HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, in two of three stairtowers within the component.

Findings include:

1. Observation on January 9, 2020, between 12:30 PM and 2:52 PM revealed stairtower doors exceeded the allowed gap margins, at the following locations:

a. 12:30 PM, 1st floor, North Stairtower door, had gaps, greater than 1/8 inch;
b. 2:52 PM, 2nd floor, South Stairtower door, had gaps, greater than 1/8 inch.

Interview with the Vice President of Operations on January 9, 2020, at 2:52 PM confirmed the stairtower doors exceeded the allowed gap margins.

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying the functional testing of battery powered emergency lighting, which serves the entire component.

Findings include:

1. Review of documentation on January 9, 2020, between 9:00 AM and 11:00 AM revealed the facility lacked documentation, verifying battery powered emergency lights had been functionally tested for ninety minutes, within the previous twelve months.

Interview with the Director of Property Management on January 9, 2020, at 11:00 AM confirmed the lack of documentation.

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to self-close, in one of nine smoke zones within the component.

Findings include:

1. Observation on January 9, 2020, at 1:10 PM revealed the double corridor doors, to the 1st floor Mechanical Room, the Oxygen Storage, failed to self-close.

Interview with the Vice President of Operations on January 9, 2020, at 1:10 PM confirmed the hazardous area door failed to self-close.

Based on observation and interview, it was determined the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers away from ignition points, in one of nine smoke zones within the component.

Findings include:

1. Observation on January 9, 2020, between 2:30 PM and 2:50 PM revealed ABHR dispensers were installed over the electrical night lights, throughout the Post Surgical Area, such as Room 2206, 2203, 2202 and 2214.

Interview with the Vice President of Operations on January 9, 2020, at 2:50 PM confirmed the dispensers were installed over an electrical item.

Based on observation and interview, it was determined the facility failed to maintain corridor doors to be free of impediments, and to positively latch, in two of nine smoke zones within the component.

Findings include:

1. Observation on January 9, 2020, at 1:50 PM revealed the 1st floor Asst. Nursing Manager's Office was held open, with a chock.

Interview at the time of the exit conference with the Vice President of Operations on January 9, 2020, at 1:50 PM confirmed the door was impeded from closing.


2. Observation on January 9, 2020, between 3:00 PM and 3:03 PM revealed corridor doors failed to positively latch, at the following locations:

a. 3:00 PM, 2nd floor, Patient Room S2106;
b. 3:03 PM, 2nd floor, Patient Room S2108.

Interview at the time of the exit conference with the Vice President of Operations on January 9, 2020, at 3:03 PM confirmed the doors failed to positively latch.

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting one of two floors within the component.

Findings include:

1. Observation on January 9, 2020, at 1:05 PM revealed an unprotected penetration of the smoke barrier wall, above the cross corridor double doors, by Room S2432.

Inteview with the Director of Property Management on January 9, 2020, at 1:05 PM confirmed the penetration was unprotected.


2. Observation on January 9, 2020, at 2:15 PM revealed an unprotected penetration of the smoke barrier wall, next to a sprinkler pipe, above the double doors by Electrical Closet S2050.

Interview with the Director of Property Management on January 9, 2020, at 2:15 PM confirmed the penetration was unprotected.

Based on observation on interview, it was determined the facility failed to maintain electrical junction boxes to be covered, affecting one of two floors within the component.

Findings include:

1. Observation on January 9, 2020, at 1:40 PM revealed an electrical junction box, without a cover plate, located within Room 2437.

Interview with the Director of Property Management on January 9, 2020, at 1:40 PM confirmed the lack of a cover plate.

Based on observation and interview, it was determined, greater than 300 cubic feet of medical gas cylinders were being stored within five feet of combustibles, in one of nine smoke zones within the component.

Findings include:

1. Observation on January 9, 2020, at 2:00 PM revealed the storage of thirteen oxygen "E" cylinders, in the 2nd floor Post Op, which exceeded the twelve per smoke compartment and were stored with combustible material within 5 feet and electrical below 60 inches.

Interview with the Vice President of Operations on January 9, 2020, at 2:00 PM confirmed more than 300 cubic feet of med gas was being stored in the smoke zone.