HospitalInspections.org

Based on observations it was determined that the health care facility failed to maintain the integrity of the spray on fire proofing in the facility.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. The spray on fire proofing in room 1E165 was damaged in several places.
2. The spray on fire proofing in room 1G113 was damaged in several places.
3. The spray on fire proofing in room 2B212 was damaged in several places.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to properly maintain the rated construction of barriers in the facility.

The Findings Include:

On 1/30/2014 it was revealed by interview and observation:

1. There were penetrations through the rated wall above the ceiling in room 1C129(x3).
2. There were penetrations through the rated wall above the ceiling in room 1F121.
3. There were penetrations through the rated wall above the ceiling above the yellow lobby doors.
4. There were cracks in a rated wall in room 1G113.


An interview on 1/30/2014 the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to maintain the proper operation of separation doors in the facility.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. The smoke doors in the OR corridor by the men's locker room would not close properly.
2. There were obstructions on the counter in the ED registration area that would prevent the role down fire door from functioning properly.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations and an interview it was determined that the health care facility failed to control storage in and the integrity of exit .

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There were items stored in the temporary exit.
2. The exit off of the OR back hall discharges into the construction site.


An interview on 1/30/2014 the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to maintain the clear width of exit corridors.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There were items stored in the soiled linen exit corridor.
2. There were items stored in the locker room exit corridor.
3. There were items stored in the OR office corridor.
4. There were items stored in the exit corridor by nuclear medicine.
5. There were portable oxygen tanks stored in the exit corridor by 1F130.(Corrected on site)


An interview on 1/30/2014 with the maintenance director confirmed this evidence

Based on observations it was determined that the health care facility failed to maintain the correct signage for exits in the facility.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There was a mislabeled exit sign in BG17F.
2. There were several new clear exit signs in Radiology that the back is not covered and could cause confusion when trying to follow the labeled exit path.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility had various fire alarm related deficiencies.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. The fire alarm panel was showing trouble.
2. There was an obstructed pull station by 1G103 in the yellow lobby.
3. There was a missing ceiling tile in 1G102.1E.(Corrected on site)
4. There were missing ceiling tiles in the doctor's lounge soda machine closet.
5. There was not a visual warning device in the Implant Storage Room addition.


An interview on 1/30/2014 with the maintenance director confirmed these findings.

Based on observations it was determined that the health care facility failed to maintain the complete coverage of the sprinkler system.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There were covered sprinkler heads on the loading dock.(Corrected on site)
2. There was new duct work installed in the second floor mechanical room that exceeds 48" in width and does not have sprinkler coverage.
3. The privacy curtains in the autopsy room block the development of the sprinkler pattern.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to maintain several sprinkler heads in the facility.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There was dust build up on a sprinkler head in room 1C132.
2. There was dust build up on a sprinkler head in the men's locker room.
3. There was dust build up on a sprinkler head in CT2.
4. There was a missing escutcheon ring in the hyperbaric and wound care area.(Corrected on site)
5. There were corroded sprinkler heads in the food prep area.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to maintain the correct storage of a portable oxygen cylinders.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There were portable oxygen cylinders not stored properly in a rack or on carts in first floor transfer room.(Corrected on site)


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility failed to maintain the requirements for the transferring of oxygen.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There was an exterior oxygen tank by Air Products that did not meet the requirements for the transferring of oxygen.


An interview on 1/30/2014 with the maintenance director confirmed this evidence.

Based on observations it was determined that the health care facility had various electrical violations.

The Findings Include:

On 1/30/2014 it was revealed by observation and interview:

1. There were daisy chained power strips in room 1A112(x2).(Corrected on site)
2. There was a power strip with exposed wires in 1A112.
3. There were daisy chained power strips in the ED nurse's station.
4. There was an extension cord used as permanent wiring in 1A100.C.
5. There was a power strip not plugged directly into a permanent outlet in 1A100.C.
6. There was a power strip not plugged directly into a permanent outlet in 1A115.A.


An interview on 1/30/2014 with the maintenance director confirmed these findings.