HospitalInspections.org

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

1) 7th floor East Hospital (West end of staff access corridor) office and utility room doors were held open by objects.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
1) The cross-corridor doors #GMB-C45 had a gap approximately ¼ " between the doors when closed and needs a smoke seal or astragal installed.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain smoke barriers and partitions as being smoke resistant. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
1) There was an uncovered penetration in the Sub basement elevator lobby wall.
2) There was an uncovered penetration in the south wall of the HVAC office (BCT 50).
The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:

1) There were 4 autoclave closets in the East Hospital Central Core that were unsprinklered.
2) The Cat Scan # 1WH411 Equipment room alcove with sliding glass doors did not have sprinkler coverage.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain the fire sprinkler system as required. This could result in the delay of the fire sprinkler system activation in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) The sprinkler head in the corridor by BWH-C38 and OR4 had backed up into the ceiling, resulting in an obstruction of its spray pattern.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to prohibit the use of furnishings or decorations of flammable material. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) There were mistletoe decorative devices containing untreated, combustible wood hanging from the ceiling of the PACU.
2) There were paper snowflakes hanging from the ceiling of the Lab.
3) Power cables hanging from the ceiling of the lab were covered in wrapping paper.
The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to properly maintain the medical gas system in the facility. This could result in the system not functioning as designed and prompt rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) The pull tab on the cover plate was missing for the medical vacuum shutoff valve by Resus 4 (1WH404).

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon staff interviews and observation on December 9 thru 10, 2014 the facility has failed to ensure Flammable liquids storage meets the requirements of NFPA 30 Flammable and Combustible Liquids Code. This could result in an unauthorized amount of flammable / combustible liquids which could overwhelm the designed fire protection features of a fire area, placing staff, patients, and visitors in danger.

The findings include, but are not limited to:

1) There were 4 flammable / combustible liquid storage cabinets in the sub-basement mechanical fire area.

NFPA 30 4.3 Design, Construction, and Capacity of Storage Cabinets.

4.3.1 Not more than 120 gal (454 L) of Class I, Class II, and
Class IIIA liquids shall be stored in a storage cabinet.
4.3.2 Not more than three storage cabinets shall be located in
any one fire area.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to ensure that electrical wiring and equipment meets the National Electrical Code. This could result in electrical shock or fire, or a delay in shutting off electrical circuits in the event of an emergency, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) The electrical panel #B5WKN1C in the kitchen was missing the dead-front panel cover, exposing the electrical buses in the panel.
2) There was storage blocking access to 3 electrical panels in the Lab.

The above was discussed and acknowledged by the Facility Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) There was an ABHR installed directly above an electrical outlet in the Admitting Lobby entrance.
2) Room 455 West Hospital ABHR mounted over an ignition source.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

1) 7th floor East Hospital (West end of staff access corridor) office and utility room doors were held open by objects.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
1) The cross-corridor doors #GMB-C45 had a gap approximately ¼ " between the doors when closed and needs a smoke seal or astragal installed.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain smoke barriers and partitions as being smoke resistant. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
1) There was an uncovered penetration in the Sub basement elevator lobby wall.
2) There was an uncovered penetration in the south wall of the HVAC office (BCT 50).
The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:

1) There were 4 autoclave closets in the East Hospital Central Core that were unsprinklered.
2) The Cat Scan # 1WH411 Equipment room alcove with sliding glass doors did not have sprinkler coverage.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to maintain the fire sprinkler system as required. This could result in the delay of the fire sprinkler system activation in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) The sprinkler head in the corridor by BWH-C38 and OR4 had backed up into the ceiling, resulting in an obstruction of its spray pattern.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to prohibit the use of furnishings or decorations of flammable material. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) There were mistletoe decorative devices containing untreated, combustible wood hanging from the ceiling of the PACU.
2) There were paper snowflakes hanging from the ceiling of the Lab.
3) Power cables hanging from the ceiling of the lab were covered in wrapping paper.
The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to properly maintain the medical gas system in the facility. This could result in the system not functioning as designed and prompt rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) The pull tab on the cover plate was missing for the medical vacuum shutoff valve by Resus 4 (1WH404).

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon staff interviews and observation on December 9 thru 10, 2014 the facility has failed to ensure Flammable liquids storage meets the requirements of NFPA 30 Flammable and Combustible Liquids Code. This could result in an unauthorized amount of flammable / combustible liquids which could overwhelm the designed fire protection features of a fire area, placing staff, patients, and visitors in danger.

The findings include, but are not limited to:

1) There were 4 flammable / combustible liquid storage cabinets in the sub-basement mechanical fire area.

NFPA 30 4.3 Design, Construction, and Capacity of Storage Cabinets.

4.3.1 Not more than 120 gal (454 L) of Class I, Class II, and
Class IIIA liquids shall be stored in a storage cabinet.
4.3.2 Not more than three storage cabinets shall be located in
any one fire area.

The above was discussed and acknowledged by the Maintenance Director.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on December 9 thru 10, 2014 the facility has failed to ensure that electrical wiring and equipment meets the National Electrical Code. This could result in electrical shock or fire, or a delay in shutting off electrical circuits in the event of an emergency, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1) The electrical panel #B5WKN1C in the kitchen was missing the dead-front panel cover, exposing the electrical buses in the panel.
2) There was storage blocking access to 3 electrical panels in the Lab.

The above was discussed and acknowledged by the Facility Maintenance Director.