ' s corridor and 2) NICU at three different locations and 3) emergency department ' s treatment bays.
A nurse call pull chord was located twice in what appeared to be its egress corridor.
NFPA 101, 2000, 19.3.6.1 .....Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5(see also 19.2.5.9), unless otherwise permitted by the following:(1)Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
Also applicable is NFPA 101: 2003: 19.2.5.8 ... ... Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to provide, at the emergency generator set location, an electrical receptacle. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.



Based on review of the records of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide accurate documentation of the grounding system at inpatient care areas. Receptacle testing in patient care areas should be at least annually and biannually in critical care areas, if any area added. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure that the essential electrical system was in full compliance. Lifestar and telematre were supplied with power from the life safety branch (1LLA) of the essential electrical system. If they are not part of a system listed below, the circuits will need to be moved to another panel.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.


Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide accurate directories at life safety panel board. All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard per NFPA 70

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the egress corridor may have been compromised.
Surgical suite ' s operating room doors did not latch and appeared to be opening onto an egress corridor. This group of rooms did not appear to be in a suite. If this is a suite, define the suite. If the doors open onto an egress corridor, the doors shall latch.


Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the egress corridor may have been compromised.
In the emergency department, all exam treatment bays are open via cubicle curtains to what appears an egress pathway. These bays did not appear to be in a suite. If this is a suite, define the suite. The bays can not open onto an egress corridor and may require doors that latch.

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the integrity of the corridor. An astragal was not present on the suite ' s/room ' s double doors at 1) second floor physical therapy and 2) emergency department double swinging doors and 3) X-ray doors.
Smoke could penetrate into the egress corridor.

It could not be determined if the nursery door is a fire rated or smoke door. This door A3-11 was labeled fire smoke door but did not latch.

Doors did not latch at 1) operating room 11; 2) kitchen door near dry ingredients room; 3) patient door C424 and 4) emergency department ' s sliding exam room doors.



Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at linen storage door

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the protection of a hazardous room. Delivery suite ' s equioment storage door and mail room door and fourth floor soiled utility room door (near the service elevators) did not latch.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain a rated door. Stair door F on lower level did not latch.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure the egress path.
At lower level Stair F, the exit stair continued beyond the floor of discharge and was not interrupted at the floor of discharge. Stairs that continue beyond the floor of discharge shall be interrupted at the floor of discharge by partitions, doors, or other effective means.

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain a clear and unobstructed egress path. Outside the exterior of stairwell 2 at the loading dock, equipment blocked the opening of the stairwell door. Inside the emergency department stairwell, janitor cart was blocking the exit

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist at 1) ultrasound suite and 2) ortho storage and 3) in egress corridor near lower level IT and 4) inside IT suite and 5) medical records department. Signs would indicate the direction of egress either out of the suite or through the egress corridor.



Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide an exit sign indicating the exit access door. An exit sign did not exist near the plant engineer department, which would indicate the direction of egress.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the FACP panel and subpanels were not labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breaker shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the fire alarm was not maintained.
Fire alarm control panel ' s trouble signal was lit at the second floor C tower ' s electrical room.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the smoke detector was not maintained. The smoke detector was not operational at third floor north labor and delivery lobby.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain safety in the kitchen. NFPA 96 states that all deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment.

Based on observations during the survey walk of the facility on the morning of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to maintain safety in the kitchen. The caps were off of the auxiliary nozzels above the range and fryers.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the electrical room was cluttered with furniture, supplies, and boxes. They are considered of combustible material. Electrical room should never be used as backup storage for combustible supplies.

Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one;
the facility failed to maintain a safe egress path. The basement egress corridor contained full laundry bins (both soiled and clean).

Based on observations during the survey walk of the facility on both 7/11/2013and 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to protect the egress corridor. Medical gas outlets are open to 1) second floor special procedure ' s corridor and 2) NICU at three different locations and 3) emergency department ' s treatment bays.
A nurse call pull chord was located twice in what appeared to be its egress corridor.
NFPA 101, 2000, 19.3.6.1 .....Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5(see also 19.2.5.9), unless otherwise permitted by the following:(1)Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
Also applicable is NFPA 101: 2003: 19.2.5.8 ... ... Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to provide, at the emergency generator set location, an electrical receptacle. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.



Based on review of the records of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide accurate documentation of the grounding system at inpatient care areas. Receptacle testing in patient care areas should be at least annually and biannually in critical care areas, if any area added. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the afternoon of 7/11/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building one; the facility failed to assure that the essential electrical system was in full compliance. Lifestar and telematre were supplied with power from the life safety branch (1LLA) of the essential electrical system. If they are not part of a system listed below, the circuits will need to be moved to another panel.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.


Based on observations during the survey walk of the facility on the afternoon of 7/12/2013, with the Director of Plant Operations and Plants Operations Supervisor, for building two; the facility failed to provide accurate directories at life safety panel board. All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard per NFPA 70