HospitalInspections.org

Based on observation and interview, the facility failed to separate the ambulatory surgical center from the business occupancy in accordance with LCS (2000) Section 19.1.1.4.1. This deficienct practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the wall separating the Sports Medicine Surgery Center from the rest of the building is not 1-hour fire rated. The door leading into the Sports Medicine Surgery Center is also not fire rated or positively latching.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the doors leading from the hospital into the KE Building are only 45-minute fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The door gap leading from the pediatric ambulance garage and the east building corridor has a gap exceeding 1/8",
2. The east tunnel door does not latch,
3. The 2-hour separation between the hospital and professional building only has a 45-minute fire door.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the waiting rooms near rooms 2-342 and 2-319 did not have smoke detectors present.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the third floor east operating room pharmacy has a dutch door that does not latch together or self-close.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that in room 324, there is a linen chute that does not self-close and several floor/ceiling penetrations. The door leading into the room is only 20-minute fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door leading into the 2-hour vertical shaft for room 2-103 was not fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that there is a floor penetration in the west basement chute room that is not properly firestopped.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observations and interview, the facility has failed to meet the requirements of NFPA 101, 2000 Edition Sections 19.2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door leading into the basement linen chute located in the east building was held open preventing it from closing.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and staff interview, the facility failed to maintain the smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3. The deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that there are penetrations above the ceiling near room F270-01 that are not properly firestopped.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the doors for rooms 119, 139 and clean storage are not fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The door leading into room 2-518 was blocked open,
2. The fire shutter window for room 1-420 was blocked open and does not close upon the activation of the fire alarm system.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The doors to rooms MB-47, MB-203, MB-241, MB-307, F17A, F92 did not self-close,
2. Room F571 has a penetration that is not properly firestopped.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, fire drills were conducted in the north building behavioral units. During the fire drills, observation revealed that:

1. There were no manual deactivation devices present that would unlock all of the doors simultaneously,
2. That when the fire alarm activation in one of the units, the staff could not unlock the doors to the adjoining units using the normal function of the locks.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to follow established policies and procedures for the use of elecrosurgical pencils. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, Minnesota Department of Health staff witnessed the surgeon in the operating room placing the electrosurgical pencil on the surgical draping after use and not returning it to the holster. The Fairview Fire Safety In The OR Policy specifically states that the electrosurgical pencil is to be returned to the holster after use.

This deficient practice was verified by the surgical staff and Minnesota Department of Health staff at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that in the Tube Room, 1-570, the room is protected by a fire sprinkler system but the office built within is not protected.

Theis deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The medical records room located in the west building on the sixth floor has storage within 18" of the fire sprinkler heads,
2. The detached building housing the generator has a pre-action fire sprinkler system that was tagged as last being inspected on 11/10/2009.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility's kitchen cooking equipment is not protected in accordance with Sec. 9.2.3 and NFPA 10. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed the the main kitchen cooking hood is protected by an Ansul Piranha System but that not all of the cooking equipment located underneath the kitchen hood were protected by this system.

This deficient practice was verified by the Hospital Maintenance Engineering Staff the time of the inspection.

Based on observations, the facility has a soiled linen chute that does not meet the requirements of Sections 19.5.4, 9.5 and 8.4 and NFPA 82. This deficient practice could affect all patients.

Findings include:
On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door to room M250 does not have a fire rated label.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of staff in an emergency situation.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed chairs, fitness equipment, desks and other furnishings located in the corridors throughout the facility.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observations, the facility has compressed gas cylinders that are not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. Signs denoting oxygen storage for rooms 2-231, 2-434 and 2-478 are missing,
2. The central medgas storage room cylinders are not properly chained and nested together.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the vacuum gauges for the operating rooms in the Sports Medicine Surgery Center are either missing or not properly calibrated.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the ambulatory surgical center from the business occupancy in accordance with LCS (2000) Section 19.1.1.4.1. This deficienct practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the wall separating the Sports Medicine Surgery Center from the rest of the building is not 1-hour fire rated. The door leading into the Sports Medicine Surgery Center is also not fire rated or positively latching.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the doors leading from the hospital into the KE Building are only 45-minute fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The door gap leading from the pediatric ambulance garage and the east building corridor has a gap exceeding 1/8",
2. The east tunnel door does not latch,
3. The 2-hour separation between the hospital and professional building only has a 45-minute fire door.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the waiting rooms near rooms 2-342 and 2-319 did not have smoke detectors present.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the third floor east operating room pharmacy has a dutch door that does not latch together or self-close.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that in room 324, there is a linen chute that does not self-close and several floor/ceiling penetrations. The door leading into the room is only 20-minute fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door leading into the 2-hour vertical shaft for room 2-103 was not fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that there is a floor penetration in the west basement chute room that is not properly firestopped.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observations and interview, the facility has failed to meet the requirements of NFPA 101, 2000 Edition Sections 19.2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door leading into the basement linen chute located in the east building was held open preventing it from closing.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and staff interview, the facility failed to maintain the smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3. The deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that there are penetrations above the ceiling near room F270-01 that are not properly firestopped.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that the doors for rooms 119, 139 and clean storage are not fire rated.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The door leading into room 2-518 was blocked open,
2. The fire shutter window for room 1-420 was blocked open and does not close upon the activation of the fire alarm system.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The doors to rooms MB-47, MB-203, MB-241, MB-307, F17A, F92 did not self-close,
2. Room F571 has a penetration that is not properly firestopped.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, fire drills were conducted in the north building behavioral units. During the fire drills, observation revealed that:

1. There were no manual deactivation devices present that would unlock all of the doors simultaneously,
2. That when the fire alarm activation in one of the units, the staff could not unlock the doors to the adjoining units using the normal function of the locks.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to follow established policies and procedures for the use of elecrosurgical pencils. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, Minnesota Department of Health staff witnessed the surgeon in the operating room placing the electrosurgical pencil on the surgical draping after use and not returning it to the holster. The Fairview Fire Safety In The OR Policy specifically states that the electrosurgical pencil is to be returned to the holster after use.

This deficient practice was verified by the surgical staff and Minnesota Department of Health staff at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that in the Tube Room, 1-570, the room is protected by a fire sprinkler system but the office built within is not protected.

Theis deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice could affect all patients.

Findings include:

During facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. The medical records room located in the west building on the sixth floor has storage within 18" of the fire sprinkler heads,
2. The detached building housing the generator has a pre-action fire sprinkler system that was tagged as last being inspected on 11/10/2009.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility's kitchen cooking equipment is not protected in accordance with Sec. 9.2.3 and NFPA 10. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed the the main kitchen cooking hood is protected by an Ansul Piranha System but that not all of the cooking equipment located underneath the kitchen hood were protected by this system.

This deficient practice was verified by the Hospital Maintenance Engineering Staff the time of the inspection.

Based on observations, the facility has a soiled linen chute that does not meet the requirements of Sections 19.5.4, 9.5 and 8.4 and NFPA 82. This deficient practice could affect all patients.

Findings include:
On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the door to room M250 does not have a fire rated label.

This deficient practice was verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of staff in an emergency situation.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed chairs, fitness equipment, desks and other furnishings located in the corridors throughout the facility.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observations, the facility has compressed gas cylinders that are not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that:

1. Signs denoting oxygen storage for rooms 2-231, 2-434 and 2-478 are missing,
2. The central medgas storage room cylinders are not properly chained and nested together.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 09/24/2012 and 09/28/2012, observation revealed that the vacuum gauges for the operating rooms in the Sports Medicine Surgery Center are either missing or not properly calibrated.

These deficient practices were verified by the Hospital Maintenance Engineering Staff at the time of the inspection.