HospitalInspections.org

Based on observation the facility failed to provide adequate protection of a vertical shaft.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was a vertical shaft that had the door propped open by a room door at 2478.02 TEE Proceedure Room PACU 22.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were penetrations in the smoke barriers at the following locations. They were: 1) 7th floor by elevator 9 in North Pavilion, NP, 2) adjacent to 6400.33, 3) adjacent to 3280, 4) adjacent to Pharmacy Order Processing 3446.06, 5) adjacent to 2219.2, 6) adjacent to 2201, Ante Partum, 7) at WCP Day Surgery Entry, 8) at WCP Day Surgery Exit, 9) adjacent to 2267.1, 10) at Entry from North Pavilion into WCP, 11) at Cath Lab to O.R., 12) adjacent to 2434.02, 13) at O.R. Entry, 14) adjacent to Endoscopy 2410.02, 15) at O.R. 1,3, & 5, 2444.04, 16) at Observation Unit 1440.06, 17) Observaton Unit 1443.09, 18) Cardiology 1425.03, 19) at Stair NC01, first floor, 20) Inside MRI at 1439.07, 21) 1318 Facility Management Services, 22) at Rear Corridor of Conference Center, 23) Staff Corridor WCP Atrium 1284.2, 24) above Wan door 1422, 25) inside of 1405.02, 26) at E.D. Entry next to Security Office, 27) at rear exit of Observation into Staff Corridor, and 28) at Staff Corridor at outside exit for employee dining.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

The following area had no closer, storage 5432.06.

At the following locations the door did not latch properly: 1) CPA access door, 4th floor, 2) storage 3274, 3) clean utility 2264, 4) soiled utility 2347, and 5) storage 1272.

Also, storage 3464 required a 45 minute door with a closer and all walls must go to deck.

Based on observation the facility failed to provide adequate sprinkler heads.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues. They were: 1) in the 6th floor shell space, 6400.08, there was a head with a guard still on the head, and in 6400.12, shell space, there was an inappropriate head, and 2) in electrical room 4403.01 a j-box was obstructing a sprinkler head.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was the following issue. There were wood pallets stored in the near the bulk oxygen tank. This type of storage must be at least 25 feet away.

Based on observation the facility failed to provide adequate medical gas piping.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

First, at the rear exit to Observations into the Staff Corridor there were three un-isolated and unlabeled medical gas lines.

Second, at the PACU in WCP there was a zone valve in the same space with the medical gas outlets that it serves.

Based on observation the facility failed to provide adequate EES environment.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was the following issue. The Diesel Pump Room for the generator was being used for storage.

Fuel and Water Preferred Customer Status

"Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems." - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide a letter from a vendor for emergency water.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was not a letter from a vendor stating that the facility had preferred status for water in the event of an emergency.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

First, there were open j-boxes in the following location: 1) near 3284, 2) in electrical room 3364, 3) at back Cath Lab corridor adjacent to 2443.01, and 3) at Environmental Service Director 1223.

Second, critical outlets in critical areas did not have permanent labels in the following locations: 1) WCP, OR #1, 2271, 2) ED 2255 - 2258, 3) Cath Labs #1 &2, 4) Endoscopy 2411, 5) Endo Procedure rooms (four of these) and a Bronch Room, and 6) C-Section OR 2244.

Third, the panel directory for ISLLS in Electrical Room 1278 had areas on the directory where it was not clear what functions the panel was serving. Only Life Safety functions may be on the Life Safety panel.

Based on observation the facility failed to provide acceptable locations for alcohol based hand rub dispensers at some locations.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were alcohol based hand rub dispensers over electrical switches in the following locations: 1) AOD multiple rooms, and 2) EDOB multiple rooms.

Based on observation the facility failed to provide adequate protection of a vertical shaft.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was a vertical shaft that had the door propped open by a room door at 2478.02 TEE Proceedure Room PACU 22.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were penetrations in the smoke barriers at the following locations. They were: 1) 7th floor by elevator 9 in North Pavilion, NP, 2) adjacent to 6400.33, 3) adjacent to 3280, 4) adjacent to Pharmacy Order Processing 3446.06, 5) adjacent to 2219.2, 6) adjacent to 2201, Ante Partum, 7) at WCP Day Surgery Entry, 8) at WCP Day Surgery Exit, 9) adjacent to 2267.1, 10) at Entry from North Pavilion into WCP, 11) at Cath Lab to O.R., 12) adjacent to 2434.02, 13) at O.R. Entry, 14) adjacent to Endoscopy 2410.02, 15) at O.R. 1,3, & 5, 2444.04, 16) at Observation Unit 1440.06, 17) Observaton Unit 1443.09, 18) Cardiology 1425.03, 19) at Stair NC01, first floor, 20) Inside MRI at 1439.07, 21) 1318 Facility Management Services, 22) at Rear Corridor of Conference Center, 23) Staff Corridor WCP Atrium 1284.2, 24) above Wan door 1422, 25) inside of 1405.02, 26) at E.D. Entry next to Security Office, 27) at rear exit of Observation into Staff Corridor, and 28) at Staff Corridor at outside exit for employee dining.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

The following area had no closer, storage 5432.06.

At the following locations the door did not latch properly: 1) CPA access door, 4th floor, 2) storage 3274, 3) clean utility 2264, 4) soiled utility 2347, and 5) storage 1272.

Also, storage 3464 required a 45 minute door with a closer and all walls must go to deck.

Based on observation the facility failed to provide adequate sprinkler heads.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues. They were: 1) in the 6th floor shell space, 6400.08, there was a head with a guard still on the head, and in 6400.12, shell space, there was an inappropriate head, and 2) in electrical room 4403.01 a j-box was obstructing a sprinkler head.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was the following issue. There were wood pallets stored in the near the bulk oxygen tank. This type of storage must be at least 25 feet away.

Based on observation the facility failed to provide adequate medical gas piping.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

First, at the rear exit to Observations into the Staff Corridor there were three un-isolated and unlabeled medical gas lines.

Second, at the PACU in WCP there was a zone valve in the same space with the medical gas outlets that it serves.

Based on observation the facility failed to provide adequate EES environment.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was the following issue. The Diesel Pump Room for the generator was being used for storage.

Fuel and Water Preferred Customer Status

"Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems." - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide a letter from a vendor for emergency water.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there was not a letter from a vendor stating that the facility had preferred status for water in the event of an emergency.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Facility Manager, the Accreditation Coordinator, Maintenance Technician(s), and Quality Management/Infection Control Representative(s) during the hours of the inspection from 12:15 pm on 12/9/2013 to 2:45 pm on 12/11/2013 that there were the following issues.

First, there were open j-boxes in the following location: 1) near 3284, 2) in electrical room 3364, 3) at back Cath Lab corridor adjacent to 2443.01, and 3) at Environmental Service Director 1223.

Second, critical outlets in critical areas did not have permanent labels in the following locations: 1) WCP, OR #1, 2271, 2) ED 2255 - 2258, 3) Cath Labs #1 &2, 4) Endoscopy 2411, 5) Endo Procedure rooms (four of these) and a Bronch Room, and 6) C-Section OR 2244.

Third, the panel directory for ISLLS in Electrical Room 1278 had areas on the directory where it was not clear what functions the panel was serving. Only Life Safety functions may be on the Life Safety panel.