HospitalInspections.org

This standard is not met as evidenced by:

During record review of this facility on April 23, 2018, surveyor 37694 did observe:

The procedures for procuring calculated amounts of food, water and fuel were not included in the Emergency Preparedness Plan.

A signed contract providing the procurement of sewage and trash disposal equipment and service was not included in the Emergency Preparedness Plan.

This standard is not met as evidenced by:

During record review of this facility on April 23, 2018, surveyor 37694 did observe:

A full-scale exercise that is community or facility based was not completed prior to November 2017.

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to the following issued found at the 2 hour wall that separated MOD & RFGH in the lobby:

1) rated door frame labels painted
2) rated doors do not latch. The door hardware does not fit in behind the frame catch
3) open penetrations on both sides of the wall in the corridor over the door
4) open penetrations where the curved wall meets the floor ceiling assembly

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to:
1) the door to waiting room just outside SCU is a 2 hour rated wall with a 45 minute rated door
2) rated wall between waiting room and interview over the door has penetrations
3) double doors at endoscopy by nurses station have open penetrations
4) rated corridor wall and chase at Stairwell F stops at the underside of insulated wrapped duct. It is not sealed and would not offer any rated protection
5) OR dbl doors next to Nurse Mgr @ Birthing Center have penetrations at door and shaft
6) rated wall @ cross corridor doors outside x-ray rm2 open penetrations and exposed spray foam and not sealed at ceiling

This building has many additions that are separated by rated walls. Open penetrations were found throughout.

This standard is not met as evidenced by:

During record review of this facility on April 23, 2018, surveyor 37694 did observe:

The door inspection report from 2017 indicated deficiencies on 150 doors. Staff indicated that these doors have not been repaired or replaced per this report.

While inspecting this facility on April 23, 2018 with the Maintenance Director, surveyor 37694 did observe:

Metal multi-tiered storage cart is impeding the path of egress from the Sterile Processing room back into the non-sterile corridor.

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to cross corridor doors that have exiting from both sides do not have door leafs that swing in opposite directions. The following locations were found:
cross corridor doors by stairwell A
rated doors in 2 hour wall by admitting office

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to:

1) door stairwell 2nd stair A was not latching
2) stair B level 2 door frame label painted
3) balusters do not meet minimum standards for existing - spacing is 10"
4) Stair F,
2nd level drywall to fire proofed steel not sealed
on lower level by endoscopy, wall is not sealed where it meets the b-deck
5) stair E:
patch corridor side of drywall - hole with only a single layer of drywall
inside stair, exterior wall over window has opening into wall over the window and exposed OSB shims
lower level, over door are open penetrations where masonry has crumbles away
6) stair C level 1 just inside the door has old recessed lights in ceiling are left open into framing and no bulb in the socket
handrail required on no less than 1 side
painted frame label
7)stair D frame not labeled
roxul in gap at drywall and deck intersection (not rated)
guards on stair landings have balusters >4" spacing

It was found there are open penetrations or non sealed wall to ceiling intersections throughout the building

This standard is not met as evidenced by:

While inspecting this facility on April 23, 2018 with the Maintenance Supervisor, surveyor 37694 did observe:

Exit sign shall be installed from OR 3 towards the Birthing Center.

Based on observation of surveyors 37695 and 16732, the electrical closet located on floor 2 contained several penetrations, penetrations must be sealed in order to maintain rating of room. This was found in the presence of the security guard.

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to painted door frame labels throughout the building

Based on the observation of surveyor 37695 and 16732 the main entrance area with a waffle ceiling is not covered by an automatic approved sprinkler system as well as the Chapel area, the business office area located off the first floor, and the electrical room located across from the morgue, and the walk in freezer did not contain sprinkler coverage. This was found in the presence of the security officer.

It was observed by inspectors 37696 & 39983 as well as Maintenance that this was not met due to the non-sprinklered corridors shall be 1 hour rated however the walls have open penetrations, some are quite large > 12"x12".

This standard is not met as evidenced by:

During record review of this facility on April 23, 2018, surveyor 37694 did observe:

The 2017 inspection report from William Frank indicates Maintenance and Compliance Deficiencies for this facility. Documentation could not be provided to show the required repairs resulting from this report.

This standard is not met as evidenced by:

While inspecting this facility on April 23, 2018 with the Maintenance Director, surveyor 37694 did observe:

5 E tanks of oxygen were found stored in the exit corridor between OR 2 and OR 3.