HospitalInspections.org

Based on observation and interview, the facility failed to provide the 2-hour fire resistance rating for structural steel in one location, on one of four floors of this component.

Findings include:

1. Observation on February 19, 2013, at 3:05 PM, revealed there was a section of unprotected structural steel (I-Beam bottom flange), on the 2nd Floor above the ceiling, between the OR Breakroom and the Doctors' Locker room.

Interview with the Director of Facility Management on February 19, 2013, at 3:05 PM, confirmed the unprotected steel.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in six locations, on two of four floors of this component.

Findings include:

1. Observation on February 19, 2013, between 1:30 PM and 1:55 PM revealed the following corridor door deficiencies:

Third Floor
a. 1:30 PM, Patient Room 8 would not close and latch, due to a computer on wheels blocking the door;
b. 1:36 PM, Patient Room 2 would not close and latch, due to a computer on wheels blocking the door;
c. 1:55 PM, Patient Room 4 would not close and latch, due to an arm chair blocking the door.

Interview with the Director of Facility Management on February 19, 2013, at 2:00 PM confirmed the corridor door obstructions.

2. Observation on February 20, 2013, between 10:50 AM and 11:30 AM revealed the following corridor door deficiencies:

Second Floor
a. 10:50 AM, Patient Room 303 would not close and latch, due to a soiled linen cart blocking the door;
b. 11:25 PM, Patient Room 6 &7 were hinge-bound and not closing and latching properly;
c. 11:30 AM, the Storage Room at the end of the corridor, by Patient Room 7, required a coordinator adjustment to properly close and latch properly.

Interview with the Director of Facility Management on February 20, 2013, at 12:00 PM confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to protect openings through the floor assembly in two locations, on two of four floors of this component.

Findings include:

1. Observation on February 20, 2013, at 10:00 AM revealed unsealed penetrations of the floor/ceiling assembly (2nd to 3rd), in the 2nd Floor CCU Equipment/Oxygen Storage Room, around 2 conduits and inside 1 conduit, located inside the door and to the left.

Interview with the Director of Facility Management on February 20, 2013, at 10:00 AM, confirmed the unsealed penetrations.

2. Observation on February 20, 2013, at 1:00 PM revealed unsealed penetrations of the floor/ceiling assembly (1st to 2nd and 1st to Ground), in the 1st Floor '87 Building Electrical Room, by the Elevators, inside 4 conduit.

Interview with the Director of Facility Management on February 20, 2013, at 1:00 PM, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the one half hour fire resistance rating of smoke barrier walls in two locations, on one of four floors of this component.

Findings include:

1. Observation on February 20, 2013, between 12:10 PM and 1:35 PM revealed the following unsealed smoke barrier penetrations:

a) 12:10 PM, inside a conduit with data wires, over the 1st Floor double corridor doors to Medical Records;
b) 1:35 PM, the smoke wall was incomplete over the 1st Floor double corridor doors, by the elevators going to Radiology, from Cardiology.

Interview with the Director of Facility Management on February 20, 2013, at 1:35 PM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating smoke barrier door openings in one location, on one of three floors of this component.

Findings include:

1. Observation on February 20, 2013, at 11:59 AM revealed the double doors, by the 2nd floor Soiled Holding Room, required a latching adjustment to properly close and latch in the frame.

Interview with the Maintenance Technician on February 20, 2013, at 11:59 AM confirmed the doors did not latch.

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by smoke resistant construction in one location, on one of four floors of the facility.

Findings include:

1. Observation on February 20, 2013, at 10:10 AM revealed there was an unsealed penetration of the 2nd Floor CCU Soiled Utility Room, above the Hand-Sani Dispenser, around an M/C electrical cable.

Interview with the Director of Facility Management on February 20, 2013, at 10:10 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of an exit component enclosure in one location, on one of four floors of this component.

Findings include:

1. Observation on February 19, 2013, at 2:55 PM revealed the '60 Building 2nd Floor stairtower door, in the Operating Area, required a closure adjustment to properly close and latch in its frame.

Interview with the Director of Maintenance on February 19, 2013, at 2:55 PM confirmed the door required an adjustment to properly latch.

Based on observation and interview, it was determined the facility failed to ensure stairways used as exits were not used for any purpose that has the potential to interfere with egress in one location, on one of three floors of this component.

Findings include:

1. Observation on February 20, 2013, at 11:17 AM revealed a domestic cold water pipe and a vent pipe ran through the East Stairwell, above the suspended ceiling, on the 3rd floor.

Interview with the Maintenance Technician on February 20, 2013, at 11:17 AM confirmed the pipes location, within the Stairwell.

Based on observation and interview, it was determined that exit access was not maintained readily accessible at all times in one location, at one of eight exits of this component.

Findings include:

1. Observation on February 20, 2013, at 11:32 AM revealed the left side, bottom exit egress door (leading to the exterior of the building) in Stairtower 48 North, was very difficult to open.

Interview with the Director of Facility Management on February 20, 2013, at 11:32 AM confirmed the required adjustment.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed in one location, on one of four floors of the building.

Findings include:

1. Observation on February 20, 2013, at 10:30 AM revealed the Wallaroo on the 2nd Floor outside Patient Room 103, was not returned and closed properly.

Interview with the Director of Facility Management on February 20, 2013, at 10:30 AM confirmed the open Wallaroo obstructed the corridor.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in two locations, on two of three floors of this component.

Findings include:

1. Observation on February 20, 2013, at 12:50 PM revealed blue wires zip-tied to the sprinkler pipe in two locations, in the 2nd floor OB/GYN Waiting Room, above the smoke barrier door.

Interview with the Maintenance Technician on February 20, 2013, at 12:50 PM confirmed the wires were supported by the sprinkler system.

2. Observation on February 20, 2013, at 1:00 PM revealed one sprinkler head, in the 1st floor Conference Room "A" Supply Closet, was missing an escutcheon.

Interview with the Maintenance Technician on February 20, 2013, at 1:00 PM confirmed the lack of an escutcheon.

Based on observation and interview, the facility failed to properly store mobile soiled linen receptacles greater than 32-gallon capacity when left unattended in one location, on one of four floors of this component.

Findings include:

1. Observation on February 19, 2013, at 1:45 PM revealed that two large soiled bins were stored in the corridor offset to the Shower Room, by 3rd floor Patient Room 4, outside of a protected hazardous storage area.

Interview with the Director of Facility Management on February 19, 2013, at 1:45 PM confirmed the soiled linen bins were stored outside of a protected hazardous storage area.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in one location, in one of two smoke compartments within this component.

Findings include:

1. Observation on February 20, 2013, at 10:05 AM revealed four unsecured oxygen cylinders, located within the Oxygen Storage Room.

Interview with the Maintenance Technician on February 20, 2013, at 10:05 AM confirmed the tanks were not secured.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas systems in accordance with the regulations in one corridor, on one of four floors of this component.

Findings include:

1. Observation on February 19, 2013, at 1:40 PM revealed the medical gas lines above the suspended ceiling, at the double corridor doors to the Acute Rehab Unit on the 3rd Floor, were unlabeled.

Interview with the Director of Facility Management on February 19, 2013, at 1:40 PM confirmed the medical gas lines were not labeled.

Based on observation and interview, the facility failed to maintain the emergency generator, which supplies power to the entire building.

Findings include:

1. Observation on February 20, 2013, at 10:55 AM revealed the two remote annunciator panels for the generators, located at the 2nd Floor Nurses' Station, by Patient Room 203, had tape covering the audible alarm. When tested, the top panel showed nothing and no audible sounded. The bottom panel had a nonfunctional trouble light and no audible alarm sounded.

Interview with the Director of Facility Management on February 20, 2013, at 10:55 AM confirmed the nonfunctioning generator annunciator alarm panels.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment in four locations, on two of three floors of this component.

Findings include:

1. Observation on February 20, 2013, at 11:15 AM revealed a temporary light fixture and associated wiring above the suspended ceiling, in the 3rd floor East Stairwell.

Interview with the Maintenance Technician on February 20, 2013, at 11:15 confirmed the temporary light and wire.

2. Observation on February 20, 2013, at 11:45 AM revealed a surge protector supplying power to a toaster and microwave, in the 3rd floor Heritage Surgical Reception Refrigerator Closet.

Interview with the Maintenance Technician on February 20, 2013, at 11:45 AM confirmed the improper use of a surge protector and the subsequent correction of the deficiency at the time of the survey.

3. Observation on February 20, 2013, at 1:04 PM revealed a surge protector supplying power to a personal space heater, in the 1st floor OB/GYN Chart Room.

Interview with the Maintenance Technician on February 20, 2013, at 1:04 PM confirmed the improper use of a surge protector.

4. Observation on February 20, 2013, at 1:14 PM revealed a three-to-one receptacle multiplier in use, in the 1st floor OB/GYN Physician's Office.

Interview with the Maintenance Technician on February 20, 2013, at 1:14 PM confirmed the use of a receptacle multiplier.