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Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one open use area on the eighth floor of the J Building was protected in accordance with 18.3.6.1. This could affect all individuals utilizing the services of this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the eighth floor a waiting area was observed at the end of the corridor. This area was open to the corridor, was fully sprinklered, but lacked smoke detection. This finding was confirmed by staff EEEE during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one hazardous area on the fifth floor of the J Building was protected by the required 3/4 hour rated door. This could affect all individuals utilizing the services in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted of the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fifth floor it was observed that soiled utility room J54-321 had a door that latched securely into the door frame and was on a self-closer; however, the door lacked the required 3/4 hour fire resistance rating. This finding was confirmed by staff EEEE during the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily available at all times. One exit in Building S was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

On 04/26/10 between the hours of 7:30 AM and 5:00 P.M. a tour of the S Building was completed with Staff EEEE and Staff FFFF. On the first floor at the outpatient laboratory area, an exit corridor was followed to determine the point of exit discharge. The exit door was numbered S-15 exit and was adjacent to S1-03, a pediatric area. An attempt to open the door failed when pressure was applied. A key swipe was noted near the exit door. Staff EEEE verified that the exit door was not to require special unlocking maneuvers and was designated as an exit for the general public to utilize.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one of three sliding horizontal fire doors in the Q Building was capable of closing in the event of fire. The hospital's census was 988 patients.

Findings include:

Tour of the Q Building was conducted on 4/21/10 from 1:00 PM until 4:30 PM with staff JJJJ, EEEE, and LLLL. At approximately 4:15 PM the three McKeon sliding horizontal fire doors separating the Q Building from the J Building were observed. The door located adjacent to the chapel was observed with a large, heavy riding-type floor scrubber parked unattended in front of the fire door. Staff present on tour needed to mount the scrubber, determine how to start the machine, and drive it out of the way of the McKeon door. It was confirmed with staff present during the tour that this heavy machine would have prevented the closing of the fire door if a fire had occurred.

Based on staff interviews, and observations, the facility failed to ensure 3 of 4 exit discharges were equipped with lighting fixtures that would prevent the discharge areas from being in darkness in the event that the lighting fixture (bulb) would fail, in accordance with the code at 7.8. This could affect all patients, staff, and visitors in this facility. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII, Staff EEE and Staff DDD. The following exits were observed with a single light fixture that contained one bulb: outside Stair E1 at 90th Street and Carnegie Street, outside Stair E2 on Carnegie Street by the skywalk, and outside Stair E4 on 90th Street on the west side of the building. There were no additional light fixtures observed in these areas. These light fixture bulbs were verified by the staff accompanying the surveyor on tour.

Based on observations and staff interviews, the facility failed to insure the fire alarm system is installed in accordance with NFPA 70 National Electrical Code and NFPA 72, 9.6.1.4. This involved one smoke detector in the building on the first floor and could affect all staff and visitors in that building. The hospital's census was 988 patients.

Findings include:

A tour was conducted in this building on 04/28/10 between 9:42 AM and 11:30 AM with Staff JJJJ, Staff EEE, and Staff HHH. The main fire panel in the first floor lobby was observed with a system trouble light. When questioned as to why the panel had a system trouble light, Staff IIII was notified by facility staff, who then notified Staff III to explain this to the surveyor. Staff III stated a new smoke detector had been installed approximately 1 to 2 months ago in the MRI unit; however, had not been fully interconnected into the fire alarm system, resulting in a system trouble light on the main fire panel. Staff IIII stated the outside contractor would be contacted to finish the work. On 04/30/10 at 11:30 AM, Staff IIII stated the smoke detector is now connected into the fire alarm system.

Based on observations and staff interviews, the facility failed to maintain sprinkler heads and escheon rings on the first floor of the E building. This involved multiple areas of this floor and could affect all the patients in the emergency room and intensive care overflow area (12 beds), along with visitors, and staff. The code at NFPA 25, 9.7.5. The hospital's census was 988 patients.


Findings include:


A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII , Staff EEE and Staff DDD. During this tour, on the first floor, dirty, heavily coated sprinkler heads or missing escheon rings were observed in the following areas:

In the ICU spill over unit rooms the sprinkler heads were observed dirty: #12, #10, #9, #8, #5, #4, #2, #1 and by the ambulance exit.
Escheon rings were missing in the ICU spill over unit in the following areas: by room E1-347, two by the elevator and hall dock area, by the coumadin clinic E1-225, in the Coumadin work room and at the entrance at E-13.

In the emergency department (ED), the following sprinkler heads were dusty/dirty:
Three sprinkler heads at the entrance into the unit, three in security office, outside security, behind the ED registration desk, by E1-147, two inside the ambulance entrance, by E1-126, outside E1-101, Room #16, and #18 additional sprinkler heads in the nurses' station and surrounding hallway.

In the E-17 unit dirty sprinkler heads were observed at the nurses' stations, in the conference room, and in the hall by room #2. An escheon ring was missing in EB-20.

In the observation area dirty sprinkler heads were observed outside beds #13, #10, #9 and at the nurses' station, in room #2.

These sprinkler heads were verified with Staff IIII on tour who confirmed the heads were in need of cleaning or needing replacement of escheon rings.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that medical gases were stored according to NFPA 99 in the surgery exit hallway on the fourth floor of the J Building. This could affect all individuals in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fourth floor, it was noted that medical gases exceeding 300 cubic feet were stored in the surgery exit corridor. The medical gases observed were: one M tank of compressed air, one H tank of compressed air; four M tanks of argon; one H tank of argon; four D tanks of helium; and four M tanks of nitrous oxide. It was confirmed by staff EEEE during the tour that these medical gases should not be stored in the open exit corridor.

Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that relative humidity was maintained equal to or greater than 35% in anesthetizing locations. The facility had 89 operating rooms located on the main campus of the facility. Two of six buildings that housed operating rooms (Buildings H and G) were affected. Building H contained 13 operating rooms. Building G contained 11 operating rooms. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

1. On 04/20/10 between 1:30 PM and 4:00 PM during tour, the monitoring location for the hospital's operating rooms humidity levels was observed with staff IIII. Staff XX and Staff A5 were present in the monitoring location. Staff A5 was asked to provide documented humidity levels for the facility's operating rooms. Staff A5 indicated that all the operating rooms humidity levels were electronically monitored and to print the information would require too many pages. Staff A5 provided a sample of one operating room located in the H building. The humidity level for the room was noted to have a high and low reading. The low was 12 percent with the high reading being 20 percent.

The staff (Staff XX and A5) indicated the electronic monitoring involved three systems. Staff XX and Staff A5 indicated that it may not be possible to obtain readings for some operating rooms. The staff was asked to provide 3 days of information, for the H building with the random dates chosen as 02/03, 02/04, and 02/05/10.

On 04/21/10, the information was provided. Review of the humidity levels for the 13 operating rooms in Building H revealed 13 of 13 operating rooms did not reach 35 percent on the dates chosen for review. All humidity levels were noted to be under 28 percent.

Staff XX and Staff A5 could not address what the desired level of humidity was for the facility's operating rooms. Review of the facility policy for environmental control revealed the surgical services locations were to have humidity levels maintained between 30 and 60 percent for ideal conditions related to health and safety.

On 04/23/10 at 10:30 A.M. interview of Staff XX revealed that operating rooms were not notified if humidity levels were too low. Staff XX stated that only when humidity levels become too high were the operating room staff notified.

On 04/28/10 at 10:25 A.M. Staff A5 obtained humidity levels for 13 operating rooms in Building H. Thirteen of 13 operating rooms had humidity levels below 35 percent. The ranges of the humidity levels for the 13 operating rooms were 19.69 percent to 30.03 percent. Humidity levels were also reviewed for 11 operating rooms located in Building G. Eleven of 11 operating rooms in Building G did not have humidity levels of 35 percent of greater. The ranges of humidity levels for the 11 operating rooms were 22.12 percent to 25.85 percent.

Doors shall be operable with not more than one releasing operation. 39.2.2.2.1, 7.2.1.5.4.

This requirement is NOT MET as evidenced by:

Based on observation and interview, it was determined that the facility failed to ensure that two of two sleeping rooms could be opened with not more than one releasing operation. The hospital's census was 988 patients.

Findings include:

Tour was conducted on 4/26/10 from 12:45 PM until 1:15 PM with staff JJJJ, staff MMMM, and individual YYYY. It was observed that the two patient sleeping room doors had handles with a device for latching the doors into the door frame. The doors also had deadbolts located approximately eight inches above the handles. If the deadbolts were secured, this would require any individual in the rooms to use two hand motions to release both locks before exiting the rooms. This finding was confirmed by staff JJJJ and individual YYYY during the tour.