HospitalInspections.org

Based on observation and interview, the facility failed to maintain building construction on one of five building levels.

Findings include:

Observation on October 19, 2016, at 1:40 PM revealed the second floor Telephone Equipment room had unsealed data wire penetrations through the fire rated floor assembly in the corner of the room to the right of the corridor door.

Interview with Carpenter on October 19, 2016, at 1:40 PM confirmed the above unsealed floor penetrations.

Based on observation and interview, the facility failed to maintain corridor doors to be smoke-tight in one of over 20 wings.

Findings include:

Observation on October 19, 2016, at 10:23 AM revealed third floor 3309B door could not close due to a large cart placed in the path of the door swing.

Interview with Carpenter on October 19, 2016, at 10:23 AM confirmed the above corridor door lacked positive latching due to a cart placed in the path of door swing.

Based on observation and interview, the facility failed to maintain smoke barrier construction on one of five building levels.

Findings include:

Observation on October 19, 2016, at 1:35 PM revealed the second floor smoke barrier wall to C.C.U. (between corridor fire barrier and suite) had an unsealed data cable above the smoke barrier doors.

Interview with Carpenter on October 19, 2016, at 1:35 PM confirmed the above unsealed smoke barrier penetration.

Based on observation and interview, the facility failed to maintain hazardous area doors on one of five building levels.

Findings include:

Observation on October 19, 2016, between 10:35 AM and 11:00 AM revealed the following hazardous area doors lacked positive latching:
A. Third floor 3A soiled utility room 3323 door (10:35 AM).
B. Third floor storage room 3318 door (10:37 AM).
C. Third floor soiled utility room door near 3331 (11:00 AM).

Interview with Carpenter on October 19, 2016, at 11:00 AM confirmed the above doors lacked positive latching.

Based on observation and interview, the facility failed to maintain exit enclosures to provide a continuous path of escape and protection against fire/smoke at five of seven exit stair towers.

Findings include:

1. Observation on October 19, 2016, between 10:33 AM and 11:30 AM revealed the following exit stair tower deficiencies:
A. Third floor stair tower 3300D (3N) had push brooms and a bucket stored on the landing at roof level (10:33 AM).
B. Third floor Behavioral Health, rear of 3C office suite exit stair tower had unsealed block and drywall above ceiling tile corridor side, unsealed hole on inside of stair tower beside the door, and stair tower door lacked positive latching (11:30 AM).

Interview with Carpenter on October 19, 2016, at 11:30 AM confirmed the above stair tower deficiencies.

2. Observation on October 20, 2016, between 9:05 AM and 9:50 AM revealed the following exit stair tower deficiencies:
A. First floor East end newly installed stair tower door lacked a metal frame around the wired glass vision panel (9:05 AM).
B. First floor East end newly installed stair tower door stays in the open position if fully open, and will not close (9:07 AM).
C. First floor stair behind Laboratory had a shovel and salt container stored inside (9:50 AM).

Interview with Carpenter on October 20, 2016, at 9:50 AM confirmed the above stair tower deficiencies.

Based on document review and interview, the facility failed to maintain exit egress to be arranged so that exits are readily accessible at all times on one of five building levels.

Findings include:

Document review on October 19, 2016, at 8:45 AM revealed facility lacked a snow removal policy.

Interview with Building Services Supervisor on October 19, 2016, at 8:45 AM confirmed the lack of snow removal policy.

Based on document review, observation, and interview, the facility failed to maintain exit egress to be arranged so that exits are readily accessible at all times on two of five building levels.

Findings include:

1. Document review on October 19, 2016, at 8:45 AM revealed facility lacked a snow removal policy.

Interview with Building Services Supervisor on October 19, 2016, at 8:45 AM confirmed the lack of snow removal policy.

2. Observation on October 19, 2016, between 10:30 AM and 11:40 AM revealed the following exit deficiencies:
A. Third floor stair tower door 3N # 3300D to the roof was not secured against unauthorized entry (10:30 AM).
B. Third floor exit stair tower door at the back of Behavioral Health suite would not open with the touch-pad release, or a key (11:40 AM).

Interview with Carpenter on October 19, 2016, at 11:40 AM confirmed the above exit deficiencies.

Based on observation and interview, the facility failed to maintain two-hour fire rated horizontal fire barriers at the following locations on three of five building levels.

Findings include:

1. Observation on October 19, 2016, between 10:25 AM and 1:30 PM revealed the following fire barrier deficiencies:
A. Third floor fire barrier outside room 3300 had an unsealed data conduit penetration above the ceiling tile (10:25 AM).
B. Third floor fire barrier on both sides of doors at 3320 had an unsealed data cable conduit (11:05 AM).
C. Second floor fire barrier above fire doors 2209A had an unsealed data cable conduit (12:50 PM).
D. Second floor fire barrier to C.C.U. from corridor had unsealed data wire conduit, inside and outside of conduit (1:30 PM).

Interview with Carpenter on October 19, 2016, at 1:30 PM confirmed the above unsealed fire barrier penetrations.

2. Observation on October 20, 2016, between 8:45 AM and 10:55 AM revealed the following fire barrier door deficiencies:
A. Second floor M.C.H. fire barrier door (left side going into suite) lacked positive latching (8:45 AM).
B. First floor Kitchen entrance fire doors near soda machine lacked positive latching (10:55 AM).

Interview with Carpenter on October 20, 2016, at 10:55 AM confirmed the above fire barrier doors lacked positive latching.

Based on observation and interview, the facility failed to maintain the fire sprinkler system in one of three smoke compartments.

Findings include:

Observation on October 20, 2016, at 11:15 AM revealed data room 1795 lacked fire sprinkler coverage.

Interview with Carpenter on October 20, 2016, at 11:15 AM confirmed the data room lacked fire sprinkler coverage.

Based on document review and interview, the facility failed to maintain special hazard suppression systems for three of three special hazard rooms.

Findings include:

Document review on October 19, 2016, at 9:00 AM revealed the last sprinkler report of August 31, 2016, noted the following: "Did not reach the ten minute agent hold time for the "Room Integrity Test" when system was first installed on 3/2009. Finish room sealing and conduct another "Room Integrity Test" ASAP. Recommend shutting down AC units and power to hazard area/room upon agent discharge. Recommend replacing TEL/dampers with electric fire dampers."
A. Third floor Data Room 3300A.
B. Third floor Computer Server Room 3301.
C. Second floor Telephone Room 2233B.

Interview with Building Services Supervisor on October 19, 2016, at 9:00 AM confirmed the above special hazard area deficiencies.

Based on observation and interview, the facility failed to maintain fire extinguishers for two of over fifty fire extinguishers.

Findings include:

1. Observation on October 19, 2016, at 11:15 AM revealed third floor fire extinguisher to the right of stair tower #3313 was blocked by three computer screens on wheels.

Interview with Carpenter on October 19, 2016, at 11:15 AM confirmed the above fire extinguisher was blocked.

2. Observation on October 20, 2016, at 11:05 AM revealed first floor Morgue fire extinguisher did not have an annual inspection for 2016.

Interview with Carpenter on October 20, 2016, at 11:05 AM confirmed the above fire extinguisher did not have an annual inspection for 2016.

Based on interview, the facility failed to maintain kitchen regulations for suppression equipment in one of one kitchen area.

Findings include:

Interview on October 20, 2016, at 10:50 AM revealed two of two staff interviewed did not know the location of the kitchen hood suppression system manual pull activation.

Interview with Carpenter on October 20, 2016, at 10:50 AM confirmed the kitchen staff shall be in-serviced as to the location of the manual pull activation for the kitchen hood suppression system over the cooking equipment.

Based on observation and interview, facility failed to maintain medical gas storage in one of one main medical gas location.

Findings include:

Observation on October 20, 2016, at 11:00 AM revealed the facility failed to separate full cylinders from empty cylinders in the first floor main oxygen storage room located on the dock area. Individual cylinders that were marked with "empty" tags were located beneath a "full" sign posted on the wall.

Interview with Carpenter on October 20, 2016, at 11:00 AM confirmed the above empty medical gas cylinders were not separated from the full cylinders.

Based on observation and interview, facility failed to maintain piped-in medical gas on one of five second floor wings.

Findings include:

Observation on October 19, 2016, at 1:25 PM revealed the second floor old T.C.C. Brokenstraw suite had medical gas shut-off valves that were labeled incorrectly as to which rooms they service.

Interview with Carpenter on October 19, 2016, at 1:25 PM confirmed the above medical gas shut off valves need updated as to the correct areas in which they service.

Based on observation and interview, facility failed to maintain electrical wiring and equipment on three of five building levels.

Findings include:

1. Observation on October 19, 2016, between 10:15 AM and 1:05 PM revealed the following electrical deficiencies:
A. Third floor room 3302 was utilizing an extension cord (10:15 AM).
B. Third floor 3301 computer room was utilizing an extension cord (10:20 AM).
C. Third floor office 3317 had a microwave oven and coffee maker plugged into a surge protector (11:10 AM).
D. Second floor office 213 had a coffee maker plugged into an extension cord (1:05 PM).

Interview with Carpenter on October 19, 2016, at 1:05 PM confirmed the above electrical deficiencies.

2. Observation on October 20, 2016, between 9:00 AM and 9:45 AM revealed the following electrical deficiencies:
A. Second floor mechanical room 2265B had exposed wires at the front of water pump for future motor installation (9:00 AM).
B. First floor medical records office had two coffee makers and a toaster plugged into a surge protector (9:15 AM).
C. First floor Laboratory admissions office had a surge protector plugged into another surge protector (9:45 AM).

Interview with Carpenter on October 20, 2016, at 9:45 AM confirmed the above electrical deficiencies.

Based on observation and interview, the facility failed to maintain building construction on one of five building levels.

Findings include:

Observation on October 19, 2016, at 1:40 PM revealed the second floor Telephone Equipment room had unsealed data wire penetrations through the fire rated floor assembly in the corner of the room to the right of the corridor door.

Interview with Carpenter on October 19, 2016, at 1:40 PM confirmed the above unsealed floor penetrations.

Based on observation and interview, the facility failed to maintain corridor doors to be smoke-tight in one of over 20 wings.

Findings include:

Observation on October 19, 2016, at 10:23 AM revealed third floor 3309B door could not close due to a large cart placed in the path of the door swing.

Interview with Carpenter on October 19, 2016, at 10:23 AM confirmed the above corridor door lacked positive latching due to a cart placed in the path of door swing.

Based on observation and interview, the facility failed to maintain smoke barrier construction on one of five building levels.

Findings include:

Observation on October 19, 2016, at 1:35 PM revealed the second floor smoke barrier wall to C.C.U. (between corridor fire barrier and suite) had an unsealed data cable above the smoke barrier doors.

Interview with Carpenter on October 19, 2016, at 1:35 PM confirmed the above unsealed smoke barrier penetration.

Based on observation and interview, the facility failed to maintain hazardous area doors on one of five building levels.

Findings include:

Observation on October 19, 2016, between 10:35 AM and 11:00 AM revealed the following hazardous area doors lacked positive latching:
A. Third floor 3A soiled utility room 3323 door (10:35 AM).
B. Third floor storage room 3318 door (10:37 AM).
C. Third floor soiled utility room door near 3331 (11:00 AM).

Interview with Carpenter on October 19, 2016, at 11:00 AM confirmed the above doors lacked positive latching.

Based on observation and interview, the facility failed to maintain exit enclosures to provide a continuous path of escape and protection against fire/smoke at five of seven exit stair towers.

Findings include:

1. Observation on October 19, 2016, between 10:33 AM and 11:30 AM revealed the following exit stair tower deficiencies:
A. Third floor stair tower 3300D (3N) had push brooms and a bucket stored on the landing at roof level (10:33 AM).
B. Third floor Behavioral Health, rear of 3C office suite exit stair tower had unsealed block and drywall above ceiling tile corridor side, unsealed hole on inside of stair tower beside the door, and stair tower door lacked positive latching (11:30 AM).

Interview with Carpenter on October 19, 2016, at 11:30 AM confirmed the above stair tower deficiencies.

2. Observation on October 20, 2016, between 9:05 AM and 9:50 AM revealed the following exit stair tower deficiencies:
A. First floor East end newly installed stair tower door lacked a metal frame around the wired glass vision panel (9:05 AM).
B. First floor East end newly installed stair tower door stays in the open position if fully open, and will not close (9:07 AM).
C. First floor stair behind Laboratory had a shovel and salt container stored inside (9:50 AM).

Interview with Carpenter on October 20, 2016, at 9:50 AM confirmed the above stair tower deficiencies.

Based on document review and interview, the facility failed to maintain exit egress to be arranged so that exits are readily accessible at all times on one of five building levels.

Findings include:

Document review on October 19, 2016, at 8:45 AM revealed facility lacked a snow removal policy.

Interview with Building Services Supervisor on October 19, 2016, at 8:45 AM confirmed the lack of snow removal policy.

Based on document review, observation, and interview, the facility failed to maintain exit egress to be arranged so that exits are readily accessible at all times on two of five building levels.

Findings include:

1. Document review on October 19, 2016, at 8:45 AM revealed facility lacked a snow removal policy.

Interview with Building Services Supervisor on October 19, 2016, at 8:45 AM confirmed the lack of snow removal policy.

2. Observation on October 19, 2016, between 10:30 AM and 11:40 AM revealed the following exit deficiencies:
A. Third floor stair tower door 3N # 3300D to the roof was not secured against unauthorized entry (10:30 AM).
B. Third floor exit stair tower door at the back of Behavioral Health suite would not open with the touch-pad release, or a key (11:40 AM).

Interview with Carpenter on October 19, 2016, at 11:40 AM confirmed the above exit deficiencies.

Based on observation and interview, the facility failed to maintain two-hour fire rated horizontal fire barriers at the following locations on three of five building levels.

Findings include:

1. Observation on October 19, 2016, between 10:25 AM and 1:30 PM revealed the following fire barrier deficiencies:
A. Third floor fire barrier outside room 3300 had an unsealed data conduit penetration above the ceiling tile (10:25 AM).
B. Third floor fire barrier on both sides of doors at 3320 had an unsealed data cable conduit (11:05 AM).
C. Second floor fire barrier above fire doors 2209A had an unsealed data cable conduit (12:50 PM).
D. Second floor fire barrier to C.C.U. from corridor had unsealed data wire conduit, inside and outside of conduit (1:30 PM).

Interview with Carpenter on October 19, 2016, at 1:30 PM confirmed the above unsealed fire barrier penetrations.

2. Observation on October 20, 2016, between 8:45 AM and 10:55 AM revealed the following fire barrier door deficiencies:
A. Second floor M.C.H. fire barrier door (left side going into suite) lacked positive latching (8:45 AM).
B. First floor Kitchen entrance fire doors near soda machine lacked positive latching (10:55 AM).

Interview with Carpenter on October 20, 2016, at 10:55 AM confirmed the above fire barrier doors lacked positive latching.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system for one of one building fire alarm system.

Findings include:

1. Document review on October 19, 2016, at 8:30 AM revealed the following fire alarm deficiencies:
A. Last fire alarm inspection of February 1, 2016, noted the batteries for the fire alarm system are over four years old and need replaced.
B. Facility lacked documentation that a semi-annual visual inspection of all fire alarm devices is performed six months after the annual inspection is completed.
C. Facility lacked documentation of a Fire policy/plan (including notifying authorities, performing a fire watch, or evacuation, when fire alarm/fire sprinkler systems are out of service for more than four hours in a 24-hour period, until the systems are returned to service).

Interview with Building Services Supervisor on October 19, 2016, at 8:30 AM confirmed the fire alarm documentation deficiencies.

2. Observation on October 19, 2016, at 1:45 PM revealed the second floor Telephone Equipment room fire alarm panel indicated there were troubles with two smoke heads.

Interview with Carpenter on October 19, 2016, at 1:45 PM confirmed the above troubles on the building fire alarm system.

Based on observation and interview, the facility failed to maintain the fire sprinkler system in one of three smoke compartments.

Findings include:

Observation on October 20, 2016, at 11:15 AM revealed data room 1795 lacked fire sprinkler coverage.

Interview with Carpenter on October 20, 2016, at 11:15 AM confirmed the data room lacked fire sprinkler coverage.

Based on document review and interview, the facility failed to maintain special hazard suppression systems for three of three special hazard rooms.

Findings include:

Document review on October 19, 2016, at 9:00 AM revealed the last sprinkler report of August 31, 2016, noted the following: "Did not reach the ten minute agent hold time for the "Room Integrity Test" when system was first installed on 3/2009. Finish room sealing and conduct another "Room Integrity Test" ASAP. Recommend shutting down AC units and power to hazard area/room upon agent discharge. Recommend replacing TEL/dampers with electric fire dampers."
A. Third floor Data Room 3300A.
B. Third floor Computer Server Room 3301.
C. Second floor Telephone Room 2233B.

Interview with Building Services Supervisor on October 19, 2016, at 9:00 AM confirmed the above special hazard area deficiencies.

Based on observation and interview, the facility failed to maintain fire extinguishers for two of over fifty fire extinguishers.

Findings include:

1. Observation on October 19, 2016, at 11:15 AM revealed third floor fire extinguisher to the right of stair tower #3313 was blocked by three computer screens on wheels.

Interview with Carpenter on October 19, 2016, at 11:15 AM confirmed the above fire extinguisher was blocked.

2. Observation on October 20, 2016, at 11:05 AM revealed first floor Morgue fire extinguisher did not have an annual inspection for 2016.

Interview with Carpenter on October 20, 2016, at 11:05 AM confirmed the above fire extinguisher did not have an annual inspection for 2016.

Based on interview, the facility failed to maintain kitchen regulations for suppression equipment in one of one kitchen area.

Findings include:

Interview on October 20, 2016, at 10:50 AM revealed two of two staff interviewed did not know the location of the kitchen hood suppression system manual pull activation.

Interview with Carpenter on October 20, 2016, at 10:50 AM confirmed the kitchen staff shall be in-serviced as to the location of the manual pull activation for the kitchen hood suppression system over the cooking equipment.

Based on observation and interview, facility failed to maintain medical gas storage in one of one main medical gas location.

Findings include:

Observation on October 20, 2016, at 11:00 AM revealed the facility failed to separate full cylinders from empty cylinders in the first floor main oxygen storage room located on the dock area. Individual cylinders that were marked with "empty" tags were located beneath a "full" sign posted on the wall.

Interview with Carpenter on October 20, 2016, at 11:00 AM confirmed the above empty medical gas cylinders were not separated from the full cylinders.

Based on observation and interview, facility failed to maintain piped-in medical gas on one of five second floor wings.

Findings include:

Observation on October 19, 2016, at 1:25 PM revealed the second floor old T.C.C. Brokenstraw suite had medical gas shut-off valves that were labeled incorrectly as to which rooms they service.

Interview with Carpenter on October 19, 2016, at 1:25 PM confirmed the above medical gas shut off valves need updated as to the correct areas in which they service.

Based on observation and interview, facility failed to maintain electrical wiring and equipment on three of five building levels.

Findings include:

1. Observation on October 19, 2016, between 10:15 AM and 1:05 PM revealed the following electrical deficiencies:
A. Third floor room 3302 was utilizing an extension cord (10:15 AM).
B. Third floor 3301 computer room was utilizing an extension cord (10:20 AM).
C. Third floor office 3317 had a microwave oven and coffee maker plugged into a surge protector (11:10 AM).
D. Second floor office 213 had a coffee maker plugged into an extension cord (1:05 PM).

Interview with Carpenter on October 19, 2016, at 1:05 PM confirmed the above electrical deficiencies.

2. Observation on October 20, 2016, between 9:00 AM and 9:45 AM revealed the following electrical deficiencies:
A. Second floor mechanical room 2265B had exposed wires at the front of water pump for future motor installation (9:00 AM).
B. First floor medical records office had two coffee makers and a toaster plugged into a surge protector (9:15 AM).
C. First floor Laboratory admissions office had a surge protector plugged into another surge protector (9:45 AM).

Interview with Carpenter on October 20, 2016, at 9:45 AM confirmed the above electrical deficiencies.