HospitalInspections.org

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations.

Findings include:

Observation on July 17, 2013 at 2:00 pm revealed unsealed common wall penetrations above the suspended ceiling at the common wall doors.

Interview with the Facility Manager on July 17, 2013 at 2:00 pm confirmed the unsealed penetrations of the common wall and subsequent correction during the survey.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of three floors.

Findings include:

Observation on July 18, 2013 at 10:00 am revealed the first floor common wall at the O.R. corridor had an unsealed penetration above the suspended ceiling at common wall doors 1687.

Interview with the Facility Manager on July 18, 2013 at 10:00 am confirmed the unsealed penetration of the the common wall.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on three of three floors.

Findings include:

1. Observation on July 17, 2013 at 11:10 am revealed the 3B North file room had a wedge holding the corridor open.

Interview with the Facility Manager on July 17, 2013 at 11:10 am confirmed the corridor door was held open with a wedge.

2. Observation on July 17, 2013 at 1:35 pm revealed the second floor WMGA room 1 corridor door was very difficult to open for egress.

Interview with the Facility Manager on July 17, 2013 at 1:35 pm confirmed the corridor door was very difficult to open.

3. Observation on July 18, 2013 at 9:35 am revealed the first floor Material Management Purchasing office corridor door lacked positive latching with the self-closer.

Interview with the Facility Manager July 18, 2013 at 9:35 am confirmed the corridor lacked positive latching with the self-closer.

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

Findings include:

1. Observation on July 17, 2013 between 11:00 am and 1:50 pm revealed the facility had unsealed smoke barrier penetrations at the following locations:
A. Third floor 3B South smoke barrier had an unsealed penetration above the suspended ceiling at the wire tray.
B. Second floor smoke barrier by the CCU had unsealed penetrations above the suspended ceiling around yellow wires.

Interview with the Facility Manager on July 17, 2013 at 1:50 pm confirmed the unsealed smoke barrier penetrations listed above.

2. Observation on July 18, 2013 at 10:40 am revealed the first floor North hall smoke barrier had an unsealed penetration above the suspended ceiling at the smoke doors by the insulated pipes.

Interview with the Facility Manager on July 18, 2013 at 10:40 am confirmed the unsealed penetration of the smoke barrier wall.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of three floors.

Findings include:

Observation on July 17, 2013 at 2:00 pm revealed the second floor smoke barrier doors by the CCU did not close completely.

Interview with the Facility Manager on July 17, 2013 at 2:00 pm confirmed the second floor smoke barrier doors did not close completely.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of two floors.

Findings include:

1. Observation on July 17, 2013 at 1:25 pm revealed the second floor storage closet 2253 does not close completely and latch with the self-closer.

Interview with Facility Manager on July 17, 2013 at 1:25 pm confirmed the storage closet did not close completely and latch with the self-closer.

2. Observation on July 17, 2013 at 1:30 pm revealed the second floor Warren Medical Group Surgeons Area soiled utility room lacks positive latching with the self-closer.

Interview with the Facility Manager on July 17, 2013 at 1:30 pm confirmed the soiled utility room latched positive latching with the self-closer.

Based upon observation and interview the width of exit corridors are not clear and unobstructed in accordance with regulations on one of three floors.

Findings include:

Observation on July 17, 2013 at 2:05 pm revealed the second floor Pediatrics area had a bed, television carts, chair wagon, medical equipment stored in the exit corridor.

Interview with the Facility Manager on July 17, 2013 at 2:05 pm confirmed the exit corridor in Pediatrics was reduced in with by items stored in the corridor.

Based upon observation and interview, the illumination of the means of egress failed to meet requirements on one of three floors.

Findings include:

Observation on July 17, 2013 at 11:25 am revealed the lighting in the third floor IBS stairwell was not illuminated due to burned out bulbs

Interview with the Facility Manager on July 17, 2013 at 11:25 am confirmed the stairwell lighting was no illuminated.

Based upon observation of the suspended ceiling system, the facility failed to maintain the integrity of the ceiling which could prevent activation of the sprinkler system on one of three floors.

Findings include:

Observation on July 18, 2013 between 11:10 am and 11:40 am revealed the facility had ceiling tile removed from the the suspended ceiling grid at the following locations:
A. First floor Radiology soiled utility room 1763
B. First floor E.R. storage room 1929.1

Interview with the Facility Manager on July 18, 2013 at 11:40 am confirmed the facility had ceiling tile removed from the ceiling grid at the above listed locations.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of three floors.

Findings include:

1. Observation on July 17, 2013 at 1:45 pm revealed that the second floor CCU room 2237C had combustibles stored within five feet of oxygen store inside the same room.

Interview with the Facility Manager on July 18, 2013 at 1:45 pm confirmed the oxygen storage was within five feet of combustibles.

2. Observation on July 18, 2013 at 10:30 am revealed the first floor Hospice had unsecured oxygen E-cylinders.

Interview with the Facility Manager on July 18, 2013 at 10:30 am confirmed the unsecured oxygen cylinders in the Hospice.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of three floors.

Findings include:

Observation on July 17, 2013 between 10:40 am and 11:45 am revealed the facility had refrigerators and/or microwave ovens plugged into surge protectors at the following locations:
A. Third floor 3A South Case Managers office had a microwave oven and a refrigerator plugged into a surge protector.
B. Second floor room 2208 in the Administration corridor had a refrigerator plugged into a surge protector.

Interview with the Facility Manager on July 17, 2013 at 11:45 am confirmed the unapproved utilization of surge protectors at the above listed locations.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations.

Findings include:

Observation on July 17, 2013 at 2:00 pm revealed unsealed common wall penetrations above the suspended ceiling at the common wall doors.

Interview with the Facility Manager on July 17, 2013 at 2:00 pm confirmed the unsealed penetrations of the common wall and subsequent correction during the survey.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of three floors.

Findings include:

Observation on July 18, 2013 at 10:00 am revealed the first floor common wall at the O.R. corridor had an unsealed penetration above the suspended ceiling at common wall doors 1687.

Interview with the Facility Manager on July 18, 2013 at 10:00 am confirmed the unsealed penetration of the the common wall.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on three of three floors.

Findings include:

1. Observation on July 17, 2013 at 11:10 am revealed the 3B North file room had a wedge holding the corridor open.

Interview with the Facility Manager on July 17, 2013 at 11:10 am confirmed the corridor door was held open with a wedge.

2. Observation on July 17, 2013 at 1:35 pm revealed the second floor WMGA room 1 corridor door was very difficult to open for egress.

Interview with the Facility Manager on July 17, 2013 at 1:35 pm confirmed the corridor door was very difficult to open.

3. Observation on July 18, 2013 at 9:35 am revealed the first floor Material Management Purchasing office corridor door lacked positive latching with the self-closer.

Interview with the Facility Manager July 18, 2013 at 9:35 am confirmed the corridor lacked positive latching with the self-closer.

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

Findings include:

1. Observation on July 17, 2013 between 11:00 am and 1:50 pm revealed the facility had unsealed smoke barrier penetrations at the following locations:
A. Third floor 3B South smoke barrier had an unsealed penetration above the suspended ceiling at the wire tray.
B. Second floor smoke barrier by the CCU had unsealed penetrations above the suspended ceiling around yellow wires.

Interview with the Facility Manager on July 17, 2013 at 1:50 pm confirmed the unsealed smoke barrier penetrations listed above.

2. Observation on July 18, 2013 at 10:40 am revealed the first floor North hall smoke barrier had an unsealed penetration above the suspended ceiling at the smoke doors by the insulated pipes.

Interview with the Facility Manager on July 18, 2013 at 10:40 am confirmed the unsealed penetration of the smoke barrier wall.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of three floors.

Findings include:

Observation on July 17, 2013 at 2:00 pm revealed the second floor smoke barrier doors by the CCU did not close completely.

Interview with the Facility Manager on July 17, 2013 at 2:00 pm confirmed the second floor smoke barrier doors did not close completely.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of two floors.

Findings include:

1. Observation on July 17, 2013 at 1:25 pm revealed the second floor storage closet 2253 does not close completely and latch with the self-closer.

Interview with Facility Manager on July 17, 2013 at 1:25 pm confirmed the storage closet did not close completely and latch with the self-closer.

2. Observation on July 17, 2013 at 1:30 pm revealed the second floor Warren Medical Group Surgeons Area soiled utility room lacks positive latching with the self-closer.

Interview with the Facility Manager on July 17, 2013 at 1:30 pm confirmed the soiled utility room latched positive latching with the self-closer.

Based upon observation and interview the width of exit corridors are not clear and unobstructed in accordance with regulations on one of three floors.

Findings include:

Observation on July 17, 2013 at 2:05 pm revealed the second floor Pediatrics area had a bed, television carts, chair wagon, medical equipment stored in the exit corridor.

Interview with the Facility Manager on July 17, 2013 at 2:05 pm confirmed the exit corridor in Pediatrics was reduced in with by items stored in the corridor.

Based upon observation and interview, the illumination of the means of egress failed to meet requirements on one of three floors.

Findings include:

Observation on July 17, 2013 at 11:25 am revealed the lighting in the third floor IBS stairwell was not illuminated due to burned out bulbs

Interview with the Facility Manager on July 17, 2013 at 11:25 am confirmed the stairwell lighting was no illuminated.

Based upon observation of the suspended ceiling system, the facility failed to maintain the integrity of the ceiling which could prevent activation of the sprinkler system on one of three floors.

Findings include:

Observation on July 18, 2013 between 11:10 am and 11:40 am revealed the facility had ceiling tile removed from the the suspended ceiling grid at the following locations:
A. First floor Radiology soiled utility room 1763
B. First floor E.R. storage room 1929.1

Interview with the Facility Manager on July 18, 2013 at 11:40 am confirmed the facility had ceiling tile removed from the ceiling grid at the above listed locations.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of three floors.

Findings include:

1. Observation on July 17, 2013 at 1:45 pm revealed that the second floor CCU room 2237C had combustibles stored within five feet of oxygen store inside the same room.

Interview with the Facility Manager on July 18, 2013 at 1:45 pm confirmed the oxygen storage was within five feet of combustibles.

2. Observation on July 18, 2013 at 10:30 am revealed the first floor Hospice had unsecured oxygen E-cylinders.

Interview with the Facility Manager on July 18, 2013 at 10:30 am confirmed the unsecured oxygen cylinders in the Hospice.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of three floors.

Findings include:

Observation on July 17, 2013 between 10:40 am and 11:45 am revealed the facility had refrigerators and/or microwave ovens plugged into surge protectors at the following locations:
A. Third floor 3A South Case Managers office had a microwave oven and a refrigerator plugged into a surge protector.
B. Second floor room 2208 in the Administration corridor had a refrigerator plugged into a surge protector.

Interview with the Facility Manager on July 17, 2013 at 11:45 am confirmed the unapproved utilization of surge protectors at the above listed locations.