HospitalInspections.org

Based upon observation and staff interview, the facility failed to ensure proper operation of the smoke barrier doors located at the MRI corridor, #1 center stairs on the 6th floor and at the Recovery Room in the Wismer Building on the 2nd floor in accordance with the LSC, section 19.2.2.2.6. This deficient practice could cause approximately 45 residents, staff and visitors to be potentially injured during a fire due to the smoke barrier doors not shutting properly and allowing heat and smoke to escape.

Findings Include:

On 3/27/14 at approximately 12:06pm, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door at the MRI corridor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

On 3/27/14 at approximately 10:13am, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door on the #1 center stairs on the 6th floor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

On 3/27/14 at approximately 10:45am, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door at the Recovery Room in the Wismer Building on the 2nd floor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier wall on the 5th floor at the Education Resource Office, corridor wall at room #553 and the soiled linen room in the laundry room in accordance with the LSC, section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could cause 28 residents on the 5th floor, staff working in these areas and visitors to be potentially injured during a fire by smoke and heat passing through the smoke barrier walls.

Findings Include:

On 3/27/14 at approximately 10:20am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the smoke barrier wall on the 5th floor at the Education Resource Office failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

On 3/27/14 at approximately 10:28am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the corridor wall at room #553 failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

On 3/27/14 at approximately 12:30am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the smoke barrier wall from the soiled linen room in the laundry room failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

Based upon observation and staff interview, it was determined that the facility failed to provide protection of hazardous areas by the door to the storage room in the old CAT Scan room not closing and latching properly in accordance with the LSC, section 19.3.2.1. This deficient practice could affect staff and visitors on the first floor potentially during a fire due to the hazardous room door not shutting and latching properly allowing heat and smoke to escape.

Findings Include:

On 3/27/14 at approximately 12:03pm, by observation and interview of DFM#1, MM#1 and FDA#1 the door on the storage room in the old CAT Scan room failed to properly closed and latch when tested. DFM#1 stated that the door-closing device must be bad and will replace it.

Based upon observation and staff interview it was determined that the facility failed to provide one-hour fire resistance rating for the exit component in the basement southeast stairwell mechanical room, mechanical room on the 7th floor and the elevator control room on the 7th floor in accordance with the LSC, section 8.2.5.2, 19.3.11. This deficient practice could potentially effect residents, staff and visitors, if a fire occurred, due to the doors allowing heat and smoke to escape into the stairwells.

Findings Include:

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the mechanical room to the southeast stairwell failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the mechanical room on the 7th floor failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the elevator control room on the 7th floor failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

Based upon observation and staff interview, it was determined that the facility failed to supply emergency lighting in generator transfer switch room in the Wismer Building and in the sprinkler riser room in the Wismer Building in accordance with the LSC, section 19.2.9.1. This deficient practice could cause any staff that is occupying these areas to potentially be injured in the event of a power outage.

Findings Include:

On 3/27/14 at approximately 10:56am, by observation and interview of DFM#1, MM#1 and FDA#1 emergency lighting failed to be installed in the generator transfer switch room in the Wismer Building. DFM#1 stated that he was unaware of this situation and would have one installed immediately.

On 3/27/14 at approximately 10:57am, by observation and interview of DFM#1, MM#1 and FDA#1 emergency lighting failed to be work properly when tested in sprinkler riser room in the Wismer Building. DFM#1 stated that he was unaware of this situation and would have it repaired immediately immediately.

Based upon observation and staff interview, it was determined that the facility failed to properly maintain the ceiling tiles and grid in the Anesthesia Office on the 2nd floor in accordance with the LSC, section 19.7.6, 4.6.12, 9.7.5. This deficient practice could cause approximately 14 patients, staff and visitors to be potentially injured during a fire due to the smoke and heat passing through the ceiling tiles and the sprinkler system to not operate properly.

Findings Include:

On 3/27/14 at approximately 10:50am, by observation and interview of DFM#1, MM#1 and FDA#1 the ceiling tiles in the Anesthesia Office on the 2nd floor were damaged. DFM#1 stated he was unaware of this condition and would have the ceiling tiles replaced.

Based upon observation and staff interview it was determined that the facility failed to ensure that the wall mounted nurse charting units closed properly at room #673, #659, #655, #653, #559, #550, #556, #411, #402 and #415 in accordance with the LSC, section 7.1.1. This deficient practice could cause 135 residents, staff and visitors to potentially be injured during a fire due to the charting units not being closed properly.

Findings Include:

On 3/27/14 at approximately 10:06am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #673 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:07am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #659 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:08am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #655 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:09am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #653 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:07am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #559 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:16am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #550 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:18am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #556 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:25am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #411 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:26am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #402 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:28am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #415 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

Based upon observation and staff interview, the facility failed to ensure proper operation of the smoke barrier doors located at the MRI corridor, #1 center stairs on the 6th floor and at the Recovery Room in the Wismer Building on the 2nd floor in accordance with the LSC, section 19.2.2.2.6. This deficient practice could cause approximately 45 residents, staff and visitors to be potentially injured during a fire due to the smoke barrier doors not shutting properly and allowing heat and smoke to escape.

Findings Include:

On 3/27/14 at approximately 12:06pm, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door at the MRI corridor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

On 3/27/14 at approximately 10:13am, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door on the #1 center stairs on the 6th floor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

On 3/27/14 at approximately 10:45am, by observation and interview of DFM#1, MM#1 and FDA#1 the smoke barrier door at the Recovery Room in the Wismer Building on the 2nd floor failed to properly close when tested. DFM#1 stated that the doors are checked monthly and would immediately have the door adjusted.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier wall on the 5th floor at the Education Resource Office, corridor wall at room #553 and the soiled linen room in the laundry room in accordance with the LSC, section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could cause 28 residents on the 5th floor, staff working in these areas and visitors to be potentially injured during a fire by smoke and heat passing through the smoke barrier walls.

Findings Include:

On 3/27/14 at approximately 10:20am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the smoke barrier wall on the 5th floor at the Education Resource Office failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

On 3/27/14 at approximately 10:28am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the corridor wall at room #553 failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

On 3/27/14 at approximately 12:30am, by observation and interview of DFM #1, MM#1 and FDA#1 penetrations of the smoke barrier wall from the soiled linen room in the laundry room failed to be properly sealed. DFM#1 indicated that they had been checking penetrations and must have missed this one.

Based upon observation and staff interview, it was determined that the facility failed to provide protection of hazardous areas by the door to the storage room in the old CAT Scan room not closing and latching properly in accordance with the LSC, section 19.3.2.1. This deficient practice could affect staff and visitors on the first floor potentially during a fire due to the hazardous room door not shutting and latching properly allowing heat and smoke to escape.

Findings Include:

On 3/27/14 at approximately 12:03pm, by observation and interview of DFM#1, MM#1 and FDA#1 the door on the storage room in the old CAT Scan room failed to properly closed and latch when tested. DFM#1 stated that the door-closing device must be bad and will replace it.

Based upon observation and staff interview it was determined that the facility failed to provide one-hour fire resistance rating for the exit component in the basement southeast stairwell mechanical room, mechanical room on the 7th floor and the elevator control room on the 7th floor in accordance with the LSC, section 8.2.5.2, 19.3.11. This deficient practice could potentially effect residents, staff and visitors, if a fire occurred, due to the doors allowing heat and smoke to escape into the stairwells.

Findings Include:

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the mechanical room to the southeast stairwell failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the mechanical room on the 7th floor failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

On 3/27/14, by observation and interview of DFM#1, MM#1 and FDA#1 the exit door from the elevator control room on the 7th floor failed to meet exit egress stairwell requirements. DFM#1, MM#1 and FDA#1 indicated that they were aware of this situation at the time of the finding.

Based upon observation and staff interview, it was determined that the facility failed to supply emergency lighting in generator transfer switch room in the Wismer Building and in the sprinkler riser room in the Wismer Building in accordance with the LSC, section 19.2.9.1. This deficient practice could cause any staff that is occupying these areas to potentially be injured in the event of a power outage.

Findings Include:

On 3/27/14 at approximately 10:56am, by observation and interview of DFM#1, MM#1 and FDA#1 emergency lighting failed to be installed in the generator transfer switch room in the Wismer Building. DFM#1 stated that he was unaware of this situation and would have one installed immediately.

On 3/27/14 at approximately 10:57am, by observation and interview of DFM#1, MM#1 and FDA#1 emergency lighting failed to be work properly when tested in sprinkler riser room in the Wismer Building. DFM#1 stated that he was unaware of this situation and would have it repaired immediately immediately.

Based upon observation and staff interview, it was determined that the facility failed to properly maintain the ceiling tiles and grid in the Anesthesia Office on the 2nd floor in accordance with the LSC, section 19.7.6, 4.6.12, 9.7.5. This deficient practice could cause approximately 14 patients, staff and visitors to be potentially injured during a fire due to the smoke and heat passing through the ceiling tiles and the sprinkler system to not operate properly.

Findings Include:

On 3/27/14 at approximately 10:50am, by observation and interview of DFM#1, MM#1 and FDA#1 the ceiling tiles in the Anesthesia Office on the 2nd floor were damaged. DFM#1 stated he was unaware of this condition and would have the ceiling tiles replaced.

Based upon observation and staff interview it was determined that the facility failed to ensure that the wall mounted nurse charting units closed properly at room #673, #659, #655, #653, #559, #550, #556, #411, #402 and #415 in accordance with the LSC, section 7.1.1. This deficient practice could cause 135 residents, staff and visitors to potentially be injured during a fire due to the charting units not being closed properly.

Findings Include:

On 3/27/14 at approximately 10:06am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #673 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:07am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #659 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:08am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #655 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:09am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #653 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:07am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #559 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:16am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #550 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:18am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #556 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:25am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #411 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:26am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #402 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.

On 3/27/14 at approximately 10:28am, by observation and interview of DFM#1, MM#1 and FDA#1 the nurse charting unit at room #415 failed to properly shut when tested. DFM#1 stated that he was unaware of this situation and would have the unit repaired.