HospitalInspections.org

It was observed by Inspectors 37696 & 39983 as well as Maintenance that this was not met by:

1) The storage of a gurney in front of the marked exit door that exits past the MRI trailer. The bed blocked the right hand door leaf.

NOTE that is gurney was removed during the inspection.

2) Marked exit from basement level is through the receiving dock and storage area (hazardous area)

It was observed by Inspectors 37693 & 39983 as well as Maintenance that the following areas of the hospital are not designated as Suites:

1) PT/OT Rehab Services Building
2) Emergency Room
3) Surgical Recovery Area

If they are not Suites, these areas are used by in-patient people and do not have the following:
a) corridors are open and would not resist the passage of smoke
b) some patient rooms do not have doors
c) if patient rooms have doors some do not latch
d) corridors are not 6' in clear width
e) not all patient rooms are visible from central nurses station
d) if not a suite, the PT/OT building is lacking exiting from inside the rehab area

If the PT/OT building is intended to be a separate building then a 2 hour rated separation is required from the main hospital and it shall not be used by in-patient people. It is currently being used by in house patients.

Based on observations with Maintenance Worker, Inspectors 39983 and 37696

The exit access to the corridor from the PT was obstructed by a work station and several chairs.

39983

Based on observations with a Maintenance Worker, Inspectors 39983 and 37696:

1) The 2nd means of egress located in the PT department is not marked with any exit signage.

2) 2nd exit from corridor by MH2018L Oncology
3) 2nd exit from corridor by MH2017
4) exit sign outside Clean Utility MH2012 directs one down the hall and not towards the actual exit
5) same exit sign also appears it should be 2 sided to direct one to the closest exit

Based on observations with a Maintenance Worker and Inspector 39983:

MH1051 electric room has multiple penetrations in the ceiling.

Based on observation with Maintenance Worker and Inspector 37696:


Electrical Closet MH2027 had multiple penetrations in the walls.

Storage Rm at MH10MJ not latching

Based on observations of the Mayo Hospital Facility by surveyors 38667 and 16776 with a facilities maintenance individual this standard is not met as evidenced by:

Within the main IT room, a quarter turn ball valve was observed within the sprinkler piping in the IT room. The quarter turn ball valve had a padlock on it and was not supervised electronically

On 08-13-2018, During Our regular Inspection Surveyor 16776 and 38667 with maintenance observed:

In OR room number 1 had paint on one sprinkler head. Needs to be replaced.

OR room number 2, had 3 sprinkler heads had paint on them. Needs to be replaced.




37695

Based on observation of surveyor 37695 and 16732 :

The maintenance department is opening the drain on the sprinkler system to flow water in order to set off fire alarm for fire drills. Only a licensed sprinkler technician can flow water through the system.

On 08-13-2018, During Our regular Inspection Surveyor 16776 and 38667 with Maintenance observed:
On the first floor Fire Doors Number MH1-023 above the door

Rated wall (2 hrs) had hole penetrations with armor Cable, Holes have to be sealed with Rated Fire Stop.

Same wall, found that the ends of both side above the door to the corridor walls, the Sheet Rock have never been sealed. Need to seal off with 2 hr rated fire stop.

It was observed by inspector 37696 & 39983 with maintenance that this was not met due to the ceilings in multiple patient rooms have perforated ceilings.

Rm MH2015 plus 2 other rooms on the same floor on the same side of the corridor. At the time of the inspection it was not possible to determine if the walls of the patient rooms and corridor were continuous to the roof deck and acted as a smoke partition.

Based on observations witnessed by Maintenance Worker and inspector 39983, the following doors do not close properly.

1. Activity room/Family waiting room on 2nd floor across from MH2082 not sealing properly.
2. MH1045 smoke door not sealing properly.
3. RC111 - PT corridor door held open with door wedge installed at base of door.

It was observed by inspector 37696 & 39983 with maintenance that this was not met due to the following:
- corridor door MH2001 exceeding the allowable gap between the door slab and door frame.
- Patient Rm Door MH2044 hits the frame on the top and closes very hard and would not latch
- Electrical room closet RC112 the active leaf would not latch

It was observed by Inspectors 37696 & 39983 as well as Maintenance that this was not met

Doors MH1044, near the elevator, that the door leafs hit each other and would not close completely.

It was observed by Inspectors 37696 & 39983 as well as Maintenance that the rooms used by Physicians for sleeping did not have smoke detection in the sleeping rooms.

It was observed by inspector 37696 & 39983 with maintenance that this was not met due to:

1) no documentation that the fabric that makes up the dedication wall to Tracey Hibbard Kasprzak is made from fire retardant materials

2) A fake tree was found in the corridor on the 2nd floor outside the Resource Elevator. There was no documentation nor known program to treat combustible decorations that are brought into the facility.

Based on record review of medical gas report dated 01/12/18 of surveyor 16732 on 08-13-18, the following findings are deficiencies with NFPA 99 the 2012 Edition with evidence as follows:

1) 1st floor OR has 3 outlets with the following: The flow of oxygen outlet on the anesthesia boom does not meet the specifications required by NFPA 99-2012 Section 5.1.12.3.10.5 - Oxygen and medical air outlets serving critical areas shall permit a transient flow rate of 170 SLPM (6 SCFM) for 3 seconds.

2) The 1st floor OR has 2 outlets with the following: The flow of oxygen outlet on the anesthesia boom does not meet the specifications required by NFPA 99-2012 Section 5.1.12.3.10.5 - Oxygen and medical air outlets serving critical areas shall permit a transient flow rate of 170 SLPM (6 SCFM) for 3 seconds.

3) Basement Floor Morgue: The zone valve controlling the medical gas outlets in the Morgue could not be located which does not meet the specifications required by NFPA 99-2012 5.1.4.6.1 All station outlet/inlets shall be supplied through a zone valve.