HospitalInspections.org

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director;
1) Two (2) doors located in two (2) trauma rooms (#43 and #28), locate din Trauma Team 3 , contained thumb latches on one of the double doors. The doors were situation in a 70/30 format, where the larger door (the 70 door) latches into the smaller door (the 30 door). These are located in the corridor and must contain a positive latching device on the door.
Per NFPA 101, section 18.3.6.3.2
a) Room #28 in Trauma Team 3
b) Room #43 in Trauma Team 3
c) Rad 3 room in Trauma Team 1 (frame 1618)
d) Trauma room 1 (frame1615)
e) Trauma room 2 (frame 1614)
f) Trauma room 3 (frame 1632)
g) Trauma room 4 (frame 1633)
2) Door to room #3189 hcontained a large gap between the door and the door frame larger than 1/2 between the 70 door and 30 door.
3) One bed blocking door from closing in room #2607

These deficiencies effected 4 smoke compartments throughout the facility

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain the smoke barrier doors.
 
During the walk through of the facility, with the Maintenance Director, one (1) smoke wall, located at the adjacent to door #2497, contained one (1) unsealed pipe penetration without fire caulking or other approved method of maintaining the smoke rating of the wall.
Per 19.3.7.3 and 8.3.2.

This deficiency effected one two (2) smoke compartments within the hospital.

Building A2 - main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director;
1) The main medical gas storage room (#0304) door would not latch into the frame when closed.
Note: This deficiency was corrected during the survey by staff
2) Two (2) doors and walls on five (5) different clean supply rooms and combustible storage rooms, located on the second (2nd) floor, are not rated. The rooms measure over 100 sq. ft. In size and must be rated at one-hour (1).
a) Storage room #2725 (doors A & B)
b) Storage room #2816 (doors A & B)
c) Storage room #2827 (doors A & B)
d) Clean utility room #2743 (doors A & B)
e) Clean utility room # 2664 (doorsA & B)
3) The trash/linen chute room (#7202) door contained tape over the latch which prevented the door from latching
Note: #3 was corrected during the survey by removing the tape from the latching device.

These deficiencies effected 4 different smoke compartments and 4 different areas within the facility.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the hazardous areas.
 
During the walk-through of the facility with the Maintenance Directors, suite #$50 contained a medical records storage room in which the self-closing device on the door was disconnected and therefore rendered the self-closing door as inoperable.

This deficiency potentially effected one suite within the building.

Building A2 - main Hospital

Through observation testing during the survey, conducted March 15 through 17, 2016, it was determined that the facility failed to maintain the exits as readily accessible at all times.
 
During the walk through of the facility, with the Maintenance Director, the delayed egress device, on door #2497, located in the pre-op area has a "pre-alarm" on the delayed egress locking device.
Per NFPA 101, section 18.2.1 and 7.2.1.6.1

This deficiency effected one (1) door within the emans of egress from one (1) smoke compartment.

Building A2 - Main Hospital

Through record review and discussions with the staff during the survey, March 15 through March 17, 2016, it was determined that the facility failed to conduct fire drills as required and at varying times and conditions on all shifts.
 
During the review of the facility records, with the Maintenance Director:
1) Fire drills completed during the 3rd shift are being completed at 6:00am. Fire drills were completed on the following dates and times: 6:12 am on Feb. 17, 2015, 6:13am on May 7, 2015, 6:02am on Sept. 3, 2015, 5:59 Dec. 29, 2015 and 6:04am Feb 5, 2016.
Per NFPA 101, section 18.7.1.2
2) Lab conducted 1 yearly fire drill, however did not conduct quarterly fire drills as required.
Per NFPA 99, section 10-2.1.4.3

These deficiencies potentially effecetd all staff, patients, and visitors.

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72.
 
During the walk through of the facility, with the Maintenance Director, the manual pull station, located in the Transitional Care waiting room, was blocked by chairs.
Note: The chairs were relocated during the survey correcting the deficiency

This deficiency potentially effected one (1) exit in one (1) smoke compartment in the facility.

Building A3 - MOB #1

Through record review during the survey, March 15 through March 17, it was determined that the facility failed to test and maintain the fire alarm system as fully functional.

During the review of the facility records, with the Maintenance Director, documentation was not available to indicate the follwoing tests were completed on the fire alarm system:
1) The sensitivity test of the smoke detectors had occured within the past 2 years
2) An inspection to reflect that a semi-annual load voltage test was conducted during the second half of 2015.

This deficiency had the potential to effect all staff, visitors, and patients.

Building A4 - MOB #2

Through record review during the survey, March 15 through March 17, it was determined that the facility failed to test and maintain the fire alarm system as fully functional.

During the review of the facility records, with the Maintenance Director, documentation was not available to indicate the follwoing tests were completed on the fire alarm system:
1) The sensitivity test of the smoke detectors had occured within the past 2 years
2) An inspection to reflect that a semi-annual load voltage test was conducted during the second half of 2015.

This deficiency had the potential to effect all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director;
1) The facility contained one (1) corroded sprinkler head located in the lobby of the Wound Care area.
Note: The deficiency was corrected during the survey
2) Four conference rooms, located in the first (1st) floor conference rooms A, B, C, and D, contain drop down Projectors that come out of the ceiling when in use. When the projectors are in use, it creates an opening in the ceiling that is not smoke resistive and will not contain hot gases to activate the sprinkler system.

The deficiency effected one smoke compartment within the facility.

Building A3 - MOB #1

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:
1) Semi-annual test of the supervisory switches during the second half of 2015
2) Semi-annual test of the water flow switches during the second half of 2015 (facility is taking advantage of the categorical waiver S&C for this testing)
3) Quarterly testing of the low air alarms serving the dry systems
4) Internal inspection of each check valve serving the system (to be completed every 5-years)
5) Internal inspection of the system pipping (to be completed every 5-years)
6) Documentation not available at the time of the inspection to reflect that a churn test is being conducted weekly on the fire pump (Note: The pump is being exercised monthly; however, the facility has not utilized the categorical S&C letter to take advantage of these new provisions).

This deficiency potentially effected all staff, visitors, and patients.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:
1) Semi-annual test of the supervisory switches during the second half of 2015
2) Semi-annual test of the water flow switches during the second half of 2015 (facility is taking advantage of the categorical waiver S&C for this testing)
3) Quarterly testing of the low air alarms serving the dry systems
4) Internal inspection of each check valve serving the system (to be completed every 5-years)
5) Internal inspection of the system pipping (to be completed every 5-years).
6) Suite 150, R & F room, has ceiling-mounted x-ray equipment that has the potential to fully obstruct one of the pendant sprinkler head in the room.
7) Suite 100 contained one concealed sprinkler head which was missing a cover plate. This plate was mising in the back hallway.


These deficiencies potentially effected all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to install fire dampers as required.
 
During the walk through of the facility, with the Maintenance Director, a fire Damper, loctaed in the storage area on 7th floor, contained a breakaway flange on the air supply duct which had been covered or is missing which violates the listing of the fire damper.
Per NFPA 101, 18.5.2.1 and NFPA 90A 18.5.2.2

This deficiency effected one (1) fire damper located in one (1) smoke compartment.

Building A2 - Main Hospital

Through record review and observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain portable space heaters as required.
 
During the review of the facility, with the Maintenance Director, three (3) portable space heaters, which were being utilized in the administration business office, did not contain information or documentation indicating that they did not reach a temperature above 212 degrees F. as required. The two manufacturers found were Dayton and Peloni.

This deficiency effected one (1) smoke compartment within the facility.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.
 
During the walkthrough of the facility, with the Maintenance Director, the following areas contained items obstructing the means of egress;
1) Storage of items in the corridor of the lab reducing the width to forty inches (40") of a six foot (6') corridor
2) Wound Care contains storage of two (2) roller carts in the corridor
3) Palliative care area has one (1) file cabinet and one (1) printer in the corridor
4) Case Management contains one (1) table in corridor
5) Value optimization area has one (1) copier and one (1) shredder in corridor
6) Occupational Health has two (2) filing cabinets and one (1) printer in the corridor
7) Marketing office has one (1) printer and numerous cardboard boxes stored in the corridor
8) Emergency Department contains two (2) stretchers in the means of egress reducing the width to six feet (6').

These deficiencies potentially effected all staff and patients in the areas listed.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain thetrash chute vacuum system tubing as required.
 
During the walk through of the facility, with the Maintenance Director, the fire wrap for the Trans Vac system in recyclable waste room was missing in one (1) section and held together by bailing wire in two (2) other sections.

This deficiency potentially effecetd one (1) room within the hospital.

Building A3- MOB #1

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to test the connect all battery back-up lighting per

During the document review, with the Maintenance Director, documentation was not available to indicate the battery back up emergency lights were tested:
1) Every month for thirty (30) seconds and
2) Yearly for ninety (90) minutes.

This deficiency potentially effected all staff, visitors, and patients.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to test the connect all battery back-up lighting per

During the document review, with the Maintenance Director, documentation was not available to indicate the battery back up emergency lights were tested:
1) Every month for thirty (30) seconds and
2) Yearly for ninety (90) minutes.

This deficiency potentially effected all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the electrical system in accordance with NFPA 70.
 
During the walk through of the facility with the Maintenance Director:
1) Materials waiting room ( #0352) contained a power-strip plugged into (or piggybacked) into another power-strip.
2) Flight for life pilot office contained contained a power-strip plugged into (or piggybacked) into another power-strip.
3) Finance office cubicle contained one (1) extension cord to power equipment
4) Flexible wiring was utilized to power an exhaust fan in a construction zone across from the trash linen room (#2498). The wiring ran from an outlet in the corridor, up the wall, through the drop ceiling, through the interstitial space and then into the construction zone.

The deficiencies potentially effected all staff, visitors, and patients in the zones and areas listed.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director;
1) Two (2) doors located in two (2) trauma rooms (#43 and #28), locate din Trauma Team 3 , contained thumb latches on one of the double doors. The doors were situation in a 70/30 format, where the larger door (the 70 door) latches into the smaller door (the 30 door). These are located in the corridor and must contain a positive latching device on the door.
Per NFPA 101, section 18.3.6.3.2
a) Room #28 in Trauma Team 3
b) Room #43 in Trauma Team 3
c) Rad 3 room in Trauma Team 1 (frame 1618)
d) Trauma room 1 (frame1615)
e) Trauma room 2 (frame 1614)
f) Trauma room 3 (frame 1632)
g) Trauma room 4 (frame 1633)
2) Door to room #3189 hcontained a large gap between the door and the door frame larger than 1/2 between the 70 door and 30 door.
3) One bed blocking door from closing in room #2607

These deficiencies effected 4 smoke compartments throughout the facility

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain the smoke barrier doors.
 
During the walk through of the facility, with the Maintenance Director, one (1) smoke wall, located at the adjacent to door #2497, contained one (1) unsealed pipe penetration without fire caulking or other approved method of maintaining the smoke rating of the wall.
Per 19.3.7.3 and 8.3.2.

This deficiency effected one two (2) smoke compartments within the hospital.

Building A2 - main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director;
1) The main medical gas storage room (#0304) door would not latch into the frame when closed.
Note: This deficiency was corrected during the survey by staff
2) Two (2) doors and walls on five (5) different clean supply rooms and combustible storage rooms, located on the second (2nd) floor, are not rated. The rooms measure over 100 sq. ft. In size and must be rated at one-hour (1).
a) Storage room #2725 (doors A & B)
b) Storage room #2816 (doors A & B)
c) Storage room #2827 (doors A & B)
d) Clean utility room #2743 (doors A & B)
e) Clean utility room # 2664 (doorsA & B)
3) The trash/linen chute room (#7202) door contained tape over the latch which prevented the door from latching
Note: #3 was corrected during the survey by removing the tape from the latching device.

These deficiencies effected 4 different smoke compartments and 4 different areas within the facility.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the hazardous areas.
 
During the walk-through of the facility with the Maintenance Directors, suite #$50 contained a medical records storage room in which the self-closing device on the door was disconnected and therefore rendered the self-closing door as inoperable.

This deficiency potentially effected one suite within the building.

Building A2 - main Hospital

Through observation testing during the survey, conducted March 15 through 17, 2016, it was determined that the facility failed to maintain the exits as readily accessible at all times.
 
During the walk through of the facility, with the Maintenance Director, the delayed egress device, on door #2497, located in the pre-op area has a "pre-alarm" on the delayed egress locking device.
Per NFPA 101, section 18.2.1 and 7.2.1.6.1

This deficiency effected one (1) door within the emans of egress from one (1) smoke compartment.

Building A2 - Main Hospital

Through record review and discussions with the staff during the survey, March 15 through March 17, 2016, it was determined that the facility failed to conduct fire drills as required and at varying times and conditions on all shifts.
 
During the review of the facility records, with the Maintenance Director:
1) Fire drills completed during the 3rd shift are being completed at 6:00am. Fire drills were completed on the following dates and times: 6:12 am on Feb. 17, 2015, 6:13am on May 7, 2015, 6:02am on Sept. 3, 2015, 5:59 Dec. 29, 2015 and 6:04am Feb 5, 2016.
Per NFPA 101, section 18.7.1.2
2) Lab conducted 1 yearly fire drill, however did not conduct quarterly fire drills as required.
Per NFPA 99, section 10-2.1.4.3

These deficiencies potentially effecetd all staff, patients, and visitors.

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72.
 
During the walk through of the facility, with the Maintenance Director, the manual pull station, located in the Transitional Care waiting room, was blocked by chairs.
Note: The chairs were relocated during the survey correcting the deficiency

This deficiency potentially effected one (1) exit in one (1) smoke compartment in the facility.

Building A3 - MOB #1

Through record review during the survey, March 15 through March 17, it was determined that the facility failed to test and maintain the fire alarm system as fully functional.

During the review of the facility records, with the Maintenance Director, documentation was not available to indicate the follwoing tests were completed on the fire alarm system:
1) The sensitivity test of the smoke detectors had occured within the past 2 years
2) An inspection to reflect that a semi-annual load voltage test was conducted during the second half of 2015.

This deficiency had the potential to effect all staff, visitors, and patients.

Building A4 - MOB #2

Through record review during the survey, March 15 through March 17, it was determined that the facility failed to test and maintain the fire alarm system as fully functional.

During the review of the facility records, with the Maintenance Director, documentation was not available to indicate the follwoing tests were completed on the fire alarm system:
1) The sensitivity test of the smoke detectors had occured within the past 2 years
2) An inspection to reflect that a semi-annual load voltage test was conducted during the second half of 2015.

This deficiency had the potential to effect all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director;
1) The facility contained one (1) corroded sprinkler head located in the lobby of the Wound Care area.
Note: The deficiency was corrected during the survey
2) Four conference rooms, located in the first (1st) floor conference rooms A, B, C, and D, contain drop down Projectors that come out of the ceiling when in use. When the projectors are in use, it creates an opening in the ceiling that is not smoke resistive and will not contain hot gases to activate the sprinkler system.

The deficiency effected one smoke compartment within the facility.

Building A3 - MOB #1

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:
1) Semi-annual test of the supervisory switches during the second half of 2015
2) Semi-annual test of the water flow switches during the second half of 2015 (facility is taking advantage of the categorical waiver S&C for this testing)
3) Quarterly testing of the low air alarms serving the dry systems
4) Internal inspection of each check valve serving the system (to be completed every 5-years)
5) Internal inspection of the system pipping (to be completed every 5-years)
6) Documentation not available at the time of the inspection to reflect that a churn test is being conducted weekly on the fire pump (Note: The pump is being exercised monthly; however, the facility has not utilized the categorical S&C letter to take advantage of these new provisions).

This deficiency potentially effected all staff, visitors, and patients.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:
1) Semi-annual test of the supervisory switches during the second half of 2015
2) Semi-annual test of the water flow switches during the second half of 2015 (facility is taking advantage of the categorical waiver S&C for this testing)
3) Quarterly testing of the low air alarms serving the dry systems
4) Internal inspection of each check valve serving the system (to be completed every 5-years)
5) Internal inspection of the system pipping (to be completed every 5-years).
6) Suite 150, R & F room, has ceiling-mounted x-ray equipment that has the potential to fully obstruct one of the pendant sprinkler head in the room.
7) Suite 100 contained one concealed sprinkler head which was missing a cover plate. This plate was mising in the back hallway.


These deficiencies potentially effected all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to install fire dampers as required.
 
During the walk through of the facility, with the Maintenance Director, a fire Damper, loctaed in the storage area on 7th floor, contained a breakaway flange on the air supply duct which had been covered or is missing which violates the listing of the fire damper.
Per NFPA 101, 18.5.2.1 and NFPA 90A 18.5.2.2

This deficiency effected one (1) fire damper located in one (1) smoke compartment.

Building A2 - Main Hospital

Through record review and observation during the survey, conducted March 15 through March 17, 2016, it was determined that the facility failed to maintain portable space heaters as required.
 
During the review of the facility, with the Maintenance Director, three (3) portable space heaters, which were being utilized in the administration business office, did not contain information or documentation indicating that they did not reach a temperature above 212 degrees F. as required. The two manufacturers found were Dayton and Peloni.

This deficiency effected one (1) smoke compartment within the facility.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.
 
During the walkthrough of the facility, with the Maintenance Director, the following areas contained items obstructing the means of egress;
1) Storage of items in the corridor of the lab reducing the width to forty inches (40") of a six foot (6') corridor
2) Wound Care contains storage of two (2) roller carts in the corridor
3) Palliative care area has one (1) file cabinet and one (1) printer in the corridor
4) Case Management contains one (1) table in corridor
5) Value optimization area has one (1) copier and one (1) shredder in corridor
6) Occupational Health has two (2) filing cabinets and one (1) printer in the corridor
7) Marketing office has one (1) printer and numerous cardboard boxes stored in the corridor
8) Emergency Department contains two (2) stretchers in the means of egress reducing the width to six feet (6').

These deficiencies potentially effected all staff and patients in the areas listed.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain thetrash chute vacuum system tubing as required.
 
During the walk through of the facility, with the Maintenance Director, the fire wrap for the Trans Vac system in recyclable waste room was missing in one (1) section and held together by bailing wire in two (2) other sections.

This deficiency potentially effecetd one (1) room within the hospital.

Building A3- MOB #1

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to test the connect all battery back-up lighting per

During the document review, with the Maintenance Director, documentation was not available to indicate the battery back up emergency lights were tested:
1) Every month for thirty (30) seconds and
2) Yearly for ninety (90) minutes.

This deficiency potentially effected all staff, visitors, and patients.

Building A4 - MOB #2

Through observation during the survey, March 15 through March 17, 2016, it was determined the facility failed to test the connect all battery back-up lighting per

During the document review, with the Maintenance Director, documentation was not available to indicate the battery back up emergency lights were tested:
1) Every month for thirty (30) seconds and
2) Yearly for ninety (90) minutes.

This deficiency potentially effected all staff, visitors, and patients.

Building A2 - Main Hospital

Through observation during the survey, March 15 through March 17, 2016, it was determined that the facility failed to maintain the electrical system in accordance with NFPA 70.
 
During the walk through of the facility with the Maintenance Director:
1) Materials waiting room ( #0352) contained a power-strip plugged into (or piggybacked) into another power-strip.
2) Flight for life pilot office contained contained a power-strip plugged into (or piggybacked) into another power-strip.
3) Finance office cubicle contained one (1) extension cord to power equipment
4) Flexible wiring was utilized to power an exhaust fan in a construction zone across from the trash linen room (#2498). The wiring ran from an outlet in the corridor, up the wall, through the drop ceiling, through the interstitial space and then into the construction zone.

The deficiencies potentially effected all staff, visitors, and patients in the zones and areas listed.