HospitalInspections.org

Based on Document review and Interview the facility failed to provide information for Subsistence needs for staff and patients in one of one Emergency Preparedness plan.

Findings include:

Document review on November 29, 2017 at 1:30 pm revealed that the facility did not include information about extinguishing systems for loss of water in an emergency situation.

Interview with Emergency Preparedness 1 (EP1) on November 29, 2017 confirmed the information about not preparing for the extinguishing systems in case of loss of water.

Based on document review and interview facility failed to provide arrangements with other facilities in one on one emergency plans.

Findings include:

Based on document review and interview, on November 29, 2017 at 2:00 pm, the facility was not specific to name outside facilities with whom they would transfer patients, staff and support help to in case of a full or partial evacuation.

Interview with EP1 on November 29, 2017 at 2:00 pm confirmed the lack of specific information in case of transferring patients.

Based on observation and interview the facility failed to ensure the division of buildings construction types in one of two components.

Findings include:

Observation on November 29, 2017, at 10:30 a.m., found that the right leaf of the two hour building separation door, did not latch in its frame with a self closing device.

Interview with Maintenance man on November 29, 2017, at 10:30 a.m., confirmed the two hour building separation door did not latch in its frame.

Based on document review and interview, the facility failed to maintain building construction type affecting three of three building levels.

Findings include:

1. Document review on November 29, 2017, at 9:30 a.m., revealed the last four-year fusible link fire damper inspection (October 20, 2017), noted four fire dampers failed.

Interview with the Director of Plant Operations on November 29, 2017, at 9:30 a.m., confirmed the above fusible link fire damper report noted deficiencies.

Based on document review, observation and interview, the facility failed to maintain building construction type affecting five of five building levels.

Findings include:

1. Document review on November 29, 2017, at 9:30 a.m., revealed the last four-year fusible link fire damper inspection (October 20, 2017) noted four fire dampers failed.

Interview with the Director of Plant Operations on November 29, 2017, at 9:30 a.m., confirmed the above fusible link fire damper report noted deficiencies.

2. Observation on November 29, 2017, between 11:05 a.m. and 11:10 a.m., revealed the third floor had structural steel beams that were missing fire retardant coating at the following locations:
A. (11:05 a.m.) ACE-3, under electrical junction box.
B. (11:10 a.m.) Outside patient room 300 in the corridor, near corridor wall.

Interview with the Director of Plant Operations on November 29, 2017, at 11:10 a.m., confirmed the above structural steel beams lacked fire retardant coating.

Based on observation and interview, the facility failed to maintain vertical openings at two of three stair towers.

Findings include:

1. Observation on November 29, 2017, at 11:45 a.m., revealed the first floor stair tower # 1 wall, within the Medical Education room, had no fire-rated product used that would prevent the fire wool from falling out of the flutes in the corrugated decking.

Interview with the Director of Plant Operations on November 29, 2017, at 11:45 a.m., confirmed the above stair tower wall was not properly sealed.

2. Observation on November 29, 2017, at 2:05 p.m., revealed the first floor stair tower #3 (near service elevator) wall, was unsealed where the wall meets the structural steel beam.

Interview with the Director of Plant Operations on November 29, 2017, at 2:05 p.m., confirmed the above stair tower was not properly sealed.

Based on observation and interview, the facility failed to maintain hazardous areas in two of seven smoke compartments.

Findings include:

1. Observation on November 29, 2017, at 1:20 p.m., revealed the first floor Kitchen store room door, was tied in the open position, and would not close with the self-closure.

Interview with the Director of Plant Operations on November 29, 2017, at 1:20 p.m., confirmed the above hazardous area door lacked positive latching due to an unauthorized hold-open.

2. Observation on November 30, 2017, at 8:45 a.m., revealed the first floor Medical Records area, had two inside fire-barrier doors (with offices) that were wedged open.

Interview with the Director of Plant Operations on November 30, 2017, at 8:45 a.m., confirmed the above hazardous area door lacked positive latching due to unauthorized hold-opens.

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

Findings include:

1. Observation on November 29, 2017, at 11:35 a.m., revealed the first floor Labor and Delivery suite soiled workroom door lacked positive latching with the self-closure.

Interview with the Director of Plant Operations on November 29, 2017, at 11:35 a.m., confirmed the above hazardous area door lacked positive latching.

Based on document review and interview, the facility failed to maintain cooking facilities in one of one Main Kitchen.

Findings include:

1. Document review on November 29, 2017, at 8:30 a.m., revealed the last kitchen hood suppression inspection (August 17, 2017) noted a necessary upgrade in order to be compliant with Life Safety. The facility installed a new system (September 5, 2017) without State Plan Review approved drawings, and an occupancy from the Division of Life Safety.

Interview with the Director of Plant Operations on November 29, 2017, at 8:30 a.m., confirmed the new kitchen suppression system was not approved through State Plan Review, or the Division of Life Safety.

2. Interview with one of one Main Kitchen staff on November 29, 2017, at 1:25 p.m., revealed the staff member was unaware of the location for the manual pull activation of the hood suppression system.

Interview with the Director of Plant Operations on November 29, 2017, at 1:25 p.m., confirmed the Kitchen staff shall be inserviced as to the location of the manual activation for the hood suppression system.

Based on document review and interview, the facility failed to maintain cooking facilities in one of one Snack Bar.

Findings include:

1. Document review on November 29, 2017, at 8:30 a.m., revealed the last kitchen hood suppression inspection (August 17, 2017) noted a necessary upgrade in order to be compliant with Life Safety. The facility installed a new system (September 5, 2017) without State Plan Review approved drawings, and an occupancy from the Division of Life Safety.

Interview with the Director of Plant Operations on November 29, 2017, at 8:30 a.m., confirmed the new kitchen suppression system was not approved through State Plan Review, or the Division of Life Safety.

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

Findings include:

1. Observation on November 29, 2017, at 1:35 p.m., revealed the first floor Light Bulb room ceiling tile was removed. This condition may delay activation of the closest fire sprinkler.

Interview with the Director of Plant Operations on November 29, 2017, at 1:35 p.m., confirmed the above room had ceiling tile removed, which may delay activation of the closest fire sprinkler.

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

Findings include:

Observation on November 29, 2017, at 10:00 a.m., revealed a large bundle of data wire was draped over the sprinkler piping, on the the third floor above Conference Room B door in the corridor.

Interview with the Maintenance Personnel on November 29, 2017, at 10:02 a.m., confirmed the large bundle of data wire laying the sprinkler piping.

Based on observation and interview, the facility failed to maintain portable fire extinguishers areas in one of seven smoke compartments.

Findings include:

1. Observation on November 30, 2017, at 9:20 a.m., revealed the first floor Pharmacy fire extinguisher (near the sink) was obstructed by a large plastic container and cardboard boxes.

Interview with the Director of Plant Operations on November 30, 2017, at 9:20 a.m., confirmed the above fire extinguisher was obstructed.

Based on observation and interview, the facility failed to maintain corridor doors at one of over 100 corridor doors.

Findings include:

1. Observation on November 29, 2017, at 10:55 a.m., revealed the third floor Dictation room, across from ACE-9 had a wedge, clothing and chair, preventing door closure. Once cleared of obstructions, this door did not positively latch in the frame.

Interview with the Director of Plant Operations on November 29, 2017, at 10:55 a.m., confirmed the above corridor door lacked positive latching.

Based on observation and interview, the facility failed to maintain portable space heaters at one of one main entrance lobby.

Findings include:

1. Observation on November 29, 2017, at 11:50 a.m., revealed the first floor main entrance Lobby Information desk was utilizing a portable space heater.

Interview with the Director of Plant Operations on November 29, 2017, at 11:50 a.m., confirmed the above resident-accessible area was utilizing a portable space heater.

Based on document review and interview, the facility failed to maintain piped-in medical gas systems in all areas of the building that supply piped-in medical gas.

Findings include:

1. Document review on November 29, 2017, at 9:00 a.m., revealed the last annual medical gas inspection (July 17, 2017) noted deficiencies in the Outlet and Central Supply section of the report.

Interview with the Director of Plant Operations on November 29, 2017, at 9:00 a.m., confirmed the above medical gas inspection report noted deficiencies.

Based on document review and interview, the facility failed to maintain piped-in medical gas systems in all areas of the building that supply piped-in medical gas.

Findings include:

1. Document review on November 29, 2017, at 9:00 a.m., revealed the last annual medical gas inspection (July 17, 2017), noted deficiencies in the Outlet and Central Supply section of the report.

Interview with the Director of Plant Operations on November 29, 2017, at 9:00 a.m., confirmed the above medical gas inspection report noted deficiencies.

Based on document review, observation and interview, the facility failed to maintain piped-in medical gas systems in all areas of the building that supply piped-in medical gas.

Findings include:

1. Document review on November 29, 2017, at 9:00 a.m., revealed the last annual medical gas inspection (July 17, 2017), noted deficiencies in the Outlet and Central Supply section of the report.

Interview with the Director of Plant Operations on November 29, 2017, at 9:00 a.m., confirmed the above medical gas inspection report noted deficiencies.

2. Observation on November 30, 2017, at 10:00 a.m., revealed the first floor X-Ray department (above the ceiling tile in the back hallway), had medical gas piping labels that did not conform to the Standard Designation Colors and Operating Pressures for Gas and Vacuum Systems in NFPA 99, 2012 edition, 5.1.11.1.1.

Interview with the Director of Plant Operations on November 30, 2017, at 10:00 a.m., confirmed the above medical gas piping did not have proper labels.

Based on observation and interview, the facility failed to maintain electrical receptacles in one of one Physical Therapy department.

Findings include:

1. Observation on November 30, 2017, at 9:30 a.m., revealed the first floor Physical Therapy department, had two hydrocollators that were not plugged into a ground-fault circuit interrupter.

Interview with the Director of Plant Operations on November 30, 2017, at 9:30 a.m., confirmed the above hydrocollators were not plugged into a ground-fault circuit interrupter.

Based on document review and interview, the facility failed to maintain emergency generators for one of two emergency generators.

Findings include:

1. Document review on November 29, 2017, at 10:00 a.m., revealed the last annual emergency generator inspection of the Kohler generator (August 2, 2017) noted that action is required; the samples tested indicated moderate amount of solids, drain day tank sediment.

Interview with the Director of Plant Operations on November 29, 2017, at 10:00 a.m., confirmed the latest emergency generator report indicated the above deficiency.

Based on document review and interview, the facility failed to maintain emergency generators for one of two emergency generators.

Findings include:

1. Document review on November 29, 2017, at 10:00 a.m., revealed the last annual emergency generator inspection of the Kohler generator (August 2, 2017), noted that action is required; the samples tested indicated moderate amount of solids, drain day tank sediment.

Interview with the Director of Plant Operations on November 29, 2017, at 10:00 a.m., confirmed the latest emergency generator report indicated the above deficiency.

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

Findings include:

1. Observation on November 29, 2017, at 10:35 a.m., revealed the fourth floor office, across from patient room 414, had a refrigerator plugged into a surge protector.

Interview with the Director of Plant Operations on November 29, 2017, at 10:35 a.m., confirmed the refrigerator was not plugged directly into an electrical receptacle.

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

Findings include:

1. Observation on November 29, 2017, at 1:45 p.m., revealed the first floor Main Medical Gas storage room had the following deficiencies:
A. A louvered grill was installed within the wall.
B. Ceiling tile was removed, negating the fire rating of the room, and possibly delaying the activation of the closest fire sprinkler.
C. Empty cylinders are not separated from full cylinders, allowing for possible confusion during an emergency.

Interview with the Director of Plant Operations on November 29, 2017, at 1:45 p.m., confirmed the above deficiencies within the Main Medical Gas storage room.