HospitalInspections.org

Based on observation and interview, the facility failed to ensure exit signage was displayed properly, affecting one of three building levels.

Findings include:

Observation on February 27, 2023, at 1:37 p.m., revealed the penthouse area and stair tower doors lacked exit and directional signage to the designated egress pathway.

Interview with the maintenance supervisor on February 27, 2023, at 1:37 p.m., confirmed the above areas lacked proper exit and directional signs.

Based on observation and interview, the facility failed to maintain vertical openings for one of over ten stair tower fire-rated doors.

Findings include:

Observation on February 27, 2023, at 1:36 p.m., revealed the penthouse stair tower fire-rated door failed to close and latch in the frame.

Interview with the maintenance supervisor on February 27, 2023, at 1:36 p.m., confirmed the above rated door failed to close and latch in the frame.

Based on observation and interview, the facility failed to maintain hazardous areas in one of over ten hazardous rooms.

Findings include:

Observation on February 27, 2023, at 12:39 p.m., revealed the ground floor medical gas storage room had a penetration around a section of copper piping in the rated wall.

Interview with the maintenance supervisor on February 27, 2023, at 12:29 p.m., confirmed the above hazardous area deficiency.

Based on document review and interview, the facility failed to ensure automatic sprinkler system components were inspected on a quarterly basis, affecting the entire facility.

Findings include:

Document review on February 27, 2023, at 10:20 a.m., revealed the facility failed to provide documentation that the mechanical waterflow alarm devices had been inspected during the second and fourth quarters of 2022.

Interview with facilities manager on February 27, 2023, at 10:20 a.m., confirmed the above missing documentation.

Based on document review and interview, the facility failed to ensure automatic sprinkler system components were inspected on a quarterly basis, affecting the entire facility.

Findings include:

Document review on February 27, 2023, at 10:20 a.m., revealed the facility failed to provide documentation that the mechanical waterflow alarm devices had been inspected during the second and fourth quarters of 2022.

Interview with facilities manager on February 27, 2023, at 10:20 a.m., confirmed the missing documentation.

Based on observation and interview, the facility failed to maintain smoke partitions, to resist the passage of smoke, on one of three floors.

Findings include:

1. Observation on February 27, 2023, between 11:46 a.m. and 12:15 p.m., revealed the following:
A. (11:46 a.m.) Ground floor, above the rated doors in the laboratory corridor, had an unsealed penetration around data cables;
B. (12:15 p.m.) Ground floor, above the rated doors between the waiting room and ER, had an unsealed penetration around a section of conduit.

Interview with the maintenance supervisor on February 27, 2023, at 12:15 p.m., confirmed the facility failed to maintain the above smoke partitions to resist the passage of smoke.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on two of three building levels.

Findings include:

1. Observation on February 27, 2023, between 10:52 a.m. and 1:02 p.m., revealed the following electrical deficiencies:
A. (10:52 a.m.) Basement mechanical/electrical room had two control valve covers missing from air handler #10;
B. (10:58 a.m.) Basement, above the rated door for the mechanical/electrical room, had a section of flex conduit with exposed wiring;
C. (11:01 a.m.) Basement mechanical/ electrical room had an open breaker slot in "Panel EEBA";
D. (11:02 a.m.) Basement mechanical/electrical room had a junction box, located above the fire alarm panel, missing the cover plate;
E. (11:51 a.m.) Ground floor laboratory had a junction box, located above the "Revco" refrigerator, missing the cover plate;
F. (12:00 p.m.) Ground floor electrical closet/room, located by the x-ray department, had items stored in front of the disconnects and panel;
G. (12:22 p.m.) Ground floor, above the fire-rated doors leading to the ER (next to room 7), had a junction box above the fire alarm panel missing the cover plate;
H. (12:54 p.m.) Ground floor boiler room had an open breaker slot in panel "LEBR";
I. (1:02 p.m.) Ground floor mechanical room had a broken section of conduit on the condensate pump.

Reference: NFPA 70-314.28(C), NFPA 70-314.17, NFPA 70-314.17, NFPA 70-408.7, and NFPA 70-110.26(a)
Interview with the maintenance supervisor on February 27, 2023, at 1:02 p.m., confirmed the above electrical system deficiencies.

Based on observation and interview, the facility failed to maintain electrical receptacles on two of three levels.

Findings include:

1. Observation on February 27, 2023, between 11:52 a.m. and 1:23 p.m., revealed the following electrical receptacle deficiencies:
A. (11:52 a.m.) Ground floor laboratory had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle;
B. (1:23 p.m.) Second floor soiled utility room had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle.

Interview with the maintenance supervisor on February 27, 2023, at 1:23 p.m., confirmed the above receptacle deficiencies existed.

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review on February 27, 2023, at 11:00 a.m., revealed the facility lacked documentation that the annual fuel analysis report was conducted for the emergency generator within the previous year.

Interview with the facilities manager on February 27, 2023, at 11:00 a.m., confirmed the above documentation was not available at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical equipment in two of over 100 rooms.

Findings include:

1. Observation on February 27, 2023, between 10:47 a.m. and 11:53 a.m., revealed the following electrical equipment deficiencies:
A. (10:47 a.m.) Basement education center had podium controls plugged into an extension cord, which was plugged into a surge protector;
B. (8:57 a.m.) Ground floor laboratory had a television plugged into an extension cord.

Interview with the maintenance supervisor on February 27, 2023, at 11:53 a.m., confirmed the above electrical cord deficiencies.

Based on observation and interview, the facility failed to ensure portable oxygen cylinders were secured on one of three building levels.

Findings include:

Observation on February 27, 2023, at 1:12 p.m., revealed the second floor inpatient therapy room had two unsecured oxygen cylinders.

Interview with the maintenance supervisor on February 27, 2023, at 1:12 p.m., confirmed two unsecured oxygen cylinders were located in the inpatient therapy room.