HospitalInspections.org

(A)
Based on observations and staff interview, it was determined the facility was a five story building with basement composed of protected fire resistive construction. The facility failed to assure minimum building construction requirements were maintained to limit the transfer of smoke. This facility has 284 certified beds and a census of 101.

Findings include:

1. Observations and staff interview on 8/28/12, revealed the a missing ceiling tile in the Occupational Health Medication Closet.
2. Observations and staff interview on 8/28/12, revealed a penetration, (approximately ? inch), around communications cables extending through the wall of the CCU Unit Data Room above the door.
3. Observations and staff interview on 8/28/12, revealed a hole, (approximately ? inch), in the wall of the CCU Unit Data Room near the door.
4. Observations and interviews on 8/28/12, revealed gaps (approximately ? inch in size) around the conduit above the electric panels located in the 3rd Floor N Wing Staff Supply Room.
5. Observations and interviews on 8/28/12, revealed a missing ceiling tile located in the Ground Floor Telephone Room.
Maintenance Staff A verified these observations during the survey process.

(B)
Based on observations and staff interview, it was determined the McDermott Building was a two-story building with basement composed of unprotected non-combustible construction. The facility failed to provide an automatic sprinkler system as required in all areas of the building. This facility has 284 beds and a census of 101.

Findings include:

Observations and staff interview on 8/28/12, revealed that the McDermott Building is not protected throughout by a complete automatic sprinkler system as required.
Maintenance Staff A verified this observation during the survey process.

Based on observation and staff interview, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. This facility has 284 certified beds and a census of 101.

Findings include:

Observation and staff interview on 8/28/12, revealed a penetration, (approximately 3/16 inch), around a 6 inch waste water pipe extending through the corridor wall of the Berm Room by the Exhaust fan in the Lower Level. Maintenance Staff A verified this observation during the survey process.

Based on observation and interview, the facility failed to ensure that doors to resident rooms, offices and other ancillary areas are provided with suitable hardware that keeps the doors shut tightly into their frames and resists the passage of smoke. This facility has a census of 101 patients and 284 certified beds.

Findings include:

1. Observation and interview on 8/28/12, revealed the corridor door to Room 4125 (Joint Replacement Suite) did not latch properly when tested.
2. Observation and interview on 8/28/12, revealed a gap (greater than 1/2 inch) at the top corner of the corridor door to Room 440.
3. Observation and interview on 8/28/12, revealed the corridor door to the Systems Training Room on Ground Level did not latch properly when tested.
4. Observation and interview on 8/28/12, revealed the main door to the Cafeteria did not close and latch properly.

Maintenance Staff A verified these observations.

Based on observation and staff interview, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

Observations and staff interview on 8/28/12, revealed a hole (approximately 1/2 in in size) and a gap (approximately 1/2 inch in size) around three white cable penetrations in the smoke barrier above the lay-in ceiling tile outside of Restroom 4108. Maintenance Staff A verified this observation.

Based on observation and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke as required by 19.3.7.5 through 19.3.7.7 of the 2000 Life Safety Code. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

Observation and staff interview on 8/28/12, revealed that the smoke barrier doors between the CCU Unit and the Chapel did not close and latch properly. Maintenance Staff A verified this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and interview on 8/28/12, revealed a gap (approximately 1 1/2 inches in size) around a chilled water line above the door to the Main Mechanical Room on the Ground Level. Maintenance Staff A verified this observation.

2. Observation and interview on 8/28/12, revealed there was a 1/4 inch hole in the west wall of the McDermott Mechanical Room.


3. Observation and interview on 8/28/12, revealed there was a 1/4 inch penetration in the wall of the McDermott 1st Floor Janitor Closet.

Based on observation and interview, the facility is not assuring that the exit within the path of egress is easily accessible. This deficient practice would affect all occupants in the Alegent Health-Mercy Hospital Physical Therapy Department located at 1702 West Broadway and all occupants in the Occupantional Health Area on the 1st Floor. This facility has 284 certified beds and at the time of the survey the census was 101.


Findings include:

1. Observation and interview on 8/28/12, revealed several items being stored at the West Exit Door.

2. Observation and interview on 8/28/12, revealed the walleroo in the Occupantional Health Area on the 1st Floor was not equipped with a self closer.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility is not conducting fire drills at varying times on each shift. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 284 and a census of 101.

Findings include:

Observation and record review on 8/28/12, revealed that all four drills on the second shift were within the same 10 minute period. First and third shift times were not varied as required either. Maintenance Staff A verified this observation.

Based on observation, staff interview and record review, the facility failed to provide a properly tested and maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition, by ensuring that all fire alarm components are in operable condition. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and staff interview on 8/28/12, revealed that the glass retainer piece was missing from the fire alarm pull station located in the Cafeteria by the Stairwell Exit.
2. Observation, staff interview and record review on 8/28/12, revealed a single page report from the fire alarm inspection company. This type of report is incomplete and not acceptable; there should be a detailed report containing more information.
3. Observation, staff interview and record review on 8/28/12, revealed that the facility failed to have a copy on site of the most recent sensitivity test of the addressable system.

Maintenance Staff A verified these observations during the survey process.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to an air supply or return can impede the operation of the smoke detector. This facility has 284 certified beds and 101 patients.

Findings include:

1. Observation and interview on 8/28/12, revealed a smoke detector installed within 36 inches of an air supply or return in the corridor of the Emergency Room by the Ambulance Entrance.
2. Observations and interviews on 8/28/12, revealed a smoke detector located within 36 inches of a HVAC vent. This detector was located in the Pyxis Room on 4th Floor East wing.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to sprinkle the entire hospital in accordance with National Fire Protection Association (NFPA) 13. This affects anyone who enters two rooms. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observations and interview on 8-28-12, revealed that Room 1435 was not sprinkled. All other areas near this room were sprinkled.

2. Observation and interview on 8/28/12, revealed the area in the Quality Room that is by the copier was not sprinkled. The rest of the room was sprinkled.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. This facility has a census of 101 and 284 certified beds.

Findings include:

1. Observation and staff interview on 8/28/12, revealed a missing escutcheon around a sprinkler head located in the Pharmacy by the Mixing Area.
2. Observation and staff interview on 8/28/12, revealed dust coated sprinkler heads in Room 322.
3. Observation and staff interview on 8/28/12, revealed a dust coated sprinkler head in 2nd East Nurse's Station above the desk.
4. Observations and interviews on 08/28/12, revealed a loose escutcheon plate on the sprinkler head located in the 2nd Floor Clean Utility Room.
5. Observation and interview on 8/28/12, revealed there was debris covering all the sprinkler heads in the Kitchen.
6. Observation and interview on 8/28/12, revealed there was debris covering all the heads in the Dock Area.
7. Observation and interview on 8/28/12, revealed all the Fire Department Connection (FDC) in the Dock Area did not rotate freely.
Maintenance Staff A verified these observations during the survey process.

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Monthly inspections shall be provided for each fire extinguisher. This facility has 284 certified beds and a census of 101.

Findings include:

Observation and staff interview on 8/28/12, revealed the fire extinguisher in the Quality Office was not inspected for the month of June 2012. Maintenance Staff A verified this observation during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This facility has a census of 101 and a capacity of 284.

Findings include:

1. Record review, observations and staff interview on 8/28/12, revealed that the facility is not providing monthly inspections of both hood and duct extinguishment systems.
2. Record review, observations and staff interview on 8/28/12, revealed an excess buildup of grease on the system and its components.

Maintenance Staff A verified these observations during the survey process.

Based on observation and staff interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and staff interview on 8/28/12, revealed a partially labeled electrical panel (right side) in the Linen Room next to Room 333.
2. Observation and staff interview on 8/28/12, revealed a partially labeled electrical panel (right side) in the Linen Room next to Room 207.
3. Observation and staff interview on 8/28/12, revealed a missing cover to a red junction box located on the ceiling of Air Handler Room #10.
4. Observation and staff interview on 8/28/12, revealed exposed wiring extending from an open end of a flexible conduit on the West Wall of the Mechanical Room in the McDermott Building.
5. Observation and interview on 8/28/12, revealed the reset button on the #3 Control Box was missing which exposed wires. This was located in the sub level Compressor Room.


Maintenance Staff A verified these observations during the survey process.

(A)
Based on observations and staff interview, it was determined the facility was a five story building with basement composed of protected fire resistive construction. The facility failed to assure minimum building construction requirements were maintained to limit the transfer of smoke. This facility has 284 certified beds and a census of 101.

Findings include:

1. Observations and staff interview on 8/28/12, revealed the a missing ceiling tile in the Occupational Health Medication Closet.
2. Observations and staff interview on 8/28/12, revealed a penetration, (approximately ? inch), around communications cables extending through the wall of the CCU Unit Data Room above the door.
3. Observations and staff interview on 8/28/12, revealed a hole, (approximately ? inch), in the wall of the CCU Unit Data Room near the door.
4. Observations and interviews on 8/28/12, revealed gaps (approximately ? inch in size) around the conduit above the electric panels located in the 3rd Floor N Wing Staff Supply Room.
5. Observations and interviews on 8/28/12, revealed a missing ceiling tile located in the Ground Floor Telephone Room.
Maintenance Staff A verified these observations during the survey process.

(B)
Based on observations and staff interview, it was determined the McDermott Building was a two-story building with basement composed of unprotected non-combustible construction. The facility failed to provide an automatic sprinkler system as required in all areas of the building. This facility has 284 beds and a census of 101.

Findings include:

Observations and staff interview on 8/28/12, revealed that the McDermott Building is not protected throughout by a complete automatic sprinkler system as required.
Maintenance Staff A verified this observation during the survey process.

Based on observation and staff interview, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. This facility has 284 certified beds and a census of 101.

Findings include:

Observation and staff interview on 8/28/12, revealed a penetration, (approximately 3/16 inch), around a 6 inch waste water pipe extending through the corridor wall of the Berm Room by the Exhaust fan in the Lower Level. Maintenance Staff A verified this observation during the survey process.

Based on observation and interview, the facility failed to ensure that doors to resident rooms, offices and other ancillary areas are provided with suitable hardware that keeps the doors shut tightly into their frames and resists the passage of smoke. This facility has a census of 101 patients and 284 certified beds.

Findings include:

1. Observation and interview on 8/28/12, revealed the corridor door to Room 4125 (Joint Replacement Suite) did not latch properly when tested.
2. Observation and interview on 8/28/12, revealed a gap (greater than 1/2 inch) at the top corner of the corridor door to Room 440.
3. Observation and interview on 8/28/12, revealed the corridor door to the Systems Training Room on Ground Level did not latch properly when tested.
4. Observation and interview on 8/28/12, revealed the main door to the Cafeteria did not close and latch properly.

Maintenance Staff A verified these observations.

Based on observation and staff interview, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

Observations and staff interview on 8/28/12, revealed a hole (approximately 1/2 in in size) and a gap (approximately 1/2 inch in size) around three white cable penetrations in the smoke barrier above the lay-in ceiling tile outside of Restroom 4108. Maintenance Staff A verified this observation.

Based on observation and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke as required by 19.3.7.5 through 19.3.7.7 of the 2000 Life Safety Code. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

Observation and staff interview on 8/28/12, revealed that the smoke barrier doors between the CCU Unit and the Chapel did not close and latch properly. Maintenance Staff A verified this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and interview on 8/28/12, revealed a gap (approximately 1 1/2 inches in size) around a chilled water line above the door to the Main Mechanical Room on the Ground Level. Maintenance Staff A verified this observation.

2. Observation and interview on 8/28/12, revealed there was a 1/4 inch hole in the west wall of the McDermott Mechanical Room.


3. Observation and interview on 8/28/12, revealed there was a 1/4 inch penetration in the wall of the McDermott 1st Floor Janitor Closet.

Based on observation and interview, the facility is not assuring that the exit within the path of egress is easily accessible. This deficient practice would affect all occupants in the Alegent Health-Mercy Hospital Physical Therapy Department located at 1702 West Broadway and all occupants in the Occupantional Health Area on the 1st Floor. This facility has 284 certified beds and at the time of the survey the census was 101.


Findings include:

1. Observation and interview on 8/28/12, revealed several items being stored at the West Exit Door.

2. Observation and interview on 8/28/12, revealed the walleroo in the Occupantional Health Area on the 1st Floor was not equipped with a self closer.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility is not conducting fire drills at varying times on each shift. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 284 and a census of 101.

Findings include:

Observation and record review on 8/28/12, revealed that all four drills on the second shift were within the same 10 minute period. First and third shift times were not varied as required either. Maintenance Staff A verified this observation.

Based on observation, staff interview and record review, the facility failed to provide a properly tested and maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition, by ensuring that all fire alarm components are in operable condition. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and staff interview on 8/28/12, revealed that the glass retainer piece was missing from the fire alarm pull station located in the Cafeteria by the Stairwell Exit.
2. Observation, staff interview and record review on 8/28/12, revealed a single page report from the fire alarm inspection company. This type of report is incomplete and not acceptable; there should be a detailed report containing more information.
3. Observation, staff interview and record review on 8/28/12, revealed that the facility failed to have a copy on site of the most recent sensitivity test of the addressable system.

Maintenance Staff A verified these observations during the survey process.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to an air supply or return can impede the operation of the smoke detector. This facility has 284 certified beds and 101 patients.

Findings include:

1. Observation and interview on 8/28/12, revealed a smoke detector installed within 36 inches of an air supply or return in the corridor of the Emergency Room by the Ambulance Entrance.
2. Observations and interviews on 8/28/12, revealed a smoke detector located within 36 inches of a HVAC vent. This detector was located in the Pyxis Room on 4th Floor East wing.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to sprinkle the entire hospital in accordance with National Fire Protection Association (NFPA) 13. This affects anyone who enters two rooms. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observations and interview on 8-28-12, revealed that Room 1435 was not sprinkled. All other areas near this room were sprinkled.

2. Observation and interview on 8/28/12, revealed the area in the Quality Room that is by the copier was not sprinkled. The rest of the room was sprinkled.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. This facility has a census of 101 and 284 certified beds.

Findings include:

1. Observation and staff interview on 8/28/12, revealed a missing escutcheon around a sprinkler head located in the Pharmacy by the Mixing Area.
2. Observation and staff interview on 8/28/12, revealed dust coated sprinkler heads in Room 322.
3. Observation and staff interview on 8/28/12, revealed a dust coated sprinkler head in 2nd East Nurse's Station above the desk.
4. Observations and interviews on 08/28/12, revealed a loose escutcheon plate on the sprinkler head located in the 2nd Floor Clean Utility Room.
5. Observation and interview on 8/28/12, revealed there was debris covering all the sprinkler heads in the Kitchen.
6. Observation and interview on 8/28/12, revealed there was debris covering all the heads in the Dock Area.
7. Observation and interview on 8/28/12, revealed all the Fire Department Connection (FDC) in the Dock Area did not rotate freely.
Maintenance Staff A verified these observations during the survey process.

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Monthly inspections shall be provided for each fire extinguisher. This facility has 284 certified beds and a census of 101.

Findings include:

Observation and staff interview on 8/28/12, revealed the fire extinguisher in the Quality Office was not inspected for the month of June 2012. Maintenance Staff A verified this observation during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This facility has a census of 101 and a capacity of 284.

Findings include:

1. Record review, observations and staff interview on 8/28/12, revealed that the facility is not providing monthly inspections of both hood and duct extinguishment systems.
2. Record review, observations and staff interview on 8/28/12, revealed an excess buildup of grease on the system and its components.

Maintenance Staff A verified these observations during the survey process.

Based on observation and staff interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has 284 certified beds and at the time of the survey the census was 101.

Findings include:

1. Observation and staff interview on 8/28/12, revealed a partially labeled electrical panel (right side) in the Linen Room next to Room 333.
2. Observation and staff interview on 8/28/12, revealed a partially labeled electrical panel (right side) in the Linen Room next to Room 207.
3. Observation and staff interview on 8/28/12, revealed a missing cover to a red junction box located on the ceiling of Air Handler Room #10.
4. Observation and staff interview on 8/28/12, revealed exposed wiring extending from an open end of a flexible conduit on the West Wall of the Mechanical Room in the McDermott Building.
5. Observation and interview on 8/28/12, revealed the reset button on the #3 Control Box was missing which exposed wires. This was located in the sub level Compressor Room.


Maintenance Staff A verified these observations during the survey process.