HospitalInspections.org

Based on observation it was determined that the facility failed to ensure that all smoke detectors had the 3 foot required clearance from the air supply and return diffusers.

The findings included:

1. Observation of the C10 elevator lobby on 2/1/11 at 8:00 A.M. revealed a smoke detector too close to the air return vent.

2. Observation of the Radiology department 8:45 A.M. revealed a smoke detector L2D29 too close to the air return vent.

3. Observation of the 8C elevator lobby at 9:00 A.M. revealed a smoke detector too close to the air supply vent.

4. Observation of the 4th floor dining room at 11:00 A.M. revealed a smoke detector that was too close to the air return vent.

5. At 1:15 P.M. a smoke detector was observed in the walkway to garage 1 outside the sliding doors that was too close to the air supply.

6. At 1:15 P.M. observation of the 9th floor revealed 2 smoke detectors that was too close to the air supply vent located in front of the doctors dictation area and outside the B elevators.

7. At 2:00 P.M. observation of the 8th floor B tower revealed 3 smoke detectors that was too close to the air supply vent located in front of the doctors dictation area, on the south corridor by the exit stair, and outside the B elevators.

8. On the 7th floor B tower at 2:20 P.M., a smoke detector was observed outside the north tower of the exit stairway being too close to the air supply vent.
In the Medical intensive care unit 2 smoke detectors were observed being to close to the air return vent by the nurses station and the stat lab.

Based on observation, it was determined that the sprinkler system was not continuously maintained.

The findings included:

1. Observation of the Chick-fil-a kitchen on 2/1/11 at 8:05 A.M. revealed 2 escutcheons missing from the sprinkler heads.

2. Observation of the lower level C elevator lobby at 8:30 A.M. revealed 5 pair of heavy electrical cable laying on top of the sprinkler piping.

3. Observation of the pediatric floor elevator lobby at 10:30 A.M. revealed electrical cables laying on top of the sprinkler line.

Based on observation, it was determined that the facility failed to designate the fire suppression system pull stations to the hood suppression system they activated.

The findings included:

Observation of the Chick-fil-a kitchen on 2/1/11 at 8:05 A.M. revealed a hood suppression system over the french fry unit and one over the chicken unit. The pull stations were not labeled.

Based on observation, it was determined that the facility failed to maintain egress free from all obstructions.

The findings included:

Observation of the 2 Radiology exit corridors on 2/1/11 at 8:45 A.M. revealed the following:
Three linen carts, 2 of 4 yellow barrels filled with x-ray film, 2 blanket warmers, a thyroid uptake unit with task chair, cabinetry for storage of items, and lead apron hangers installed on the opposite side of the walls.

Based on observation, it was determined that the facility failed to maintain separation from medical gas lines to other metals.

The findings included:

1. Observation of the chiller room on the lower level of the BD wing on 2/1/11 at 8:20 A.M. revealed the nitrous and medical air lines were resting on metal struts in front of chiller 1 with no insulation.

2. Observation of the C elevator on the 3rd floor at 8:30 A.M. revealed a 3 inch oxygen line with a steel elbow resting on the piping with no insulation.

3. Observation of the 9th floor at 8:40 A.M. revealed a medical air line touching electrical conduit and a vacuum line touching the sprinkler piping above the ceiling outside room C9117.

4. At 11:07 A.M. on the 5th floor a medical vacuum line was found above the ceiling at C5122 with 2 flex conduit lines resting on the piping.

5. At 1:15 P.M. on the 3rd floor an oxygen line was found above the ceiling touching a sprinkler line at the horizontal exit door.

Based on observation, it was determined the facility failed to maintain smoke barriers.

The findings included:

1. Observation of the basement floor on 2/1/11 at 8:00 A.M. revealed a penetration in the wall to the left of the back door of the Chick-fil-a kitchen.

2. Observation above the 2 hour fire doors on the 1st floor across from the Carter waiting room at 9:15 A.M. revealed 2 penetrations.

3. Observation of the 2nd floor 2D fire doors at 9:30 A.M. revealed a 3 inch metal sleeve that was not sealed and a blue flex cable that was not sealed inside the conduit.

4. Observation of the 3rd floor C tower electrical room at 1:15 P.M. revealed a penetration to the rear wall.

Based on observation, it was determined that the facility failed to install ground fault circuit interrupter receptacles on electrical equipment within 3 feet of a water source.

The findings included:

Observation of the facility on 2/1/11 from 7:30 A.M. until 3:PM revealed the following items were not connected to a ground fault circuit interrupter.
1. Water fountain in radiology.
2. Water fountain across from C8109.
3. Ice maker in C8 supply room.
4. Water fountain across from C7109.
5. Electrical receptacle at sink in medicine room C7.
6. Staff lounge receptacle at sink in staff lounge at C6
7. Medicine room sink at C6.
8. Water fountain at C6109.
9. Bathroom sink receptacle at C4111.
10. Clean supply room sink at C4.
11. Water fountain across from C4123.
12. Women's restroom sink near exit door stairs on 4B.
13. Ice maker on 8B nutritional room.
14. Ice maker on 7B nutritional room.

Based on observation it was determined that the facility failed to ensure that all smoke detectors had the 3 foot required clearance from the air supply and return diffusers.

The findings included:

1. Observation of the C10 elevator lobby on 2/1/11 at 8:00 A.M. revealed a smoke detector too close to the air return vent.

2. Observation of the Radiology department 8:45 A.M. revealed a smoke detector L2D29 too close to the air return vent.

3. Observation of the 8C elevator lobby at 9:00 A.M. revealed a smoke detector too close to the air supply vent.

4. Observation of the 4th floor dining room at 11:00 A.M. revealed a smoke detector that was too close to the air return vent.

5. At 1:15 P.M. a smoke detector was observed in the walkway to garage 1 outside the sliding doors that was too close to the air supply.

6. At 1:15 P.M. observation of the 9th floor revealed 2 smoke detectors that was too close to the air supply vent located in front of the doctors dictation area and outside the B elevators.

7. At 2:00 P.M. observation of the 8th floor B tower revealed 3 smoke detectors that was too close to the air supply vent located in front of the doctors dictation area, on the south corridor by the exit stair, and outside the B elevators.

8. On the 7th floor B tower at 2:20 P.M., a smoke detector was observed outside the north tower of the exit stairway being too close to the air supply vent.
In the Medical intensive care unit 2 smoke detectors were observed being to close to the air return vent by the nurses station and the stat lab.

Based on observation, it was determined that the sprinkler system was not continuously maintained.

The findings included:

1. Observation of the Chick-fil-a kitchen on 2/1/11 at 8:05 A.M. revealed 2 escutcheons missing from the sprinkler heads.

2. Observation of the lower level C elevator lobby at 8:30 A.M. revealed 5 pair of heavy electrical cable laying on top of the sprinkler piping.

3. Observation of the pediatric floor elevator lobby at 10:30 A.M. revealed electrical cables laying on top of the sprinkler line.

Based on observation, it was determined that the facility failed to designate the fire suppression system pull stations to the hood suppression system they activated.

The findings included:

Observation of the Chick-fil-a kitchen on 2/1/11 at 8:05 A.M. revealed a hood suppression system over the french fry unit and one over the chicken unit. The pull stations were not labeled.

Based on observation, it was determined that the facility failed to maintain egress free from all obstructions.

The findings included:

Observation of the 2 Radiology exit corridors on 2/1/11 at 8:45 A.M. revealed the following:
Three linen carts, 2 of 4 yellow barrels filled with x-ray film, 2 blanket warmers, a thyroid uptake unit with task chair, cabinetry for storage of items, and lead apron hangers installed on the opposite side of the walls.

Based on observation, it was determined that the facility failed to maintain separation from medical gas lines to other metals.

The findings included:

1. Observation of the chiller room on the lower level of the BD wing on 2/1/11 at 8:20 A.M. revealed the nitrous and medical air lines were resting on metal struts in front of chiller 1 with no insulation.

2. Observation of the C elevator on the 3rd floor at 8:30 A.M. revealed a 3 inch oxygen line with a steel elbow resting on the piping with no insulation.

3. Observation of the 9th floor at 8:40 A.M. revealed a medical air line touching electrical conduit and a vacuum line touching the sprinkler piping above the ceiling outside room C9117.

4. At 11:07 A.M. on the 5th floor a medical vacuum line was found above the ceiling at C5122 with 2 flex conduit lines resting on the piping.

5. At 1:15 P.M. on the 3rd floor an oxygen line was found above the ceiling touching a sprinkler line at the horizontal exit door.

Based on observation, it was determined the facility failed to maintain smoke barriers.

The findings included:

1. Observation of the basement floor on 2/1/11 at 8:00 A.M. revealed a penetration in the wall to the left of the back door of the Chick-fil-a kitchen.

2. Observation above the 2 hour fire doors on the 1st floor across from the Carter waiting room at 9:15 A.M. revealed 2 penetrations.

3. Observation of the 2nd floor 2D fire doors at 9:30 A.M. revealed a 3 inch metal sleeve that was not sealed and a blue flex cable that was not sealed inside the conduit.

4. Observation of the 3rd floor C tower electrical room at 1:15 P.M. revealed a penetration to the rear wall.

Based on observation, it was determined that the facility failed to install ground fault circuit interrupter receptacles on electrical equipment within 3 feet of a water source.

The findings included:

Observation of the facility on 2/1/11 from 7:30 A.M. until 3:PM revealed the following items were not connected to a ground fault circuit interrupter.
1. Water fountain in radiology.
2. Water fountain across from C8109.
3. Ice maker in C8 supply room.
4. Water fountain across from C7109.
5. Electrical receptacle at sink in medicine room C7.
6. Staff lounge receptacle at sink in staff lounge at C6
7. Medicine room sink at C6.
8. Water fountain at C6109.
9. Bathroom sink receptacle at C4111.
10. Clean supply room sink at C4.
11. Water fountain across from C4123.
12. Women's restroom sink near exit door stairs on 4B.
13. Ice maker on 8B nutritional room.
14. Ice maker on 7B nutritional room.