HospitalInspections.org

Based on observation, on January 12, 2010 at approximately 11:45am onward, there are holes in the corridor wall in the following areas:

a. communication closet near medical surgery - emt conduit is not sealed above the ceiling

b. communication room near room 2107

Based on observation, on January 12, 2010 at approximately 11:45am onward, there are latching hardware devices installed greater than forty-eight inches above the finished floor in the following areas:

a. Behavioral health - observation room

b. Same day surgery - exit access door from the suite

Based on observation, on January 12, 2010 at approximately 11:45am onward, hazardous areas in the following areas are incomplete:

a. central supply room near sterile room - duct penetrations of enclosure walls are not equipped with fire dampers.

b. pantry(day stock in kitchen area) - room is greater than one hundred square feet without minimum one hour rated enclosure. Fire doors are not three quarter hour rated with listed hardware.

c. elevator equipment room serving elevators #1, and #2 - large gaps around ceiling fire damper assembly.

A. Based on observation, on January 12, 2010 at approximately 11:45am onward, there are incomplete special locking arrangements used in the following areas:

a. Labor/Delivery Unit - locks are not equipped with master release switch and release switches not greater than three from the exit access doors as stated in required codes. Locks did release during activation of the facility fire alarm system.

Note: The facility is not equipped with a complete sprinkler system or detection system as required by codes when utilizing special locking arrangements.

B. Based on observation, on January 12, 2010 at approximately 11:45am onward, there is no guardrail between the required exit discharge path and the loading dock area.

Based on observation, on January 13, 2010 at approximately 9:45am onward, fire doors in the following areas are noncompliant:

a. east stairway near elevator - door will not self-close and latch.

b. first floor exit passageway - doors are blocked open by kickstops and wedges.

Based on observation, on January 12, 2010 at approximately 11:45am onward, the exit discharge lighting for stairway near administration could not be verified as wired to the Life Safety Branch of the essential electrical system. Existing lights are unacceptably wired to a time clock.

Based on observation, on January 13, 2010 at approximately 9:45am onward, there are no unitary lights in the corridors serving the cardiac rehabilitation unit.

Based on observation, on January 12, 2010 at approximately 11:45am onward, oxygen bank areas are exposed to extremes of weather without canopies.

Based on observation, on January 13, 2010 at approximately 9:30am onward, the relative humidity monitors in operating room #2, and #5 are indicating humidity levels below 35%. Humidity levels in operating room #2, and #5 are 16% and 25% respectively.

Based on observation, on January 12, 2010 at approximately 11:45am onward, the essential electrical system is incomplete due to the following:

a. generator annunciator panel at ER reception area - panel doesn't monitor all malfunctions of the emergency generator as required by NFPA 99. Panel did not indicate emergency power system supplying load during loss of normal power to the Life Safety Branch automatic transfer switch.

b. lack of task lighting with battery backup at the generator set locations.

Based on observation, on January 12, 2010 at approximately 11:45am onward, electrical systems in the following areas are incomplete:

a. operating room #2 - surgical light contains armored cable that does not terminate in a junction box required to maintain continuity of grounding system.

b. central supply room beside sterile room - storage within three feet of transformer and electrical switches.

c. occupational health - patient room 2118 is utilizing a multioutlet power tap.

Based on observation, on January 12, 2010 at approximately 11:45am onward, there are holes in the corridor wall in the following areas:

a. communication closet near medical surgery - emt conduit is not sealed above the ceiling

b. communication room near room 2107

Based on observation, on January 12, 2010 at approximately 11:45am onward, there are latching hardware devices installed greater than forty-eight inches above the finished floor in the following areas:

a. Behavioral health - observation room

b. Same day surgery - exit access door from the suite

Based on observation, on January 12, 2010 at approximately 11:45am onward, hazardous areas in the following areas are incomplete:

a. central supply room near sterile room - duct penetrations of enclosure walls are not equipped with fire dampers.

b. pantry(day stock in kitchen area) - room is greater than one hundred square feet without minimum one hour rated enclosure. Fire doors are not three quarter hour rated with listed hardware.

c. elevator equipment room serving elevators #1, and #2 - large gaps around ceiling fire damper assembly.

A. Based on observation, on January 12, 2010 at approximately 11:45am onward, there are incomplete special locking arrangements used in the following areas:

a. Labor/Delivery Unit - locks are not equipped with master release switch and release switches not greater than three from the exit access doors as stated in required codes. Locks did release during activation of the facility fire alarm system.

Note: The facility is not equipped with a complete sprinkler system or detection system as required by codes when utilizing special locking arrangements.

B. Based on observation, on January 12, 2010 at approximately 11:45am onward, there is no guardrail between the required exit discharge path and the loading dock area.

Based on observation, on January 13, 2010 at approximately 9:45am onward, fire doors in the following areas are noncompliant:

a. east stairway near elevator - door will not self-close and latch.

b. first floor exit passageway - doors are blocked open by kickstops and wedges.

Based on observation, on January 12, 2010 at approximately 11:45am onward, the exit discharge lighting for stairway near administration could not be verified as wired to the Life Safety Branch of the essential electrical system. Existing lights are unacceptably wired to a time clock.

Based on observation, on January 13, 2010 at approximately 9:45am onward, there are no unitary lights in the corridors serving the cardiac rehabilitation unit.

Based on observation, on January 12, 2010 at approximately 11:45am onward, oxygen bank areas are exposed to extremes of weather without canopies.

Based on observation, on January 13, 2010 at approximately 9:30am onward, the relative humidity monitors in operating room #2, and #5 are indicating humidity levels below 35%. Humidity levels in operating room #2, and #5 are 16% and 25% respectively.

Based on observation, on January 12, 2010 at approximately 11:45am onward, the essential electrical system is incomplete due to the following:

a. generator annunciator panel at ER reception area - panel doesn't monitor all malfunctions of the emergency generator as required by NFPA 99. Panel did not indicate emergency power system supplying load during loss of normal power to the Life Safety Branch automatic transfer switch.

b. lack of task lighting with battery backup at the generator set locations.

Based on observation, on January 12, 2010 at approximately 11:45am onward, electrical systems in the following areas are incomplete:

a. operating room #2 - surgical light contains armored cable that does not terminate in a junction box required to maintain continuity of grounding system.

b. central supply room beside sterile room - storage within three feet of transformer and electrical switches.

c. occupational health - patient room 2118 is utilizing a multioutlet power tap.