HospitalInspections.org

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: Room 1-118 has med gas lines penetrating the room and was not properly enclosed in the wall and ceiling.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following building construction type item was non-compliant:

There were unsealed penetration in ceiling 1st floor IST room VP1C118.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following interior finish was non-compliant: There was untreated plywood used to mount wall TV in break room, express care area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following corridor door was non-compliant: Corridor Door OB-18-1-072 did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following vertical opening was non-compliant: In the Pent House area, the access door to the 2 hr. fire rated vertical shaft did not close, latch and seal.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following smoke wall was non-compliant:

A. Smoke Wall 7th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

B. Smoke Wall 6th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.

C. Smoke wall located above the ceiling in the Soiled holding room Main 3S-3-032 has holes that have not been sealed in order to maintain the required rating of the area.

D. Smoke tight shutters in the labs rated wall did not close after three fire alarm tests were conducted.

E. There was not a rated sleeve on the penetration in the one hour rated wall on 2 South (main 2S-2-2006)

By observation on November 9th, 2011 at approximately 2:00 PM onward the following doors in smoke barriers was non-compliant: The door in smoke wall located next to VP-GD021A did not close smoke tight.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following hazardous area was non-compliant: The corridor hall door to the Janitor storage closet OB-18-1-035 was not self closing.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant: The exterior exit access/discharge from the rear of building, near x-ray area, was not a solid path (easily maintained in inclement weather) to a public way.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit access was non-compliant:

A. Facility is equipped with special locking and the facility is not 100% sprinkler coverage. Areas not cover by sprinkler coverage will need to be protected with heat and/or smoke detector. The Doctor wash closets located in PST-4-042 Labor and Delivery does not have sprinkler coverage and is not provided with smoke detectors.

B. The override switch for mag locks at nurses station not labeled (ICU)

C. Machine blocking access to override switch for magnetic locking devices at nurses station (express care)

D. The exit cross corridor door Main 2NA-2-011 is equipped with mag locks and when tested did not drop out upon activation of fire alarm. The doors did release with switch at the door and master override switch.

E. Exit door PST 1-006 required more that 15 lbs of force to open.
Doors shall be operable with not more than one releasing operation, 7.2.1.5.4

F. Main Building 4th floor, Flower shop, requires two motions of the hand to exit the room.

G. Clinical educator office and adjoining room has bathroom that requires two motions of the hand exit the room. Location North Hall 4th floor 4-016 and 4-011.

H. The restroom located in the elevator lobby location 3-W-3-080 requires two motions of the hand to exit the room.

I. 2 South door going into old prep room, requires two motions of the hand to exit the room.

J. Rehab bathroom 2-662 and nourishment room 2-038, requires two motions of the hand to exit the room.

K. Door in old cath lab, 2W-2-038, requires two motions of the hand to exit the room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following illumination of means of egress was non-compliant:

A. There was not a light on emergency power or a battery operated emergency light located in the two ultra sound rooms.

B. The emergency light near the MRI door did not function properly when tested.

C. There is not proper coverage of emergency illumination in the back hall office area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following exit and directional signs were non-compliant:

A. Additional exit and directional signage is needed from the 4th Floor West Wing corridor back into the NICU unit. At present exit directional signage is provided in one direction only.

B. Additional exit and directional signage is needed from the 3rd Floor West Wing corridor back into the Respiratory Therapy Unit. At present exit directional signage is provided in one direction only.

C. Additional exit and directional signage is need in the connecting corridor between NICU and 4th floor west wing.

D. Additional exit and directional signage needed between A and UB Lab 2nd Floor Main Connecting Corridor.

E. Additional exit and directional signage needed in the outer center core of the surgical suite.

F. Exit signage is needed above exit door PST 1-006.

G. Additional exit and directional signage needed In the Medical Records and Health Management suite leading individual to a second means of egress from the area.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following fire alarm component was non-compliant:

There was not a smoke detector in old cath lab/2 west storage room.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system and components were non-compliant:

A. The recessed sprinkler head located in the patient room Main 6-634 located in front of patient bed was out of adjustment and would not provide coverage for the area.

B. There is no sprinkler coverage in the sleep lab bathrooms 1, 3, & 5 and in rehab.

C. The sprinkler heads, on the loading dock, are not uniform across the entire area and are not properly rated in all areas. 200 degree (green) heads are mixed in with 155 degree (red) heads. Sprinkler head ratings in the area should be 155 degree (red) unless documentation would indicate otherwise.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following sprinkler system supervision was non-compliant:

A. In the South Tower there are three valves on the main sprinkler line that are not supervise with an electronically supervised tamper alarms.

B. In the South Tower the tamper alarms on the fire pump did not activate and alarm when tested.

C. In the Patient Service Tower area in main building the tamper alarm on the fire pump did not sound an alarm when tested.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The 5th floor elevator equipment room had an individual Heating Ventilating and Air Conditioning (HVAC) unit within the two hour enclosure that did not shut down with fire alarm activation.

B. The 3rd floor HVAC unit did not have an emergency HVAC shut down switch.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following means of egress was non-compliant:

A. Multiple items such as equipment and a charting table stored in front of each ICU breakaway door. In an emergency rolling multiple beds out of the suite would be difficult because of multiple items that would be rolled in the exit egress to use the breakaway door.

B. IST workstation did not close, blocking exit path between rooms 2 & 3 (express care).

C. IST workstation did not close, blocking exit path across from fire door main 2S-2-701.

D. IST workstation did not close, blocking exit path from CSICU/2 west.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following trash collection was non-compliant:

Trash containers greater than 32 gallons were found stored in the corridor area leading to central supply.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following medical gas storage was non-compliant:

A. Full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (8th and 5th floor oxygen storage rooms)

B. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] Medical gas cylinders located in room Main 3W-3-080 were found gang chained together.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. In CYSTO 2 surgery room the Relative Humidity gauge was not operational.

B. In the OR suites the Relative Humidity gauges were not operational.

C. In Short Stay surgical suite there were not Relative Humidity gauges present.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following operational inspection and testing was non-compliant:

Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

By observation on November 9th, 2011 at approximately 2:00 PM onward the following was non-compliant:

A. The medication refrigerator located on 4th floor in the intermediate NICU unit (small refrigerator) is not connected to emergency power.

B. The pyxis station at old nursery and med room is not connected to emergency power.