HospitalInspections.org

Based on observation and an interview, it was determined that the hospital failed to ensure that the doors to the corridor are capable of preventing the passage of smoke.

The findings include:

It was observed on 6/21/11 at approximately 11 A.M. that the doors to room 3123 and 3129 cannot close completely and latch. Also it was observed on 6/21/11 in the afternoon that there were gaps in excess of 1/2 of an inch between the doors and the door frames when the doors are fully closed for bedrooms 2309 and 2321. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the floor openings are properly sealed.

The findings include:

It was observed on 6/21/11 that there were 2 penetration holes on the floor of room 3114. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to ensure that the smoke barriers are capable of withstanding the passage of smoke.

The findings include:

It was observed on 6/21/1 at approximately 10 A.M. that there were 4 penetration holes in the smoke barrier near room 3111. Also on 6/22/11 at approximately 4 PM there 3 penetration holes around electrical cables above the drop ceiling near room 2087. The Facility Operations Vice President concurred with the observations at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the hazardous areas are properly enclosed.

The findings include:

It was observed on 6/21/11 that the doors to soiled utility rooms 2270 and 2220 could not closed and latch. Also there were no self closing mechanism to the door of soiled utility room 2251. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to maintain egress stairways.

The findings include:

It was observed on 6/21/11 that the balusters and balustrades on the 3 rd floor of the outside exit stairs were rusted and loose outside doors # 18 and door # 20. It was observed on 6/21/11 that there was a loose step between the 3 to the 2nd floors in stairway # 6. Also, there was a electrical transformer located on the landing of the 2nd floor protruding 8 inches in the path of exit of stairway #6. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to maintain the fire alarm system as per NFPA 72.

The findings include:

It was observed on 6/22/11 at approximately 3:30 P.M. that the fire alarm system main panel was showing a "trouble" signal. There was no technician on site trouble shooting the system at the time. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that sprinkler coverage is extended to all areas of the building.

The findings include:

It was observed on 6/22/11 at approximately 11 A.M. that there were no sprinkler coverage for the rear loading platform. There was an accumulation of combustibles such as wood and plastic foam containing chairs on the loading dock. Also the loading platform is used for storage of wood dust and chips from the Carpentry Shop. The Operations Vice President concurred with observation at the time of the survey.

Based on record review and an interview, it was determined that the hospital failed to maintain the sprinkler system as per NFPA 25.

The findings include:

On 6/22/11 the Facility Operations Vice President and the Safety Officer could not locate the Sprinkler Maintenance manual for the building. The Safety Officer and the Facility Operations Vice President concurred with the finding at the time of the survey.

Based on record review, observation and an interview, it was determined that the hospital failed to ensure that the sprinkler system is maintained according to NFPA 25.

The findings include:

It was observed on 6/21/11 that the sprinkler high point drain pipe and valve in the exit stairway outside door #25 is severely rusted. there was an HVAC air duct leaning on a sprinkler pipe, above the drop ceiling near room 3046. Also, there was an accumulation of dirt and grime on the sprinklers in the medication room across from room 3129. On 6/22/11 the Facility Operations Vice President and the Safety Officer could not locate the Sprinkler Maintenance manual for the building. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to ensure that the HVAC system is according to NFPA 90A.

The findings include:

It was observed on 6/22/11 at 7:30 A.M. during a test of the emergency power for the building that the fumes from the emergency generator engine exhaust 45 feet away and 30 above the main HVAC air intake for the building. The Facility Operation Vice President went to shut off the air intake fan and stated this is the standard operating procedure to shut off the air intake when the emergency generator is running. NFPA 90A, chapter 2-2.1.4.

Also on 6/21/11 several leaks in the system were felt above the drop ceiling. There was an aluminum foiled used to repair a duct above the drop ceiling above room 2220. This is not permitted by NFPA 90A, chapter 2-3.1. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that cooking equipment are maintained as per NFPA 96.

The findings include:

It was observed on 6/22/11 that there was a significant amount of grease that was beading on the vent and extinguishing pipes over the deep fat fryer and griddle in the kitchen. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the medical gases are properly stored.

The findings include:

It was observed on 6/22/11 at approximately 2 P.M. there were 5 medical gases tanks unrestrained on the floor of the EMS storage room near the EMS entrance on the first floor. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview was determined that the hospital failed to ensure that the emergency power is according to NFPA 99.

The findings include:

It was observed on 6/22/11 that there was a defective light for emergency generator remote annunciator panel. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the lightning protection is not according to NFPA 780.

The findings include:

It was observed on 6/21/11 at approximately 7:30 A.M. that the lightning rods were no longer affixed to the the parapets and were lying down on the roof. The Facility Operation Vice President confirm the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to ensure that the doors to the corridor are capable of preventing the passage of smoke.

The findings include:

It was observed on 6/21/11 at approximately 11 A.M. that the doors to room 3123 and 3129 cannot close completely and latch. Also it was observed on 6/21/11 in the afternoon that there were gaps in excess of 1/2 of an inch between the doors and the door frames when the doors are fully closed for bedrooms 2309 and 2321. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the floor openings are properly sealed.

The findings include:

It was observed on 6/21/11 that there were 2 penetration holes on the floor of room 3114. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to ensure that the smoke barriers are capable of withstanding the passage of smoke.

The findings include:

It was observed on 6/21/1 at approximately 10 A.M. that there were 4 penetration holes in the smoke barrier near room 3111. Also on 6/22/11 at approximately 4 PM there 3 penetration holes around electrical cables above the drop ceiling near room 2087. The Facility Operations Vice President concurred with the observations at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the hazardous areas are properly enclosed.

The findings include:

It was observed on 6/21/11 that the doors to soiled utility rooms 2270 and 2220 could not closed and latch. Also there were no self closing mechanism to the door of soiled utility room 2251. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to maintain egress stairways.

The findings include:

It was observed on 6/21/11 that the balusters and balustrades on the 3 rd floor of the outside exit stairs were rusted and loose outside doors # 18 and door # 20. It was observed on 6/21/11 that there was a loose step between the 3 to the 2nd floors in stairway # 6. Also, there was a electrical transformer located on the landing of the 2nd floor protruding 8 inches in the path of exit of stairway #6. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to maintain the fire alarm system as per NFPA 72.

The findings include:

It was observed on 6/22/11 at approximately 3:30 P.M. that the fire alarm system main panel was showing a "trouble" signal. There was no technician on site trouble shooting the system at the time. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that sprinkler coverage is extended to all areas of the building.

The findings include:

It was observed on 6/22/11 at approximately 11 A.M. that there were no sprinkler coverage for the rear loading platform. There was an accumulation of combustibles such as wood and plastic foam containing chairs on the loading dock. Also the loading platform is used for storage of wood dust and chips from the Carpentry Shop. The Operations Vice President concurred with observation at the time of the survey.

Based on record review and an interview, it was determined that the hospital failed to maintain the sprinkler system as per NFPA 25.

The findings include:

On 6/22/11 the Facility Operations Vice President and the Safety Officer could not locate the Sprinkler Maintenance manual for the building. The Safety Officer and the Facility Operations Vice President concurred with the finding at the time of the survey.

Based on record review, observation and an interview, it was determined that the hospital failed to ensure that the sprinkler system is maintained according to NFPA 25.

The findings include:

It was observed on 6/21/11 that the sprinkler high point drain pipe and valve in the exit stairway outside door #25 is severely rusted. there was an HVAC air duct leaning on a sprinkler pipe, above the drop ceiling near room 3046. Also, there was an accumulation of dirt and grime on the sprinklers in the medication room across from room 3129. On 6/22/11 the Facility Operations Vice President and the Safety Officer could not locate the Sprinkler Maintenance manual for the building. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the hospital failed to ensure that the HVAC system is according to NFPA 90A.

The findings include:

It was observed on 6/22/11 at 7:30 A.M. during a test of the emergency power for the building that the fumes from the emergency generator engine exhaust 45 feet away and 30 above the main HVAC air intake for the building. The Facility Operation Vice President went to shut off the air intake fan and stated this is the standard operating procedure to shut off the air intake when the emergency generator is running. NFPA 90A, chapter 2-2.1.4.

Also on 6/21/11 several leaks in the system were felt above the drop ceiling. There was an aluminum foiled used to repair a duct above the drop ceiling above room 2220. This is not permitted by NFPA 90A, chapter 2-3.1. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that cooking equipment are maintained as per NFPA 96.

The findings include:

It was observed on 6/22/11 that there was a significant amount of grease that was beading on the vent and extinguishing pipes over the deep fat fryer and griddle in the kitchen. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview it was determined that the hospital failed to ensure that the medical gases are properly stored.

The findings include:

It was observed on 6/22/11 at approximately 2 P.M. there were 5 medical gases tanks unrestrained on the floor of the EMS storage room near the EMS entrance on the first floor. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview was determined that the hospital failed to ensure that the emergency power is according to NFPA 99.

The findings include:

It was observed on 6/22/11 that there was a defective light for emergency generator remote annunciator panel. The Facility Operations Vice President concurred with the observation at the time of the survey.

Based on observation and an interview, it was determined that the lightning protection is not according to NFPA 780.

The findings include:

It was observed on 6/21/11 at approximately 7:30 A.M. that the lightning rods were no longer affixed to the the parapets and were lying down on the roof. The Facility Operation Vice President confirm the observation at the time of the survey.