HospitalInspections.org

A) (New 12/10/12): The Main Lobby door to the Gift Shop was obstructed by display clothing hanging over th top of the door and by clothing that was hanging on the door closer. These obstruction would delay staff's ability to close this door in a fire emergency.

Evidence includes:

A) Based upon personnel interview and random observation during all three days of the survey, the surveyors find that vertical openings are not enclosure in accordance 19.3.1.1 and NFPA 90A:

1) The 2nd, 3rd and 4th Floor patient rooms have bathrooms that are back to back. The plumbing wall between each pair of bathrooms contains an exhaust duct that is continuous, vertically, from the 2nd Floor ceiling to the roof mounted exhaust fan. Each bathroom exhaust duct communicates to the 2nd, 3rd and 4th Floors, and penetrates two fire rated floor assemblies.

a) Each duct is not enclosed in a fire rated
shaft enclosure in accordance with
19.3.1.1 and NFPA 90A

b) Each exhaust duct lacks fire dampers
where the ducts branch out of a shaft at
each floor (above the ceiling).

c) Fire dampers have been installed at the
floor of each exhaust duct below the
plane of the 3rd Floor slab and th 4th
Floor slab. This installation does not
comply with NFPA 90A but was done in
conjunction with an FSES in 2007. The
installation does not comply with
current CMS policies which do not
allow an FSES for this condition.

d) The duct in each pair of bathrooms is
installed directly against the corridor
wall with only one layer of drywall
between the duct and the corridor. The
drywall is not secured at the top of this
wall and at the bottom of the wall at the
floor and the wall is not fire rated (as
part of a shaft enclosure).

2) The surveyors find from random observation and review of plans, that there are concrete block shaft enclosures at the west side of the West stair and at the east side of the East Stair on the 2nd, 3rd and 4th Floors. Duct penetrations through the floor and/or into these shaft enclosures lack fire dampers in accordance with NFPA 90A. Access to investigate this condition was limited by ceiling conditions and/or due to semi-sterile envirnonments with no access on some floors.

3) Deleted 03/09/12

4) Corrected 03/08/12

Failure to construct shaft enclosures in accordance with NFPA 90A and NFPA 101 and failure to install and maintain fire dampers could allow fire to spread from floor to floor and throughout patient areas. See also K067.

.



20224


Based on random observation during the survey walk through on the afternoon of 9/20/2011, the surveyor accompanied by the Director of Facilities finds that vertical openings are not enclosed comply with 8.2.5.3. Unenclosed shafts may affect patient care areas on several floors and smoke compartments, preventing the safe movement of patients, visitors and staff during a fire emergency.

Finding as follows:

A). Corrected 12/10/12

2. Corrected 12/10/12

3. 2nd floor, corridor # C-22 adjacent to Stair # 3 and to Cardinal Sleep Lab, several bathroom exhaust ducts extend up to the floor(s) above within a shaft that is open to this corridor.

B). On the morning of 09/19/2011, duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers to comply with 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. Corrected 03/08/12

2. 3rd floor, visitor's lobby # 344, shaft adjacent to toilet #310A

The correction date for the above item is confusing and does not match other project dates.

3. Corrected 03/08/12

Based on random observation on the morning of 09/20/2011 during the survey walk through, the surveyor accompanied by the Facility Director finds that not all stair shafts are constructed or maintained as fire resistive assemblies to comply with 8.2.5.4.

Findings include:

A. Modified 03/08/12): Stair enclosures were observed which are not separated from adjacent areas and do not provide an enclosed protected means of egress to an exit discharge. Location observed:

1. Required exit stair located near the main
entry is an unenclosed stair on both
levels. This condition does not comply
with 39.3.1.1(3) and 8.2.5.8 for a
vertical enclosure with a minimum 1
hour fire rating as a required component
for a means of egress.

12/10/12: The provider lacks
documentation for the glazing used in
the stair door at the Lower Level.

12/10/12: The stair door at the lower
level is held open with a magnetic hold
open device; the door lacks smoke
detection within five feet of the door
(7.2.1.8).

2. Corrected 03/08/12

3. Corrected 03/08/12

4. The required Exit stair (near Pharmacy
Storage) located within the original part
of the building (not sprinkler protected)
does not comply with Chapter 7 and 8 of
NFPA 101.

a. Corrected 12/10/12

b. The stair on both levels is used for
storage (deficiency includes waste
containers, supplies, coat racks, etc.)

12/10/12 the above item was not
corrected; a wheeled cart was left
on the lower stair landing. The
provider lacks affective means to
prevent re-occurrence

c. Corrected 12/10/12

d. Corrected 12/10/12

e. Duct penetrations at the Lower
Level lack fire dampers. The Upper
Level has a plenum return air
opening in the stair enclosure
wall above the ceiling. A fire
damper is installed in this opening.
The opening is not smoke tight
and a combination fire/smoke
damper with a smoke detector in
the plenum is not provided

12/10/12 two of four penetrations
are for unducted plenum openings
that lack smoke detectors at the
dampered plenum opening into the
stair.

A) Corrected 03/09/12

.



20224


Based on random observation during the survey walk-through while accompanied by the Director of Facilities the surveyor finds that not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1.

Findings include:

A). The lack of separation between a hazardous area and an exit access corridor may prevent the use of the corridor by staff, patients and visitors for safe egress to the nearest discharge. Locations and conditions observed include:

1. On the morning of 09/20/2011,Surgery Suite- Center Core located between all O.R.'s. This room which is greater than 100 square feet, is considered a hazardous area due to the amount of combustible storage. This room does not maintain a smoke tight separation from the corridor and adjacent rooms due to the following:

a. The doors do not appear to provide a
physical condition equivalent to a 20
minute smoke tight door installation due
to the following:

i. Doors display decay across the
bottom and at the latch side.

ii. Finish is delaminated in areas and
the interior core may be viewed.

iii. Several of these doors appear to be
out of plumb with the door frames
which does not maintain a resistance
to smoke.

2. Corrected 03/09/12

3. Corrected 03/08/12

4. Corrected 03/09/12

B). Corrected 03/09/12

C). Corrected 12/10/12

.

Findings include:

A) Based upon random observation the surveyor finds that required exit stairs are not maintained as fire rated enclosures in accordance with 19.3.1.1. The fire door from the 1st Floor Physical Therapy area to the East Exit Passageway does not always close to latch.

12/10/12: The above item was uncorrected - the door does not always latch.

Failure to maintain opening protection in fire rated shaft enclosures could allow fire and smoke to spread from floor to floor.

.



20224


A). Corrected 03/08/12





.

A) Corrected 03/08/12

B) Corrected 12/10/12

C) Corrected 03/09/12

D) 12/10/12: (New): pairs of cross corridor doors on the 2nd Floor have magnetic locking devices. Signs are not provided in accordance with 7.2.1.6.1. on each side of the doors for the direction of exit travel.


.

Evidence includes:

A) Corrected 12/10/12

B) 9/21/11: From random observation throughout the building, the surveyors find that the sprinkler system is installed with metal pipe in some areas and plastic pipe in other areas. Arm-over and/or end of branch bracing is not provided for sprinkler heads on all five floors throughout the building in accordance with Section 6-2.3.3 of NFPA 13 - 1999.

Note: This deficiency does not occur in everywhere because sidewall heads are used in many locations. Examples of where arm-over bracing for uplift is not provided include but is not nearly limited to 3rd Floor Group Therapy Room and the Ground Floor E R Registration area.

The above item will remain open until the end of all corrections.

C) Corrected 03/09/12

D) Corrected 03/09/12

.

.
A) Corrected 03/09/12

B. Corrected 03/08/12









07113


A. Uncorrected deficiencies were transferred from the Complaint Survey of 06/22/11: The provider failed to provide and maintain a safe and sanitary environment for patients and staff.

4. Corrected 03/08/12

5. 06/21/11: Wall mounted toilets throughout the facility are not installed in accordance with the Plumbing Code and/or the manufacturer's requirements. The joint between the finish wall and the toilet is open and not sealed with a water resistant material. This allows moisture, cleaning fluids and debris to fall between the toilet and into the chase behind the toilet.

Modified 9/21/11: The surveyors observed that most bathrooms, dietary, and other areas identified in the compliant survey had been cleaned and visible evidence of housekeeping deficiencies, stains and possible surface mold was cleaned up. The condition of the joints between the toilets and the wall was not re-investigated. Based upon interviews of Hospital personnel and the onsite outside contractor's personnel, the surveyor finds that the Hospital believes that many of the hidden mold problems and some of the surface conditions were caused by the failure of the plumbing seal for the waste of the wall mounted toilets. These toilets are installed throughout the facility. Further, it is required, based on the information provided from thr facility, that corrective actions will be necessary.

C. New deficiencies based upon the 9/21/11 Survey:

Interim Life Safety Measures as an alternative to full compliance with NFPA 101 - 2000: Due to the severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1. The provider failed to implement interim life safety measures for deficiencies cited under the survey dated 9/21/11.

E. (New deficiencies based upon 9/21/11 Survey): Based upon the conditions observed on 6/22/11 and observed on 9/21/11 and based upon personnel interview and document review, the surveyors find that mold has been found in the concealed spaces between bathrooms. Hospital personnel indicated that they expect to find this condition in most if not all bathrooms on all floors (see also Item "B 5" above).

1. On the morning of 9/19/20 and on the afternoon of 9/21/11, the Hospital provided access to two bathrooms on the 3rd Floor for rooms that were no longer used as patient rooms (Rooms 309A and 310A). The two back to back bathrooms have been partially demolished by an outside contractor (that was also present). The floor and ceiling finishes of the two bathrooms were removed. The sinks and toilets were removed. The wall finishes and wall (studs and drywall) between the two bathrooms were completely removed.. The Hospital's representative and the contractor were both interviewed on 9/19/11 and 9/21/11 with the following results:

a. The contractor indicated that the
demolition and removal was conducted
in accordance with the Hospital's rules
for projects, infection control and for
mold abatement. This included negative
ventilation of the project area and double
bagging of the demo materials being
removed.

b. The contractor indicated that no mold
was found under the floor finishes.

c. The contractor indicated that mold was
found on the inside portions of the
drywall as much as 12" above the floor.
The contractor also indicated that the
lower portion or drywall was soggy or
soft. No samples of this material were
save and no testing was conducted to
determine what type of mold was
present, whether it was active or inert,
and/or if the substances observed were
mold.

d. The contractor indicated that the stud
track at the floor was rusted away and
that the lower portion of the wall studs
were significantly deteriorated. Again,
none of this material was saved for
testing or later examination.

e. The Hospital's representative indicated
that the Hospital expects to find this
same condition in most of the bathrooms
in the facility.

From observation the surveyor also finds:

f. The plumbing wastes, including two
toilets were capped off with rags.

g. The sprinkler heads in each space were
not turned up to the deck when the
ceilings were removed; this condition
requires interim life safety measures.

The above findings support that findings from the complaint survey of 6/22/11, which concluded that there is mold in the bathrooms of the building on multiple patient floors. Based upon multiple interviews, the surveyors find that the Hospital expects to find mold and deteriorating wall conditions in bathrooms. The scope of this condition is expected throughout the building. The severity of this condition has not been determined; see below

2. The bathroom mirror in Room 416 was removed on the afternoon of 9/20/11, to allow viewing of the plumbing cavity behind the bathroom. This room is an example of a project that took place recently in which the 4th Floor bathrooms were renovated. In the bathroom of 416, the surveyors observed no mold. The surveyors observed that the drywall on both sides of the wall had been replaced from the floor to about four feet above the floor. The light gage steel wall studs were partially removed from the floor to about four feet above the floor and were replaced with new studs. However, the existing studs were cut off at roughly four feet above the floor and the new studs were not spliced into the existing studs and were not run from deck to deck. The drywall in the bathroom (5' x 8') on each side of the plumbing wall was is stiffened only by steel stud with a break in the middle of each wall.

The corridor wall has about 12" of drywall at the floor that is not supported by studs or a stud track. This portion of the corridor wall is also part of an unrated shaft that is also cited under K 020. This condition is typical of many of the 4th Floor bathrooms

3. The Hospital has indicated that some form of outside testing was conducted. The information about who did the testing, what testing was conducted, where the testing conducted, the results of the testing and the qualifications of the testing agency was not available. There is no evidence that indicates that the Hospital has engaged the services of an industrial hygienist, a mold or moisture abatement consultant and/or contractor that specializes in abatement.

4. The Hospital has adopted a management plan for investigation, containment and abatement of mold that is based upon OSHA and/or EPA references. This plan contains four levels of contamination with Level I being the lowest level and Level IV the highest. Level III and Level IV includes recommendations for consultation with an industrial hygienist, or environmental health and safe professionals.

a. The provider was not able to identify
which Level of contamination has been
found at their facility and how this was
determined. There is no evidence or
report that identifies that source(s) of
mold that may be found in the bathroom
plumbing walls.

b. A project architect was also present for
the survey on all three days. The project
architect has identified a project that is
proposed to repair bathrooms walls,
abate any mold or deteriorating
conditions, replace shaft enclosures and
replace bathroom toilets in every
bathroom in the facility.

The shaft correction in many bathrooms
(but not all) will necessitate demolition
and removal of bathroom walls. In
other bathrooms, demolition is proposed
to install new floor mounted toilets and
to abate deteriorated wall conditions.
There is no indication of what Level of
abatement is necessary for all portions of
this project, based upon the Hospital
policies.

The following conditions are cited on the Complaint Survey dated 6/22/11 under tag A 700 and are repeated herein. They support the findings above. No attempt was made to determine whether portions of the findings below have been corrected as of 9/21/11.

The informatoin below are based upon random observation, personnel interview and limited document review during the complaint survey of 6/22/11. The following citations are also based upon observations throughout the hospital by looking; at wall and floor finishes, above ceilings and using existing access panels to view concealed spaces. Rooms with patients were not inspected with the exception of one Room on the 4th Floor . The investigation was mostly confined to toilet and shower rooms on Floors 2, 3 and 4. Random inspections were conducted on the 1st Floor and Ground Floor. No destructive demolition was conducted and no special means (pin hole cameras, etc) were used to observe concealed spaces.

Findings include:

A. The presence of what appears to be molds in patient bathrooms was confirmed by the surveyor. Based upon the following, the surveyor expects to find mold and moisture problems throughout toilet rooms (and/or in the plumbing chases for toilet rooms) on every floor.

1. There is a plumbing chase between patient room 404 and 403 with wall mounted sinks and wall mounted toilets installed back to back. The wall finishes, cove base and floor finishes are ceramic tile. The ceramic tile on the wall is new and has white grout. The ceramic cove base and floor tiles are older and the grout in the joint work is stained, discolored and damaged.

Access into the plumbing chase is limited to a small access panel under the sink. This access panel allows very little access (not enough to view into the space and not enough room for a camera. The surveyor reached into the cavity near the floor to feel the wall surface that the toilet is mounted to. The wall surface in the chase was soft and mushy (as opposed to hard drywall) near the floor. The surveyor's fingers were coated with a gray/blue/black residue after touching the wall in the chase. The surveyor finds that the lower portions of the wall are damaged by moisture problems in the wall and the residue is most likely mold growing on the wall. The extent of this problem in this room could not be determined further without demolition to expose the chase.

However, the surveyor observed the joint work in the ceramic tile at the plumbing wall was broken and discolored with a yellow material. There is waste water brown stain under the wall mounted toilet that appears to be a leak from the toilet. Much of the grout work in the floor tile around the toilet is stained or discolored.

Further, the surveyor observed a slight hump in the corridor wall along the outside of this bathroom. The wall surface and base moves slighting when pressed upon. This indicates that the wall is not attached to the floor track or floor plate at the base of the wall or it indicates that the steel track or plate inside the wall has deteriorated from moisture.

2. Patient Room 415: The surveyor observed a plastic barrier in the corridor in front of this room and observed that the toilet room was being renovated. A contractor was in the bathroom working on new ceramic tile wall finishes and ceramic tile floor finishes. It was readily obvious that portions of the drywall had been replaced. The demolished materials were not found in the room. The surveyor interviewed the contractor working on the toilet room. The contractor indicated that the old ceramic tile finishes had been removed. He indicated that the drywall on three walls was removed and replace to about four feet above the floor. When asked, he indicated that the drywall that was removed had mold on it. When asked, the contractor indicated that the steel floor track had to be replaced because it had rusted away.

The Director of Plant Operations indicated that the ceramic floor tile had mold under the tile and that the substrate was removed.

Patient Room 416: The surveyor found that the adjacent patient room was occupied. Staff asked for and received the patient's permission to look in the bathroom. The bathroom is back to back with Patient Room 415 and shares a plumbing chase. The bathroom has no access panel to the plumbing chase. The room has similar conditions, visually, to most of the bathrooms on this floor. The surveyor observed no evidence of any repair to wall or floor finishes or substrates.

3. 3rd Floor Shower Room near Room 318. This shower room is typical for most shower rooms in the building. Most but not all patients rooms have no showers in the patient bathrooms. Instead patient showers are provided off the corridors on each floor. The shower room near Room 318 has no ventilation and was much more humid that other showers observed. The shower was not clean. The ceramic tile finishes were discolored and coated with grime.

03/08/12: Ventilatoin was not provided for the above shower room in accordance with the last submitted PoC.

4. Patient Room 318 has a toilet room with back to back fixtures and a shared plumbing chase with the adjacent patient room.

The corridor wall surface is loose near the floor along the bathroom wall.

The wall and floor finishes are heavily discolored and the wall and cove base are loose at the toilet. The joints are not watertight. The surveyor observed wood blocking in the plumbing chase.

5. Dietitian's Office 314 (formerly a patient room and typical of many): The toilet room is typical of most patient toilet rooms on this floor.

There is no water tight seal between the toilet and the wall. The ceramic tile wall finishes have failed and the joints between the water and the floor are buckled. There are heavy stains on the wall under the toilet

6. Office 2-211 (with a typical patient toilet room): The cove base is vinyl and it is ripped and buckled. The toilet is not sealed to the wall finish.

7. Room 2-253: The ceramic tile joints in this room were originally white but have turned brown and black. The discoloration does not come out with rubbing or scraping. This is typical of many patient toilet rooms.

8. Room 2-214: Sheet vinyl flooring and a vinyl cover based have been installed directly over the ceramic tile. Some of the joints have failed at the vinyl cove base. There is discoloration at the joints and along the top of the cover based.

9. From random observation via access panels in patient toilet rooms the surveyor finds that plumbing chases to be full of debris and rags.

10. Ground Floor patient toilet room near an X-ray Room: The wall mounted toiled in this bathroom is not sealed to the wall with a water resistant seal or caulking material. This allows dirt, soiled materials and moisture behind the toilet and possibly into the plumbing chase.

End

.

A) Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. The following Life Safety Panels are serving loads other than those allowed by NFPA-70, Section 517-32 and NFPA-99, Section 3-4.2.2.2(b) .

a. Corrected 03/08/12

b. Corrected 12/10/12

c. Corrected 12/10/12

d. The only generator loads allowed to be
served by the Life Safety Branch are
selected lighting and receptacles at the
generator set location. Several Life
Safety Panels had circuits serving battery
chargers, heaters, louvers and other
generator loads.

e. Corrected 03/09/12

2. Corrected 03/09/12

3. Corrected 03/09/12

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Evidence includes:

A) From random observation, the surveyors find that electrical installations and materials do not comply with NFPA 70 -1999.

1) The surveyor finds the electrical extension cords and plug strips plugged in in series are in permanent use throughout the facility. Locations include but are not limited to:

a) Corrected 03/08/12

b) Corrected 03/09/12

c) Corrected 03/09/12

d) Corrected 03/09/12

e) Corrected 03/09/12

f) Corrected 03/09/12

g) Ground Floor Communication Room
(accessed through Electrical Room)

h) (New 12/10/12) Orange extension
cords at 1st Floor Lobby Christmas
tree and flower case near the Gift
Shop

i) (New 12/10/12) Orange extension
cord Christmas tree - Room G260.

2) Corrected 12/10/12

3) Corrected 03/09/12

4) Corrected 03/09/12

5) (New 12/10/12) Boiler Room: access to switchgear was blocked by multiple stored items adn equpment.

Failure to maintain and identify devices and equipment in accordance with NFPA 70 could result: in failure of devices and systems, delayed response by staff or fire personnel and/or fires in devices that are not installed in accordance with NFPA 70.

.



17659


Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Corrected 12/10/12

2. Corrected 12/10/12

3. Two of the three operating rooms were not equipped with battery operated emergency lighting as required by NFPA-99, Section 3-3.2.1.2(a)5e.

4. Corrected 12/10/12

Evidence includes:

A) The provider lacks documentation of monthly testing of fire fighter service on all elevators in accordance with 9.4.6. of NFPA 101 and ASME/ANSI A17.3.

B) Corrected 12/10/12


.



17659


1. Corrected 12/10/12

2. Corrected 12/10/12
.

A) (New 12/10/12): The Main Lobby door to the Gift Shop was obstructed by display clothing hanging over th top of the door and by clothing that was hanging on the door closer. These obstruction would delay staff's ability to close this door in a fire emergency.