HospitalInspections.org

Based on observation and staff interview, the facility did not ensure that the existing one-hour fire protection materials were maintained to meet the previously approved construction classification type IIA (111) protected steel frame as required per NFPA 101-Life Safety Code, LSC 18.1.6.2. This deficient practice may affect all patients and an unknown number of staff and visitors.

Findings include:

1. On 04/26/2022 at 10:22 am, observation in the IDF Telecom Room revealed that beam clamps mounted on the structural support were not fireproofed by an approved method, and fire-proof insulation had been removed to install them.

2. On 04/26/2022 at 10:22 am, observation at the ambulance entrance room #1255 revealed that a 3-inch PVC plastic pipe cut into the steel beam's fire-proof insulation reducing the thickness of the insulation.

3. On 04/27/2022 at 11:27 am, observation in the Penthouse revealed that except for grounding clamps all other beam clamps mounted on the structural supports were not fireproofed by an approved method, and fire-proof insulation had been removed to install them.

The deficient practices were acknowledged by the Staff W, Staff X and Staff Y at the time of discovery.

Based on observation and staff interview, the facility did not ensure that egress corridors are continuously maintained free of materials or devices that obstruct egress as required per NFPA 101 (2012 edition) sections 18.2.1, 7.1.10.2.1 & 7.2.1.6.1.1 (3). The deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings Include:

On 04/26/2022 at 03:39 pm, observation revealed that the double exit door on 2nd floor, near patient room #2115, has an exit sign mounted on the ceiling and panic hardware, but door is locked.

The deficient practice w coasnfirmed at the time of discovery by a concurrent interview with Staff W and Staff X and Staff Y.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.2.1.5.1, 7.2.1.5.10, & 7.2.1.5.10.2. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

1. On 04/26/2022 at 11:28 am, observation revealed that corridor doors outside of examination room #4 (HIL 1256) had a "push to exit" button to unlock the magnetic lock on the door therefore requiring two operations to unlock the doors.

2. On 04/27/2022 at 12:10 pm, observation revealed that the steel egress exit door in the penthouse to the roof deck locked after exiting to the roof. Any person lacking a key would then be trapped on the roof.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff W, Staff X and Staff Y.

Based on observation and staff interview, the facility did not maintain clear access to exits free of obstructions in accordance with NFPA 101 18.2.1, 7.1.10.2.1. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings Include:

On 04/26/2022 at 11:44 am, observation in the first-floor center smoke compartment north exit revealed a highchair obstructing access to the exit.

This deficient practice was confirmed by Staff W and Staff X at the time of discovery.

Based on observation and interview, the facility did not provide a level walking surface in the path of egress in accordance with the requirements of NFPA 101, 2012 edition, Sections 18.2.7, 7.1.6.2, 7.1.6.3, 7.1.7, 7.7.1, .2.1.3.1 & 7.7.2 (3). These deficient practices could affect all residents and an undetermined number of staff and visitors.

Findings Include:

1. On 04/26/2022 at 09:32 am, observation in the north stairwell on the first floor revealed that the exit did not terminate at an exterior exit discharge or public way and this interior exit discharge was not readily visible and identifiable from the point of discharge from the exit.

2. On 04/27/2022 at 11:45 am, observation in the penthouse revealed a difference in height of approximately 24 inches between the inside floor of the penthouse and the exit door threshold on to the roof and a 6 inch drop to the outside. Walking surfaces must be level on either side of the door.

These conditions were confirmed at the time of discovery by an interview with Staff W, Staff X and Staff Y.

Based on observation and staff interview, the facility did not provide exit and directional signs displayed in accordance with NFPA 101 (2012) sections 18.2.10.1 & 7.10. This deficient practice could affect all patients an undetermined number of staff and visitors.
Findings include:

1. On 04/26/2022 at 11:54 am, observation of the double corridor doors next to family lounge room #1339 revealed no exit signs above the doors from both directions.

2. On 04/27/2022 at 03:25 pm, observation of the horizontal sliding fire door assembly "WON door" on the second floor revealed that there was no exit sign for the WON door's exit access door on either side of the door indicating the location of the exit when the WON door is closed.

These deficient practices were confirmed at the time of discovery by concurrent interview with Staff W and Staff X.

Based on observation and interview, the facility failed to maintain all framing of interior walls and partitions of non-combustible construction in accordance with the requirements of NFPA 101 2012 edition, section 18.3.2.1, 8.7.1.1 18.2.1.8, 8.4,1.6.3. This deficient practice could affect all patients in the building.

Findings include:

On 04/26/2022 at 10:29 am, observation revealed an open sliding window approximately 2 foot X 3 foot in Environmental Services Office/Storage. No windows are permitted in storage rooms greater than 100 square feet containing combustible material.

The deficient practice was confirmed by Staff W and Staff X at the time of discovery.

Based on observation and interview, the facility failed to maintain the fire alarm system as required by NFPA 101 (2012 edition), 18.3.4, 18.3.6.1 and 9.6 and NFPA 72 (2010 edition), 8.6, and 17.7.5.6. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 04/26/2022 at 09:30 am, observation revealed a missing smoke detector at the top of the north stairwell required for held open stairwell door.
2. On 04/26/2022 at 09:30 am, observation revealed a missing smoke detector in the cafeteria on the first floor which is open to the corridor required the area open to a corridor.
3. On 04/27/2022 at 01:18 pm, observation revealed smoke barrier door #1299F which was held open by a release devise tied to the fire alarm system, did not have a smoke detector within 5 feet of door on the side of doors that have the 24-inch door header wall.
4. On 04/27/2022 at 02:19 pm, observation revealed a missing fire alarm indicating device (strobe) in the Hospitalist Room #1335 to notify staff.
5. On 04/27/2022 at 02:20 pm, observation revealed a missing fire alarm indicating device (strobe) in the Social Worker Office #1334 to notify staff.
6. On 04/27/2022 at 02:53 pm, observation revealed a missing fire alarm indicating device (strobe) in the On Call room #1305 to notify staff.
7. On 04/27/2022 at 02:54 pm, observation revealed a missing fire alarm indicating device (strobe) in the On Call room #1306 to notify staff.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 18.3.5, and NFPA 13 (2010 edition) sections 8.1, 8.5.5.2.1, 8.7 & 8.10.7.3.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 04/26/2022 at 08:32 AM, observation in the north stairwell revealed that sprinkler coverage under the stair did not have proper water spray coverage. The head under the 'lower' stair had the head upright instead of the angle of the stair. The area by the door to the Atrium, the sprinkler was blocked by the upper stairs and the other side wall sprinkler was too far away for coverage.

2. On 04/26/2022 at 09:56 AM, observation in the kitchen's cooler revealed that there was no sprinkler head in the cooler, but there was a sprinkler head in the adjacent freezer.

3. On 04/26/2022 at 03:52 PM, observation in the open area outside of horizontal sliding fire door on second floor revealed that a sprinkler head was blocked by an exit sign mounted on the ceiling.

4. On 04/27/2022 at 02:59 PM, observation on the first floor in the CT room connected to 1244A storage room revealed one sprinkler head too close to an obstruction caused by equipment rails mounted on the ceiling.

5. On 04/27/2022 at 04:32 PM, observation on the first floor in the x-ray room revealed that all 4 heads were too close to obstructions caused by equipment tracks mounted on the ceiling.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and staff interview, the facility did not ensure that corridor doors in corridor walls in accordance with NFPA 101 (2012 edition), 18.3.6.3.5. These deficient practices could affect an undetermined number of patients, outpatients, staff and visitors.

Findings include:

1. On 04/26/2022 at 09:20 am, observation on the first floor revealed that corridor doors to conference room A3 did not latch.

2. On 04/26/2022 at 09:21 am, observation on the first floor revealed that corridor doors to conference room A2 did not close properly. The door sometimes required additional pushing to close because it was dragging on the floor.

3. On 04/26/2022 at 03:00 pm, observation on the first-floor CT room with storage room #1244A attached the double corridor door coordination hangs up and doors will not latch.

4. On 04/26/2022 at 03:13 pm, observation on the first-floor electric room # HIL 1261 the left door of the double doors to the electric room opens outward 90 degrees blocking corridor. Doors that open to corridor must swing 180 degrees.

5. On 04/26/2022 at 03:14 pm, observation on the first-floor electric room # HIL 1261 the right door of the double doors to the electric room opens outward 90 degrees blocking corridor and interfering with the operation of the adjacent smoke doors. Doors that open to corridor must swing 180 degrees.

These deficiencies were confirmed at the time of discovery by an interview with Staff W & Staff X.

Based on observation and staff interview, the facility did not ensure that transfer grilles in doors located in corridor walls were in accordance with NFPA 101 (2012 edition), 18.3.6.4.1 . The deficient practice could affect an undetermined number of patients, staff and visitors.

Findings include:

On 04/26/2022 at 08:30 am, observation in the main lobby area's elevator machine room revealed an approximate 18" x 18" transfer grille in the corridor door to the machine room. Room requires a 1 hr. fire barrier wall and 3/4 hour fire rated door. Air transfer grills are not permitted in corridor doors.

The deficiency was confirmed at the time of discovery by an interview with Staff W & Staff X.

Based on observation and interview, the facility did not maintain smoke and fire barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.7, 18.3.7.1, 18.3.7.3, 8.5, 8.5.2 and 8.5.6. The deficient practices could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 04/26/2022 at 10:20 am, observation in the IDF telecom room revealed 9 open conduits that penetrated the wall whose ends were not properly fire stopped.

2. On 04/26/2022 at 11:01 am, observation in room # 1117 revealed a pipe penetration in the 1-hour fire rated wall was not properly fire stopped.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications, NFPA 101 (2012) 18.5.2.1 & 9.2 and NFPA 90A (2012) 4.3.15.1 with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. The deficiencies had the potential to affect all patients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/26/2022 at 11:56 am, observation revealed on first floor two patient rooms next to the two patient rooms under construction, that airflow between the corridor and these rooms was not neutral. There was supply air, but no return air. Return grill had been taped over. A HEPA filter fan unit which penetrated the exterior wall was present but was not running.
2. On 04/27/2022 at 01:19 pm, observation outside of sterilizer room number 2150 (dirty room) revealed that air flows under a positive pressure into the hallway from under the door.
3. On 04/27/2022 at 03:15 pm, observation outside of the decontamination room on the first- floor east smoke compartment revealed that air flows under a positive pressure into the hallway from under the door.
4. On 04/27/2022 at 03:19 pm, observation outside of the endoscopy scope cleaning room on second floor surgery suite revealed that air flows under a positive pressure into the hallway from under the door.
5. On 04/26/2022 at 11:56 am, observation revealed on first floor two patient rooms under construction, that the design airflow between the corridor and these rooms was not slightly negative as required for a negative pressure room. The design called of 10 air changes per hour of exhaust but additional supply air was not being supplied. The additional 400 CFM or more air was coming from the corridor. Two other patient rooms in the clinic area are also under construction with no additional source of supply air (upper floor). Two additional patient rooms are planned but not under construction (Lower floor).

These conditions were confirmed at the time of discovery by an interview with Staff W and Staff X.

Based on staff interview, the facility failed to have one staff properly instructed and informed of staff response in the event of fire in accordance with the NFPA 101 2012 edition 18.7.1, 18.7.1.8 and 18.7.2.3. This deficiency had a potential to affect patients, staff and visitors in the facility.

Findings include

On 04/26/22 at 10:41 am, interview with Staff Z, a cook in the kitchen, revealed that the staff Z was not aware of the pull station for the activation of the hood fire suppression system. Staff Z believed it was the pull station for the fire alarm. After asking what she would do if a fire was on the stove, staff Z indicated they would pull the fire alarm. Staff Z was not certain of the next actions to take. Asked about the fire extinguisher in the kitchen, staff Z indicated the type K fire extinguisher could be used on a fire in the kitchen. The fire extinguisher is a type K, for grease fires, and should not be used on other types of fire.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and interview, the facility failed to store soiled linen and trash receptacles in accordance with the requirements of NFPA 101 (2012 edition), Sections 18.7.5.7.1. This deficient practice could affect all patients, staff and visitors.

Findings include:

1. On 04/26/2022 at 10:04 am, observation in the cafeteria dishwashing area revealed two 32-gallon trash containers and one 13-gallon container next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.
2. On 04/26/2022 at 10:04 am, observation in the Exam Room #6 HIL 1251 revealed two 32-gallon trash roller bin, one gray bin and one bio-hazard bin next to each other. This exceeds the limit of 32 gallons in a 64 square foot area.
3. On 04/27/2022 at 04:27 pm, observation in the Lab revealed 5 waste containers that exceed the 32-gallon waste container in 64 square feet requirement.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff W and Staff X

Based on record review, observation and staff interview, the facility did not provide a smoke evacuation system in the atrium as required by the code; in accordance with NFPA 101 (2012 edition) sections 18.3.1, sections 8.6.7 (5). This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 04/26/2022 at 08:30 am, observation and review of the construction plans of the atrium revealed that there were no exhaust ducts in the ceiling of the atrium. No smoke removal system was observed.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and interview, the facility did not provide the required battery powered emergency illumination equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 18.2.9.1, 18.2.9.2 and 7.9.3 and NFPA 99 (2021 edition) 6.3.2.2.11. The facility failed to properly provide Ground-Fault Circuit-Interrupter (GFCI) protection in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70, 2011 Edition, Sections 210.8 (B) (5). This deficient practice could potentially affect an undermined number of patients,staff and visitors.

Findings include:

1. On 04/27/2022 at 03:07 pm, observation revealed that there was no battery-powered emergency light in the #2 procedure room. General anesthesia is administered at this location.
2. On 04/26/2022 at 10:01 am, observation in the kitchen on the first floor found a duplex outlet that was not a GFCI located near the oven and within 6 feet of a sink. Outlet was labeled NAL A1-1. Outlet might be electrically protected by another GFCI, but it must be labeled as such.
3. On 04/26/2022 at 10:03 am, observation in the kitchen on the first floor found duplex outlet labeled 1 NK1 1A-37 near the vegetable cleaning sink was not labeled as GFCI.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.

Based on observation and interview, the facility failed to maintain a clear working space in front of electrical disconnects in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 , 110.34 & 408.4(A). The deficient practice could affect an undetermined number of patients, staff and visitors

Findings include:

1. On 04/26/2022 at 10:06 am, observation in the kitchen dishwashing area on first floor revealed that access to the two electrical disconnects above and on either side of the dishwasher was less than the minimum required 3'-0" clearance due to dishwashing equipment located directly below.

2. On 04/27/2022 at 02:50 pm, observation in the Operating Room revealed that the breaker identification was missing in the secondary panel.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff W and Staff X.