HospitalInspections.org

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, on one of three floors.

Findings include:

Observation on December 21, 2011, at 11:40 AM revealed the door to the Ground Level Break/Vending Machine Room corridor door lacked hardware to properly close and latch in the frame.

Interview with the Director of Facilities Managment on December 21, 2011, at 11:40 AM confirmed the lack of hardware.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls, on three of three floors.

Findings include:

1. Observation on December 20, 2011, at the times and locations stated below, revealed the following unsealed smoke barrier penetrations:

a. 9:45 AM, 2nd Floor B-Wing, Men's Room, outside Out-Patient Services, above the ceiling, over the lightswitch;
b. 11:00 AM, 2nd Floor, over corridor double doors to CCU, around yellow, white and red data wires and at each corner of the top track;
c. 11:15 AM, 2nd Floor, corridor outside CCU and OR's, inside and around various conduits;
d. 11:25 AM, 2nd Floor, corridor outside Pre-Op, above the time clock, across from the elevators;
e. 11:45 AM, 1st Floor, over corridor double doors, off Lobby and over door to Tel Data Room NCC168, around data wires;
f. 1:50 PM, 1st Floor, back entrance door Nuclear Medicine, inside a 2 1/2-inch conduit with yellow wires;
g. 1:55 PM, 1st Floor, over door D127 to EEG, around yellow and green data wires.

Interview with the Director of Facilities Managment on December 20, 2011, at 2:15 PM confirmed the above unsealed penetrations.

2. Observation on December 21, 2011, at 10:55 AM revealed an unsealed smoke barrier penetration, inside a 3-inch conduit with yellow data wires, over the corridor double doors, from A Building to overlooking the Lobby.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:55 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by one-hour fire rated or smoke resisted construction, in sprinklered areas, with self-closing and positive latching doors, at two locations within the facility.

Findings include:

1. Observation on December 19, 2011, at 1:50 PM revealed the set of doors in the Ground Level, between B04 Storage and the Mechanical Space, just off the Kitchen, required a door coordinator adjustment to properly close and latch in its frame.

Interview with the Director of Facilities Management on December 19, 2011, at 1:50 PM confirmed the needed adjustment.

2. Observation on December 19, 2011, at 1:55 PM revealed an unsealed penetration in the Ground Level Mechanical Room, off the Kitchen, around blue and white data wires, over Panel Box N4G6.

Interview with the Director of Facilities Managment on December 19, 2011, at 1:55 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined that exit access was not being maintained readily accessible, at all times.

Findings include:

Observation on December 21, 2011, at 11:25 PM revealed the 2 Exit Doors, from the Generator Room, were equipped with key activated dead-bolts, which lock the doors against egress.

Interview with the Director of Facilities Managment on December 21, 2011, at 11:25 PM confirmed the keyed locked dead bolts.

Based on observation and interview, it was determined that the sprinkler piping was not supported properly, in accordance with the regulations.

Findings include:

Observation and interview on December 20, 2011, at 9:40 AM revealed the sprinkler piping, located in the B-Wing 2nd Floor corridor, outside Out-Patient Services, between the Men's and Ladies Restroom, needed a hanger to properly hold the sprinkler head in place.

Interview with the Director of Facilities Managment on December 20, 2011, at 9:40 AM confirmed the needed hanger.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in accordance with the regulations in one location, on one of three floors.

Findings include:

Observation on December 21, 2011, at 10:00 AM revealed 6 oxygen "E" cylinders were stored in the 1st Floor E-Wing Equipment Storage Room, the lightswitch was less than 60 inches from the floor, the cylinders were mixed, full and empty within the same rack, lacked required signage, and had combustibles stored within 5 feet.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:00 AM confirmed the above conditions exist.

Based on observation and interview, the facility failed to maintain electrical wiring and
proper use and protection of electrical equipment/receptacle multipliers, on the 2nd Floor.

Findings include:

1. Observation on December 20, 2011, at the times and locations stated below, revealed the following electrical deficiencies.

a. 9:40 AM, B-Wing 2nd Floor outside Out-Patient Services, over Exit Sign above the ceiling, two electrical junction boxes that lacked cover plates;
b. 10:10 AM, 2nd Floor C-Wing Nurses' Admin Office, a 6-way receptacle multiplier being used;
c. 11:15 AM, 2nd Floor, above the ceiling, in the corridor outside CCU and OR's, a junction box with unterminated grey and brown wires.

Interview with the Director of Facilities Managment on December 20, 2011, at 11:15 AM confirmed the above conditions.

2. Observation on December 21, 2011, at 10:20 AM revealed an unsealed penetration in the Ground Level D-Wing Electrical Room, between 2 El-Bee connectors, above Transfer Switch #5 Panel EM4 DPI.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:20 AM confirmed the unsealed penetration.

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, on one of three floors.

Findings include:

Observation on December 21, 2011, at 11:40 AM revealed the door to the Ground Level Break/Vending Machine Room corridor door lacked hardware to properly close and latch in the frame.

Interview with the Director of Facilities Managment on December 21, 2011, at 11:40 AM confirmed the lack of hardware.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls, on three of three floors.

Findings include:

1. Observation on December 20, 2011, at the times and locations stated below, revealed the following unsealed smoke barrier penetrations:

a. 9:45 AM, 2nd Floor B-Wing, Men's Room, outside Out-Patient Services, above the ceiling, over the lightswitch;
b. 11:00 AM, 2nd Floor, over corridor double doors to CCU, around yellow, white and red data wires and at each corner of the top track;
c. 11:15 AM, 2nd Floor, corridor outside CCU and OR's, inside and around various conduits;
d. 11:25 AM, 2nd Floor, corridor outside Pre-Op, above the time clock, across from the elevators;
e. 11:45 AM, 1st Floor, over corridor double doors, off Lobby and over door to Tel Data Room NCC168, around data wires;
f. 1:50 PM, 1st Floor, back entrance door Nuclear Medicine, inside a 2 1/2-inch conduit with yellow wires;
g. 1:55 PM, 1st Floor, over door D127 to EEG, around yellow and green data wires.

Interview with the Director of Facilities Managment on December 20, 2011, at 2:15 PM confirmed the above unsealed penetrations.

2. Observation on December 21, 2011, at 10:55 AM revealed an unsealed smoke barrier penetration, inside a 3-inch conduit with yellow data wires, over the corridor double doors, from A Building to overlooking the Lobby.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:55 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by one-hour fire rated or smoke resisted construction, in sprinklered areas, with self-closing and positive latching doors, at two locations within the facility.

Findings include:

1. Observation on December 19, 2011, at 1:50 PM revealed the set of doors in the Ground Level, between B04 Storage and the Mechanical Space, just off the Kitchen, required a door coordinator adjustment to properly close and latch in its frame.

Interview with the Director of Facilities Management on December 19, 2011, at 1:50 PM confirmed the needed adjustment.

2. Observation on December 19, 2011, at 1:55 PM revealed an unsealed penetration in the Ground Level Mechanical Room, off the Kitchen, around blue and white data wires, over Panel Box N4G6.

Interview with the Director of Facilities Managment on December 19, 2011, at 1:55 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined that exit access was not being maintained readily accessible, at all times.

Findings include:

Observation on December 21, 2011, at 11:25 PM revealed the 2 Exit Doors, from the Generator Room, were equipped with key activated dead-bolts, which lock the doors against egress.

Interview with the Director of Facilities Managment on December 21, 2011, at 11:25 PM confirmed the keyed locked dead bolts.

Based on observation and interview, it was determined that the sprinkler piping was not supported properly, in accordance with the regulations.

Findings include:

Observation and interview on December 20, 2011, at 9:40 AM revealed the sprinkler piping, located in the B-Wing 2nd Floor corridor, outside Out-Patient Services, between the Men's and Ladies Restroom, needed a hanger to properly hold the sprinkler head in place.

Interview with the Director of Facilities Managment on December 20, 2011, at 9:40 AM confirmed the needed hanger.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in accordance with the regulations in one location, on one of three floors.

Findings include:

Observation on December 21, 2011, at 10:00 AM revealed 6 oxygen "E" cylinders were stored in the 1st Floor E-Wing Equipment Storage Room, the lightswitch was less than 60 inches from the floor, the cylinders were mixed, full and empty within the same rack, lacked required signage, and had combustibles stored within 5 feet.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:00 AM confirmed the above conditions exist.

Based on observation and interview, the facility failed to maintain electrical wiring and
proper use and protection of electrical equipment/receptacle multipliers, on the 2nd Floor.

Findings include:

1. Observation on December 20, 2011, at the times and locations stated below, revealed the following electrical deficiencies.

a. 9:40 AM, B-Wing 2nd Floor outside Out-Patient Services, over Exit Sign above the ceiling, two electrical junction boxes that lacked cover plates;
b. 10:10 AM, 2nd Floor C-Wing Nurses' Admin Office, a 6-way receptacle multiplier being used;
c. 11:15 AM, 2nd Floor, above the ceiling, in the corridor outside CCU and OR's, a junction box with unterminated grey and brown wires.

Interview with the Director of Facilities Managment on December 20, 2011, at 11:15 AM confirmed the above conditions.

2. Observation on December 21, 2011, at 10:20 AM revealed an unsealed penetration in the Ground Level D-Wing Electrical Room, between 2 El-Bee connectors, above Transfer Switch #5 Panel EM4 DPI.

Interview with the Director of Facilities Managment on December 21, 2011, at 10:20 AM confirmed the unsealed penetration.