HospitalInspections.org

Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.1.

Findings include:

1. During an observation on 6/26/24 at 10:18 a.m., the second-floor west campus southeast door near the nurse's station was observed. The door was marked as an emergency exit. A table was observed, stored in front of the exit and blocking the means of egress.

Based on observation, the facility failed to:

a) maintain egress doors with operating forces in accordance with NFPA 101, 2012 Edition, Section 7.2.1.4.5.; and
b) maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

Findings include:

1. During an observation on 6/25/24 at 3:12 p.m. the stairwell door by the break room on the second floor was inspected. The crash bar on the door was found to be stuck and required extreme force to unlatch the door to the stairwell.


40068

2. During an observation on 6/25/24 at 2:41 p.m., OR 2 was inspected. The egress door was fitted with a slide bolt lock.

3. During an observation on 6/25/24 at 2:42 p.m., OR 3 was inspected. The egress door was fitted with a slide bolt lock.

4. During an observation on 6/25/24 at 2:43 p.m., OR 1 was inspected. The egress door was fitted with a slide bolt lock.

Based on observations, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2.

Findings include:

1. During an observation on 6/26/24 at 10:27 a.m., the wound care clinic was inspected. There was an exit sign on a door outside wound care leading to the behavioral health, and the door the was found to be locked. Marked exits cannot be locked unless the door is equipped with a special locking feature such as delayed egress.

2. During an observation on 6/26/24 at 10:35 a.m., the pain clinic was inspected. There was a marked egress door leading to the old pediatric therapy area which was found to be magnetically locked. Occupants could not follow the marked exit path through the door.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 6/25/24 at 8:43 a.m., the elevator vestibule door on the 2nd floor was inspected. The door was exercised twice and failed to close and latch under the power of the self-closing device.

Based on observation, the facility failed to prevent the use of an enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3.

Findings include:

1. During an observation on 6/26/24 at 11:00 a.m., the staff entrance stairwell was inspected. There was a chair and a wooden shelf found to be stored in the stairwell.

Based on observation, the facility failed to ensure smoke-proof rated stairway enclosures were continuously maintained per NFPA 101-2012, Section 7.2.3.3.1.

Findings include:

1. During an observation on 6/25/24 at 1:08 p.m., the OR exit stairwell door was exercised. The door would not close and positively latch.

Based on observations, the facility failed to ensure smoke-proof rated stairway enclosures were continuously maintained per NFPA 101 Life Safety Code, 2012 Edition, Section 7.2.3.3.1.

Findings include:

1. During an observation on 6/26/24 at 9:55 a.m., the first floor west campus exit stairwell door, next to room G-105, was exercised. The exit stairwell door would not close and positively latch.

2. During an observation on 6/26/24 at 10:21 a.m., the second floor of west campus was inspected. The southeast exit stairwell door (210) would not close and positively latch when exercised.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 19.2.10 and 7.10.

Findings include:

1. During an observation on 6/25/24 at 11:05 a.m., the mammography suite was inspected. The suite lacked exit signage to lead occupants to the general waiting room for imaging.

2. During an observation on 6/25/24 at 11:15 a.m., the NICU was inspected. The exit sign to the south stairwell was not able to be seen from a distance, as it was blocked by a corner of a wall.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 19.2.10 and 7.10.

Findings include:

1. During an observation on 6/25/24 at 2:10 p.m., hall number 2042 in the occupancy had no visible exit signage leading occupants to stairwells for egress, as the way was not obvious in that hall.

2. During an observation on 6/25/24 at 2:18 p.m., halls 3104 and 3097 had no exit signs visible to the occupants to lead them to the stairwells and out of the building.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 19.2.10 and 7.10.

Findings include:

1. During an observation on 6/25/24 at 9:17 a.m., the north end vestibule between the lab and GI was was observed to be lacking an exit sign on the lab side. The path of egress was not obvious.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 39.2.10 and 7.10.

Findings include:

1. During an observation on 6/26/24 at 8:54 a.m., the corridor in south clinic 1 was inspected. The corridor lacked an illuminated exit sign at the north end of the corridor.

Based on an observations the facility failed to provide exit signage in accordance with NFPA 101-2012, Sections 39.2.10, 7.10.2.1. and 7.10.5.2.1.

Findings Include:

1. During an observation on 6/26/24 at 10:53 a.m., the second floor of MOB 31 suite 202 was inspected. Illuminated exit signage was not present.

2. During an observation on 6/26/24 at 10:54 a.m., the second floor of MOB 31 conference room 205 suite was inspected. Illuminated exit signage was not present.

3. During an observation on 6/26/24 at 10:54 a.m., the second floor of MOB 31 college of nursing private entrance was inspected. Illuminated exit signage was not present.

Based on observation the facility failed to properly label doors in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 7.10.8.3.1

Findings include:

1. During an observation on 6/26/24 at 10:22 a.m., the second floor southeast common area was inspected. The room had two glass doors that lead to the rooftop. The doors could be mistaken for an exit in an emergency.

Based on observations, the facility failed to ensure hazardous rooms or rooms being used as storage had doors which were able to close and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 6/25/24 at 8:36 a.m., the corridor door to the soiled side of the laundry was exercised. The door failed to close and latch under the power of the self-closer.

2. During an observation on 6/25/24 at 9:38 a.m., resident room 319 was inspected. The room is over 50 sq. ft. and was found to be used as a storage room. The room was lacking the required self-closing device on the corridor door.

3. During an observation on 6/25/24 at 9:39 a.m., resident rooms 321 and 322 were inspected. The rooms were over 50 sq. ft. and were found to be used as a storage rooms. The rooms were lacking the required self-closing devices on the corridor doors.

4. During an observation on 6/25/24 at 9:44 a.m., resident room 324 was inspected. The room is over 50 sq. ft. and was found to be used as a clothing storage room. The room was lacking the required self-closing device on the corridor door.

5. During an observation on 6/25/24 at 9:55 a.m., EVS rooms 385-389 and 360 were all found to be used as storage rooms, and lacked the required self-closing devices, as all the rooms were over 50 sq. ft.


40068

6. During an observation on 6/25/24 at 10:10 a.m., the seventh floor of the North Tower was inspected. The surgical storage room (715) was used to store various medical equipment and did not have a self-closer on the door.

7. During an observation on 6/25/24 at 10:20 a.m. the eighth floor of the North Tower was inspected. Room 815, a storage room, was used to store various medical equipment and did not have a self-closer on the door.

Based on observation, the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (7).

Findings include:

1. During an observation on 6/25/24 at 11:03 a.m., the fourth floor South Tower storage room was inspected. The room was used as storage and would not close under the power of the self-closure.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 6/25/24 at 10:38 a.m. the x-ray suite was inspected. There was an ABHR dispenser mounted too closely or over a light switch.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 6/25/24 at 1:12 p.m., the decontamination room in the OR tower was inspected. The ABHR dispenser in the room was found to be mounted over a light switch.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 6/25/24 at 1:01 p.m., the Neptune docking station room was inspected. There was a sprinkler head next to a ceiling mounted light in the room. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to ensure pendant type sprinkler heads were mounted at proper distances under unobstructed construction per NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1.

Findings include:

1. During an observation on 6/26/24 at 9:32 a.m., the chapel was inspected. There was a pendant-type sprinkler head found to be less than 1" from being level with the drop down ceiling. There was not enough clearance between the deflector and the ceiling.

Based on observation, the facility failed to maintain the sprinkler system by installing sprinkler heads too close to walls in accordance with NFPA 13 Standard for Automatic Sprinkler Systems, 2010 Edition, Section 8.5.5.2.2

Findings Include:

1. During an observation on 6/26/24 at 10:54 a.m., the sprinkler heads near the nurse's station were inspected. One sprinkler head was found to be mounted within 2" of the wall. Minimum clearance to a wall for a pendant type head is 4".

Based on observation and record review, the facility failed to test or replace gauges on the sprinkler system every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2; and failed to maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

Findings include:

1. Review of the facility's sprinkler reports and during an observation on 6/25/24 at 2:56 p.m., revealed the sprinkler gauges showed they had not been replaced within the required 5-year interval, as they had 2017 written on them.

2. During an observation 6/25/24 at 2:56 p.m., the spare sprinkler head box was found to be missing directional replacement sprinkler heads. The facility had a directional head located in the electrical room.

Based on observation and record review, the facility failed to:

a) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3);
b) maintain a wrench in the spare sprinkler cabinet in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.9.6; and
c) maintain escutcheon plates around sprinkler heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.1.

Findings include:

1 During on observation on 6/25/24 at 10:47 a.m., the linen chute room was inspected. There were ceiling tiles missing from the the drop-down ceiling structure in the room.


40068

2. During an observation on 6/25/24 at 8:45 a.m., the south sprinkler riser room was inspected. A wrench was not located in the spare sprinkler cabinet.

3. During an observation on 6/25/24 at 8:53 a.m., the first floor cart washing area (1411) was inspected. A ceiling tile was observed missing.

4. During an observation on 6/25/24 at 9:21 a.m., the first floor South Tower Goodnow board room was inspected. The A/V closet was missing ceiling tiles, and an escutcheon ring was missing around the sprinkler head.

Based on observation and record review, the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.;
b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.;
c) maintain a supply of spare sprinklers for each type of sprinkler head in accordance with NFPA 25 Water-Based Fire Protection Systems 2011 Edition, Section 5.4.1.4 and 5.4.1.4.1.; and
d) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).

Findings include:

1. During an observation on 6/26/24 at 9:29 a.m., the Clark Fork conference room was inspected. There were two sprinkler heads in the room missing the required escutcheon ring.

2. During an observation on 6/26/24 at 9:39 a.m., the data room was inspected. There was a large power wire to the UPS observed to be suspended off the sprinkler pipe in the room.


40068


3. During an observation on 6/26/24 at 10:01 a.m., the west campus spare sprinkler box was inspected. There were no spare directional sprinkler heads in the sprinkler cabinet. There were directional sprinkler heads located in the vestibule near the dining room.

4. During an observation on 6/26/24 at 10:07 a.m., the west campus loading dock was inspected. A sign was observed hanging off the sprinkler piping.

5. During an observation on 6/26/24 at 10:36 a.m., the west campus third floor electrical/telephone closet was inspected. There was a missing ceiling tile observed.

Based on observation and record review, the facility failed to:

a) test or replace gauges on the sprinkler system every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2;
b) failed to ensure spare sprinklers were available in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.; and
c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).,

Findings include:

1. Review of the facility's sprinkler reports and observation of the standpipe gauges on 6/26/24 at 8:27 a.m., showed standpipe gauges were found to have 2017 written on them as the last time they were replaced.

2. During an observation 6/26/24 at 8:27 a.m., the spare sprinkler head box at the stand pipe was found to be missing directional replacement sprinkler heads. The facility had a directional heads in use in the building.


40068

3. During an observation on 6/26/24 at 8:14 a.m., the SCI cyber knife vault room was inspected. There were five ceiling tiles missing.

4. During an observation on 6/26/24 at 8:20 a.m., the SCI, HDR room was inspected. There was a hole observed in a ceiling tile.

5. During an observation on 6/26/24 at 8:59 a.m., the SCI building was inspected. Outside the conference room, two ceiling tiles were missing.

Based on observation, the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During an observation on 6/25/24 at 10:52 a.m., the electrical room in dermatology was inspected. The room was found to have missing ceiling tiles from the drop-down ceiling structure.

Based on observation, the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During an observation on 6/25/24 at 1:38 p.m., radiology room number 1078 was found to have a ceiling tile missing from the drop-down ceiling structure in the room. There was also two large square cuts, approximately 6"x6" cut out of two of the ceiling tiles in the room.


40068

2. During an observation on 6/25/24 at 1:52 p.m., the first floor of MOB4 was inspected. A ceiling tile was missing in the first floor hallway.

Based on observations, the facility failed to:

a) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.;
b)ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).; and
c) maintain fire department access in accordance with NFPA 25 Water-Based Fore Protection 2011Edition, Section 6.1.3.

Findings include:

1. During an observation on 6/25/24 at 8:33 a.m., the soiled side of the laundry was inspected. There was a hard pipe line suspended from the facility sprinkler pipe in the room.

2. During an observation on 6/25/24 at 9:42 a.m., the 3rd floor soiled utility room was inspected. There was a ceiling tile observed to be missing from the ceiling structure within the room.


40068

3. During an observation on 6/25/24 at 9:58 a.m., the fifth-floor North Tower housekeeping closet (549) was inspected. There was a penetration observed in the ceiling tile.

4. During an observation on 6/25/24 at 10:04 a.m., the fifth-floor North Tower was inspected. Near room 587, a cabinet was observed with signage which read, "Standpipe for Fire Department Use Only." The door was painted shut and was not accessible.

5. During an observation on 6/25/24 at 10:30 a.m., the eighth floor North Tower data closet (803) was inspected. There were two ceiling tiles that had been removed.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 6/26/24 at 9:01 a.m., the kitchen area was inspected. There was a portable K-type extinguisher in the room next to the kitchen which was blocked from immediate access by a chair and a broom.

Based on observation, the facility failed to:

a) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.; and
b) install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.4 and 6.1.3.8.1.

Findings include:

1. During an observation on 6/26/24 at 10:23 a.m., the ambulatory pharmacy was inspected. There was a portable fire extinguisher blocked from immediate access by a small cabinet stored directly in front of it.


40068

2. During an observation on 6/26/24 at 9:38 a.m., the west campus kitchen was inspected. The portable K-tank was mounted 65 inches from the ground.

Based on observations, the facility failed to:

a) ensure corridor doors were resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Sections 19.3.6.3.1.; and
b) maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10.

Findings include:

1. During an observation on 6/25/24 at 10:02 a.m., third floor room 381 was found to be completely lacking a corridor door.


40068

2. During an observation on 6/25/24 at 10:06 a.m., the fifth floor of the North Tower was inspected. The dialysis supply room (560) door wasobserved being held open by a wedge.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1.

Findings include:

1. During an observation on 6/25/24 at 1:06 p.m., the OR suite (N291) smoke doors were exercised. The doors would not close and latch when exercised.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1.

Findings include:

During an observation on 6/26/24 at 9:34 a.m., the west campus basement smoke doors near the cafeteria were exercised. The south leaf would not close and latch when exercised.

Based on observations, the facility failed to ensure latching fire barrier doors were maintained per NFPA 101-2012, Section 19.1.1.4.1.1 and 8.3.3.3.

Findings include:

1. During an observation on 6/25/24 at 8:40 a.m., the first floor South Tower east hall two-hour barrier doors (5-150) were exercised. The doors would not close and latch under the power of the self-closer.

2. During an observation on 6/25/24 at 10:42 a.m., the fourth floor south 400 two-hour barrier doors were exercised. The doors would not close and latch under the power of the self-closer.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 6/24/24 at 8:00 a.m., it was determined the facility had not completed a fire drill for the evening shift of the second quarter of 2023.

Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 6/25/24 at 9:40 a.m., the third floor clean utility room was inspected. There were items found to be stored in front of the electrical panel in the room.

Based on an observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 6/25/24 at 9:30 a.m., the fire alarm panel room (1143) was inspected. There was storage observed in front of the electrical panel.

Based on an observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 6/26/24 at 8:36 a.m., SCI electrical room (330) was inspected. There was storageobserved in front of the electrical panel.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 6/25/24 at 1:03 p.m., OR 6 was inspected. There was a cart stored in front of the electrical panel.

2. During an observation on 6/25/24 at 1:15 p.m., the electrical room (2515) was inspected. There was storage in front of the electrical panel.