HospitalInspections.org

Based on observation, it was revealed that the facility failed to maintain the building construction type. This affects 6 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 10:54 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed in the maintenance shop in the basement.

On 5-24-2013 at approximately 10:26 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor at stair 2.

On 5-24-2013 at approximately 11:00 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor in room 2-053.

On 5-24-2013 at approximately 11:02 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor in room 2-052.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the construction of the mobile MRI suite, when docked to the building, does not appear to meet the same type construction as the remainder of the facility.

On 5-28-2013 at approximately 1:45 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on ground floor in room G-052.

On 5-28-2013 at approximately 2:49 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed in the floor on ground floor in PT room at aquacizer.

On 5-28-2013 at approximately 3:02 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on basement floor in room B-103b.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the corridor with smoke tight construction. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-28-2013 at approximately 1:54 PM, it was revealed by observation that a corridor door was removed causing an area to be open to the corridor. This was observed in room G-308.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the shafts with fire rated construction. This affects 5 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 11:59 AM, it was revealed by observation that the main mechanical shaft has multiple unprotected penetrations.

On 5-23-2013 at approximately 2:03 PM, it was revealed by observation that a mechanical shaft has multiple unprotected penetrations. This was observed in room 2-500.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain hazardous areas with smoke tight construction. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-24-2013 at approximately 1:24 PM, it was revealed by observation that a door to a hazardous area does not self close. This was observed in room 1-313.

On 5-24-2013 at approximately 2:11 PM, it was revealed by observation that there were unprotected penetrations to the required smoke tight walls for the lab. This was observed in the lab at room 1-115.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain exits that are readily accessible. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 2:35 PM, it was revealed by observation that an exit door with delayed egress is being utilized without proper signage. This was observed at stair 1 on floor 2.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the marked exit in the mobile MRI suite docked to the building does not appear to lead to an discharge.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to install the fire alarm system in accordance with NFPA 70, 1999 Edition. This violation affects 1 of 12 smoke compartments.

Survey findings include:
On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the fire alarm system in the mobile MRI suite docked to the building does not appear to be connected to the main building fire alarm system.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to install the sprinkler system in accordance with NFPA 13, 1999 Edition. This violation affects 6 of 12 smoke compartments.

Survey findings include:
On 5-23-13 at approximately 10:14 AM, it was revealed by observation that there are quick response sprinklers installed adjacent to standard response sprinklers in the same area without being separated. This was observed in the maintenance shop.

On 5-23-13 at approximately 11:38 AM, it was revealed by observation that there is a closet that is not sprinklered. This was observed in the closet of room 3-122.

On 5-24-13 at approximately 10:40 AM, it was revealed by observation that there is an obstruction to the sprinkler that creates an unsprinklered area. This was observed in an alcove at the main elevators on the 2nd floor. NFPA 13-1999 Edition, 5-6.5.1.2

On 5-24-13 at approximately 11:40 AM, it was revealed by observation that the ceiling is being supported by the sprinkler system. This was observed above the PACU ceiling. NFPA 13-1999ed. 6-1.1.5

On 5-24-13 at approximately 1:20 PM, it was revealed by observation that a wall is obstructing the sprinkler creating an unsprinklered area. This was observed in the room across from the lab entrance.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the mobile MRI suite docked to the building does not appear to be protected with a suppression system. This suite is open to the building. Patient care is being performed in the MRI suite.

On 5-28-13 at approximately 3:45 PM, it was revealed by observation that there are nonsystem components (wires) attached to the sprinkler system. This was observed in materials management.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the sprinkler system in a reliable operating condition. This affects 12 of 12 smoke compartments.

Survey findings include:

On 5-28-2013 at approximately 3:34 PM, it was revealed by observation that an escutcheon is missing. This was observed in the EMS transport room.

On 5-28-2013 at approximately 3:44 PM, it was revealed by observation that there is no signage nor documentation that the gauges located on the fire pump have been replaced or calibrated within 5 years. NFPA 25-1997 2-3.2

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the hood suppression system in a reliable operating condition. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-28-2013 at approximately 1:51 PM, it was revealed by observation that the hydrostatic date on the suppression bottles were greater than 12 years. This was observed in the kitchen hood system. NFPA 96-1998 7-2.2.1, NFPA 17A-1998 5-5

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the location of soiled linen receptacles greater than 32 gallons in a hazardous area. This violation affected 1 of 12 smoke compartments.

Survey findings include:

On 5-24-2013 at approximately 2:02 PM, it was revealed by observation that there were soiled linen receptacles over 32 gallons left unattended without being located in a protected hazardous area. This was observed in room 1-335.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the electrical system in accordance with NFPA 70. This violation affects 1 of 12 smoke compartments.

Survey findings include:

On 5-23-2013 at approximately 11:23 AM, it was revealed by observation that there is an unfused multiplug being used. This was observed in the conference room on 3rd floor. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 1:55 PM, it was revealed by observation that there is a listed medical device plugged into a non medical listed relocatable power tap. This was observed in 2-505. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 1:57 PM, it was revealed by observation that there is a listed medical device plugged into a non medical listed relocatable power tap. This was observed in 2-509. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 2:11 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in 2-506. NFPA 70-1999 art.110-3(b)

On 5-24-2013 at approximately 10:35 AM, it was revealed by observation that an extension cord is being used as permanent wiring. This was observed in the lobby. NFPA 70-1999 art.400-8

On 5-24-2013 at approximately 11:45 AM, it was revealed by observation that an extension cord is being used as permanent wiring. This was observed in 2-209. NFPA 70-1999 art.400-8

On 5-24-2013 at approximately 1:54 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in the room across from the lab entrance. NFPA 70-1999 art.110-3(b)

On 5-24-2013 at approximately 2:34 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in room 1-109. NFPA 70-1999 art.110-3(b)

On 5-28-2013 at approximately 2:50 PM, it was revealed by observation that there is a damaged plug. This was observed in the PT room on the upper body cycle.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the building construction type. This affects 6 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 10:54 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed in the maintenance shop in the basement.

On 5-24-2013 at approximately 10:26 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor at stair 2.

On 5-24-2013 at approximately 11:00 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor in room 2-053.

On 5-24-2013 at approximately 11:02 AM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on 2nd floor in room 2-052.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the construction of the mobile MRI suite, when docked to the building, does not appear to meet the same type construction as the remainder of the facility.

On 5-28-2013 at approximately 1:45 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on ground floor in room G-052.

On 5-28-2013 at approximately 2:49 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed in the floor on ground floor in PT room at aquacizer.

On 5-28-2013 at approximately 3:02 PM, it was revealed by observation that the floor ceiling assembly has an unprotected penetration. This was observed above the ceiling on basement floor in room B-103b.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the corridor with smoke tight construction. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-28-2013 at approximately 1:54 PM, it was revealed by observation that a corridor door was removed causing an area to be open to the corridor. This was observed in room G-308.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the shafts with fire rated construction. This affects 5 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 11:59 AM, it was revealed by observation that the main mechanical shaft has multiple unprotected penetrations.

On 5-23-2013 at approximately 2:03 PM, it was revealed by observation that a mechanical shaft has multiple unprotected penetrations. This was observed in room 2-500.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain hazardous areas with smoke tight construction. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-24-2013 at approximately 1:24 PM, it was revealed by observation that a door to a hazardous area does not self close. This was observed in room 1-313.

On 5-24-2013 at approximately 2:11 PM, it was revealed by observation that there were unprotected penetrations to the required smoke tight walls for the lab. This was observed in the lab at room 1-115.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain exits that are readily accessible. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-23-2013 at approximately 2:35 PM, it was revealed by observation that an exit door with delayed egress is being utilized without proper signage. This was observed at stair 1 on floor 2.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the marked exit in the mobile MRI suite docked to the building does not appear to lead to an discharge.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to install the fire alarm system in accordance with NFPA 70, 1999 Edition. This violation affects 1 of 12 smoke compartments.

Survey findings include:
On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the fire alarm system in the mobile MRI suite docked to the building does not appear to be connected to the main building fire alarm system.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to install the sprinkler system in accordance with NFPA 13, 1999 Edition. This violation affects 6 of 12 smoke compartments.

Survey findings include:
On 5-23-13 at approximately 10:14 AM, it was revealed by observation that there are quick response sprinklers installed adjacent to standard response sprinklers in the same area without being separated. This was observed in the maintenance shop.

On 5-23-13 at approximately 11:38 AM, it was revealed by observation that there is a closet that is not sprinklered. This was observed in the closet of room 3-122.

On 5-24-13 at approximately 10:40 AM, it was revealed by observation that there is an obstruction to the sprinkler that creates an unsprinklered area. This was observed in an alcove at the main elevators on the 2nd floor. NFPA 13-1999 Edition, 5-6.5.1.2

On 5-24-13 at approximately 11:40 AM, it was revealed by observation that the ceiling is being supported by the sprinkler system. This was observed above the PACU ceiling. NFPA 13-1999ed. 6-1.1.5

On 5-24-13 at approximately 1:20 PM, it was revealed by observation that a wall is obstructing the sprinkler creating an unsprinklered area. This was observed in the room across from the lab entrance.

On 5-24-13 at approximately 1:22 PM, it was revealed by observation that the mobile MRI suite docked to the building does not appear to be protected with a suppression system. This suite is open to the building. Patient care is being performed in the MRI suite.

On 5-28-13 at approximately 3:45 PM, it was revealed by observation that there are nonsystem components (wires) attached to the sprinkler system. This was observed in materials management.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the sprinkler system in a reliable operating condition. This affects 12 of 12 smoke compartments.

Survey findings include:

On 5-28-2013 at approximately 3:34 PM, it was revealed by observation that an escutcheon is missing. This was observed in the EMS transport room.

On 5-28-2013 at approximately 3:44 PM, it was revealed by observation that there is no signage nor documentation that the gauges located on the fire pump have been replaced or calibrated within 5 years. NFPA 25-1997 2-3.2

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the hood suppression system in a reliable operating condition. This affects 1 of 12 smoke compartments.

Survey findings include:
On 5-28-2013 at approximately 1:51 PM, it was revealed by observation that the hydrostatic date on the suppression bottles were greater than 12 years. This was observed in the kitchen hood system. NFPA 96-1998 7-2.2.1, NFPA 17A-1998 5-5

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the location of soiled linen receptacles greater than 32 gallons in a hazardous area. This violation affected 1 of 12 smoke compartments.

Survey findings include:

On 5-24-2013 at approximately 2:02 PM, it was revealed by observation that there were soiled linen receptacles over 32 gallons left unattended without being located in a protected hazardous area. This was observed in room 1-335.

The Maintenance Lead confirmed this evidence by observation and interview.

Based on observation, it was revealed that the facility failed to maintain the electrical system in accordance with NFPA 70. This violation affects 1 of 12 smoke compartments.

Survey findings include:

On 5-23-2013 at approximately 11:23 AM, it was revealed by observation that there is an unfused multiplug being used. This was observed in the conference room on 3rd floor. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 1:55 PM, it was revealed by observation that there is a listed medical device plugged into a non medical listed relocatable power tap. This was observed in 2-505. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 1:57 PM, it was revealed by observation that there is a listed medical device plugged into a non medical listed relocatable power tap. This was observed in 2-509. NFPA 70-1999 art.110-3(b)

On 5-23-2013 at approximately 2:11 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in 2-506. NFPA 70-1999 art.110-3(b)

On 5-24-2013 at approximately 10:35 AM, it was revealed by observation that an extension cord is being used as permanent wiring. This was observed in the lobby. NFPA 70-1999 art.400-8

On 5-24-2013 at approximately 11:45 AM, it was revealed by observation that an extension cord is being used as permanent wiring. This was observed in 2-209. NFPA 70-1999 art.400-8

On 5-24-2013 at approximately 1:54 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in the room across from the lab entrance. NFPA 70-1999 art.110-3(b)

On 5-24-2013 at approximately 2:34 PM, it was revealed by observation that there is a listed medical device plugged into a non-medical listed relocatable power tap. This was observed in room 1-109. NFPA 70-1999 art.110-3(b)

On 5-28-2013 at approximately 2:50 PM, it was revealed by observation that there is a damaged plug. This was observed in the PT room on the upper body cycle.

The Maintenance Lead confirmed this evidence by observation and interview.