HospitalInspections.org

Based on observation and staff interview, it was determined the facility failed to ensure means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 1 of 5 floors. Findings included:

During a tour of the Medical Office Building on 8/23/18, the following was observed:

The exit door from the 1st floor mechanical room (108) did not unlock with 15 pounds of pressure.

This finding was confirmed by Plant Maintenance Director A at 2:30 PM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to ensure means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 1 of 5 floors. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

Exit door from Sameday services off of DuPont hallway - the right leaf did not unlock with 15 pounds of pressure.

This finding was confirmed by Maintenance Mechanic A at 9:45 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to ensure fire barriers were maintained for 1 of 4 fire barriers observed during the survey. Findings included:

During a tour of the 7th Street Building on 8/23/18, the following was observed:

The fire doors to the Intensive Care Unit Surgical Suites latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Maintenance Lead A at 10:07 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to ensure fire barriers were maintained for 1 of 5 fire barriers observed during the survey. Findings included:

During a tour of the Medical Office Building on 8/23/18, the following was observed:

The 4th floor fire doors to the Medical Services Building latching mechanism did not function when released from the open position.

This finding was confirmed by Maintenance Lead A at 10:07 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to ensure fire barriers were maintained for 4 of 7 fire barriers observed during the survey. Findings included:

During a tour of the Medical Services Building on 8/23 - 8/27/18, the following was observed:

a) Two (2) approximately 2" (inch) data tubing and multiple wiring penetrations not sealed properly above the suspended ceiling by the 2nd floor fire doors by suite 200.

This finding was confirmed by Maintenance Lead A at 2:41 PM on 8/24/18.

b) Two (2) approximately 1" data tubing penetration and approximately a 6" by 4" hole not sealed properly above the suspended ceiling by the fire doors to the 2nd floor parking garage entrance lobby.

This finding was confirmed by Maintenance Lead A at 2:46 PM on 8/24/18.

c) Approximately ½" data tubing penetration not sealed properly above the suspended ceiling by the 3rd floor fire doors by the elevators.

This finding was confirmed by Maintenance Lead A at 2:51 PM on 8/24/18.

d) Approximately 1" data tubing and wiring penetrations not sealed properly were observed above the suspended ceiling by the 4rd floor fire doors.

This finding was confirmed by Maintenance Lead A at 2:55 PM on 8/24/18.

e) Three (3) approximately 2" data tubing penetration and approximately a 2" by 4" hole not sealed properly above the suspended ceiling by the 5th floor fire door.

This finding was confirmed by Maintenance Lead A at 2:58 PM on 8/24/18.

Based on observation and staff interview, it was determined the facility failed to ensure fire barriers were maintained for 5 of 10 fire barriers observed during the survey. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

a) The 3rd floor fire doors to the Surgical Suite latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Maintenance Mechanic A at 9:37 AM on 8/23/18.

b) The fire doors, by the Emergency Department Clinical Nurse Leader office, latching mechanism did not function when release from the open position.

This finding was confirmed by Plant Maintenance Director A at 10:00 AM on 8/23/18.

c) The fire doors to Material Management latching mechanism did not function when released from the open position.

This finding was confirmed by Maintenance Lead A at 11:07 AM on 8/23/18.

d) The 2nd floor fire doors to the Sharps Room latching mechanism did not function when released from the open position.

This finding was confirmed by Plant Maintenance Director A at 11:30 AM on 8/23/18.

e) The 1st floor fire doors at the crossway to the Emergency Supply Storage latching mechanism did not function when released from the open position.

This finding was confirmed by Plant Maintenance Director A at 11:30 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to ensure fire barriers were maintained for 6 of 24 fire barriers observed during the survey. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

a) The 6th floor North fire doors latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Plant Maintenance Director A at 11:15 AM on 8/22/18.

b) An approximately 2" (inch) data tube penetration not sealed properly above the suspended ceiling by the 6th floor North fire doors.

This finding was confirmed by Plant Maintenance Director A at 1:00 PM on 8/22/18.

c) A ceiling penetration by the Director's Office room 600 was not sealed by the fire door's maglock door device.

This finding was confirmed by Plant Maintenance Director A at 1:10 PM on 8/22/18.

d) The fire doors, by patient room 534, latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Plant Maintenance Director A at 1:24 PM on 8/22/18.

e) Data wire penetrations not sealed properly above the suspended ceiling by the 5th floor North fire doors.

This finding was confirmed by Maintenance Lead A at 1:30 PM on 8/22/18.

f) The fire doors, by patient room 508, latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Maintenance Lead A at 1:35 PM on 8/22/18.

g) The fire doors, by dressing room 429A, latching mechanism did not function at the bottom when released from the open position.

This finding was confirmed by Maintenance Lead A at 1:57 PM on 8/22/18.

Based on observation and staff interview, it was determined the facility failed to maintain the fire barrier fire resistance rating to hazardous areas for 1 of 5 floors. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

a) The Pharmacy storage room was missing ceiling tiles.

This finding was confirmed by Plant Maintenance Director A at 10:24 AM on 8/23/18.

b) The fire doors to Receiving latching mechanism did not function when released from the open position.

This finding was confirmed by Plant Maintenance Director A at 11:13 AM on 8/23/18.

c) The double doors to the Machine Room by Receiving had broken hardware and the door hold open devices were not installed properly.

This finding was confirmed by Plant Maintenance Director A at 11:15 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to maintain the fire barrier fire resistance rating to hazardous areas for 4 of 7 floors. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

a) An approximately 6" (inch) by 18" section of the fire wall was not sealed properly in the Penthouse by the elevator room door.

This finding was confirmed by Plant Maintenance Director A at 10:52 AM on 8/22/18.

b) The fire wall was not sealed properly at the roof decking in the Penthouse elevator room.

This finding was confirmed by Plant Maintenance Director A at 10:57 AM on 8/22/18.

c) The patient rooms on the 6th floor South Wing were being used for storage.

This finding was confirmed by Plant Maintenance Director A at 11:15 AM on 8/22/18.

d) Storage room 600C did not have a self-closing device or automatic release device on the door.

This finding was confirmed by Plant Maintenance Director A at 11:49 AM on 8/22/18.

e) The door to storage room 413B did not have positive latching.

This finding was confirmed by Plant Maintenance Director A at 2:15 PM on 8/22/18.

f) The Gift Shop storage room door had ventilating louvers.

This finding was confirmed by Plant Maintenance Director A at 2:56 PM on 8/22/18.

Based on observation and staff interview, it was determined the facility failed to properly install alcohol based hand rub dispensers for 1 of 2 floors. Findings included:

During a tour of the 7th Street Building on 8/23/18, the following was observed:

An alcohol based hand rub dispenser was installed over a power outlet in the Intensive Care Unit room 15.

This finding was confirmed by Plant Maintenance Director A at 10:09 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to properly install alcohol based hand rub dispensers for 1 of 5 floors. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

An alcohol based hand rub dispenser was installed over a power outlet in Radiology.

This finding was confirmed by Plant Maintenance Director A at 9:50 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to properly install alcohol based hand rub dispensers for 1 of 7 floors. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

An alcohol based hand rub dispenser was installed over a power outlet in the 6th floor South end hallway.

This finding was confirmed by Plant Maintenance Director A at 11:41 AM on 8/22/18.

Based on observation and staff interview, it was determined that the facility failed to ensure fire alarm systems were installed as required for 1 of 1 fire alarm systems. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

The staff sleeping rooms (area) in Labor and Delivery were not equipped with smoke detectors.

This finding was confirmed by Maintenance Lead A at 9:22 AM on 8/23/18.

Based on observation and staff interview, it was determined that the facility failed to ensure 1 of 2 automatic sprinkler systems were installed as required. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

A sprinkler head was not installed in the 4th floor electrical closet by patient room 430.

This finding was confirmed by Plant Maintenance Director A at 2:03 PM on 8/22/18.

Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 1 automatic sprinkler systems. Findings included:

During a tour of the 7th Street Building on 8/23/18, the following was observed:

The Intensive Care Unit waiting room bathroom was missing a ceiling tile.

This finding was confirmed by Plant Maintenance Director A at 10:12 AM on 8/23/18.

Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 1 automatic sprinkler systems. Findings included:

During a tour of the Medical Services Building on 8/23 - 8/27/18, the following was observed:

a) The 6th floor Information Technology (IT) Room had missing ceiling tiles.

This finding was confirmed by Plant Maintenance Director A at 10:12 AM on 8/23/18.

b) Two (2) escutcheon plates were missing in the gastrointestional consultants conference room.

This finding was confirmed by Plant Maintenance Director A at 1:41 PM on 8/23/18.

c) Missing concealed sprinkler cover plates in:

1. Two (2) concealed sprinkler cover plates missing in adjoining area by the gastrointestional consultants conference room.

This finding was confirmed by Plant Maintenance Director A at 1:42 PM on 8/23/18.

2. Four (4) concealed sprinkler cover plates missing in Cardiology.

This finding was confirmed by Plant Maintenance Director A at 1:43 PM on 8/23/18.

d) The Cardiology storage closet items were stored within 18 inches from the sprinkler head.

This finding was confirmed by Plant Maintenance Director A at 1:45 PM on 8/23/18.

e) Nemours duPont Pediatrics Network room had missing ceiling tiles.

This finding was confirmed by Plant Maintenance Director A at 1:58 PM on 8/23/18.

f) The suspended ceiling wires drafted over the sprinkler piping by suite 200.

This finding was confirmed by Maintenance Lead A at 2:46 PM on 8/24/18.

g) The suspended ceiling insulated flexible ductwork resting on the sprinkler piping by 4th floor fire doors.

This finding was confirmed by Maintenance Lead A at 2:55 PM on 8/24/18.

h) The suspended ceiling wires drafted over the sprinkler piping by 5th floor fire doors.

This finding was confirmed by Maintenance Lead A at 2:58 PM on 8/24/18.

Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 2 automatic sprinkler systems. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

a) Painted sprinkler heads:

1. Penthouse by air conditioner unit AC B4.

This finding was confirmed by Plant Maintenance Director A at 11:04 AM on 8/22/18.

2. Secretary supply room 700.

This finding was confirmed by Plant Maintenance Director A at 11:33 AM on 8/22/18.

b) Several ceiling penetrations not sealed properly by patient room 732.

This finding was confirmed by Plant Maintenance Director A at 11:36 AM on 8/22/18.

c) Several ceiling penetrations not sealed properly in the 6th floor South Housekeeping closet.

This finding was confirmed by Plant Maintenance Director A at 11:44 AM on 8/22/18.

d) Above the suspended ceiling, wires drafted over the sprinkler piping by patient rooms 608, 534, 508 and dressing room 429A.

These finding were confirmed by Maintenance Lead A at 1:17 PM, 1:24 PM, 1:31 PM and 2:00 PM respectively on 8/22/18.

e) Several ceiling penetrations not properly sealed in 2nd floor Mechanical electric room.

This finding was confirmed by Plant Maintenance Director A at 2:42 PM on 8/22/18.

Based on observation and staff interview, it was determined that the facility did not properly maintain 1 of 2 automatic sprinkler systems. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

a) The Cafeteria/Kitchen area had broken/improperly cut ceiling tiles.

This finding was confirmed by Plant Maintenance Director A at 3:08 PM on 8/22/18.

b) The "old" CT Scan (computer tomography scan) control room had missing/broken ceiling tiles.

This finding was confirmed by Maintenance Mechanic A at 9:47 AM on 8/23/18.

c) The Pharmacy room 228G had ceiling penetrations from the track system that were not properly sealed.

This finding was confirmed by Plant Maintenance Director A at 10:26 AM on 8/23/18.

Based on observation and staff interview, it was determine the facility did not ensure corridor doors were properly maintained for 2 of 5 floors. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

a) The Gift Shop door was being held open by a wooden type chock.

This finding was confirmed by Plant Maintenance Director A at 2:56 PM on 8/22/18.

b) The double set of doors to physical therapy room 287 had gapping greater than 1/8" (inch) between the leading edges of both doors.

This finding was confirmed by Plant Maintenance Director A at 11:17 AM on 8/23/18.

Based on observation and staff interview, it was determined the facility failed to maintain corridor doors capable of resisting the passage of smoke for 1 of 7 floors. Findings included:

During a tour of the Clayton Building on 8/22/18, the following was observed:

The double set of doors to patient room 634 had gapping greater than 1/8" (inch) between the leading edges of both doors.

This finding was confirmed by Plant Maintenance Director A at 1:24 PM on 8/22/18.

Based on observation and staff interview, it was determined the facility failed to ensure cylinders of nonflammable gases were properly secured for 1 of 1 oxygen storage rooms. Findings included:

During a tour of the DuPont Building on 8/22 - 8/23/18, the following was observed:

Four (4) "E" type oxygen cylinders and six (6) other compressed gas cylinders standing upright on the floor of the 2nd floor oxygen storage room were not properly chained or supported in a proper cylinder stand, cart or rack.

This finding was confirmed by Plant Maintenance Director A at 11:39 AM on 8/23/18.