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 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 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 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 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 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.