HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee # 11) and Plant Manager (employee # 12), it was determined that patient's doors protecting corridors on the fifth floor #504, #506, # 507, #508 and #513 do not close completely (do not latch) , the doors locks are loose and all room doors are made of wood as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 3/13/14 through 3/13/14 from 8:30 am till 3:30 pm and it was found that patient's room doors #504, #506, #507, #508 and #513 do not latch, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

2. During the tour for life safety from fire all patients ' sleeping room doors were observed from 3/12/14 through 3/13/14 from 10:00 am and it was found that are made of wood and does not have any labeling to prove the fire protection ratings. Fire Department of PR gave the approved permit (endorsement) and inspection for the facility on October 23, 2013 until October 23, 2014. The fire department did not make any recommendation for this matter.

Based on observations made during the survey for life safety from fire and tests on doors with the facility's physical plant manager (employee # 12), it was determined that the facility failed to ensure that 1 out of 2 emergency room exit doors provides direct access as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.1.2.

Findings include:

The emergency room was visited on 3/14/14 at 4:30 pm and provided evidence that there is a door that separates the waiting area from the triage area and the rest of the emergency room. This door is opened by an electronic door release that is operated by the clerical staff. In a hurried egress of patients and staff within the treatment area, the door that separates the waiting area from the triage area and the rest of the emergency room can not be opened manually by the occupants; it has to be opened by clerical staff with an electronic door release. If clerical staff is not there to open the door, staff and patients can be trapped at this point inside of the emergency room.

Based on observations made during the survey for life safety from fire with the facility's safety officer (employee #28), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in the medical record room in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency lighting (battery operated lamps) in the medical room area as observed on 03/13/14 at 10:00 am. Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails.

Based on observation made during the survey for life from fire with the facility ' s Engineer (employee #11), plant manager and Safety Officer (employee # 28), it was determined that the facility ' s failed in the implementation of ashtray of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.4, 19.7.4.

Findings include:

1. During the tour for the life safety from fire, on 3/12/14 at 8:00 am it was observed there are no designated smoking areas. Cigarette butts shows all around.
2. During the tour for the life safety from fire on 3/12/14 at 8:00 am cigarette butts was observed all around the 10,000 diesel tank and the small diesel tanks. The non-smoking sign in the electrics generators are too small for the area.
3. During the tour for the life safety from fire on 3/12/14 at 1:00 pm it was observed in the fire escape stairs floors 7th, 5th, 4th, 3rd and 1st cigarette butts. Making this evident that people are smoking inside the building, plant manager (employee #12) and Safety Officer (employee #28 ), it was determined that the facility ' s failed in the implementation of ashtray of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.4, 19.7.4.

Based on observations made during the survey for life safety from fire with the facility ' s Safety Officer (employee 28), it was determined that the facility failed to ensure that the automatic fire suppression system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic fire suppression system above the stoves was observed on 3/14/14 at 8:30 am with the facility's Safety Officer (employee # 28) and the Engineer (employee # 11) failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the fire suppression system is activated.
b. Verification that activation of the fire suppression system activates the facility's fire alarm.
c. The kitchen's hood exhaust system six month maintenance was requested, however no evidence was found of the updated required hood/duct exhaust fan inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule. This certification should be posted on the side of the hood system visible for inspection.

Based on observations made during the survey for life safety from fire with the facility's safety officer (employee # 28), it was determined that the facility failed to maintain free from obstructions one means for egress corridor that is use as a waiting area of an Oby-Gyn private physician office, to ensure that means of egress are in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. On 3/14/14 at 2:40 pm as observed, patients sat waiting to be attended by the private doctors at the hallway on the first floor. This hallway leads to an exit access and was found with people sitting on the floor, baby strollers in the middle of the hallway and trash between the chairs. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the emergency room head nurse coordinator (employee # 32) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour in the emergency room there is not a dirty linen storage room. On 03/14/14 at 4:30 pm with the emergency room head nurse coordinator (employee#32) it was determined that personnel are using the isolation room in the pediatric area to place dirty linen, it had one large hamper full of dirty linen. The emergency room employee #32 stated during an interview on 03/14/14 at 4:40 pm that sometimes this room is used as a holding area until personnel make their rounds and remove them from the room.

Based on observation made during the survey for life from fire with the facility ' s plant manager (employee #12) , it was determined that the facility ' s failed filling penetrations of smoke barriers by ducts are protected as required by the 2000 edition of the Life Safety Code of the NFPA Section 8.3.6
Findings include:
1.During the touring on 3/12/14 at 9:35 am in the medical supplies storage on the 1st floor pipes crossing the walls and ceiling without filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
2. During the touring on 3/12/14 at 8:45 am in the mechanical room on the 1st floor pipes
crossing the walls and the ceiling without filled with a material that is capable of maintanining the smoke resistance of the smoke barrier. Two of the pipes filled with not fire resistant material.

3. During the touring on 3/12/14 at 1:45 pm in the fire stair escapes on 7th, 6th, 5th, 4th , 3rd, 2nd and 1st floor unsealed pipe crossing from ceiling through the next floor.

4. During the touring on 3/13/14 at 8:50 am in the 5th floor on the escort room the fire
suppression system pipes crossing the walls are not sealed with fire stopping material.

5. During the touring on 3/14/14 at 4:30 pm in the emergency room the fire suppression system pipe crossing the ceiling it is not sealed with a material that is capable of maintaining the smoke resistance of the smoke barrier.

6.During the touring on 3/14/14 at 4:30 pm in the isolation room of the adult emergency
room one hole in the ceiling it is not sealed with fire stopping material.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #11) and Plant Manager (employee #12), it was found that this facility ensure compliance with other Life Safety Code requirements not in CMS-2786-S related to the storage of oxygen tanks, storage of hazardous material in the kitchen, evacuation plans not posted in front elevators and unsealed wall joints.

Findings include:
1. Observations made on 3/14/14 at 9:30 am of the surgery department provided evidence that three small cylinders of oxygen (Type E) were on the floor next to the recovery room. The cylinders were not fastened to the wall or in stands to prevent them from falling. Oxygen cylinders must be secured in order to prevent them from falling and possible explosion.

2. Tools room looks like a regular storage; two wicker basket, small cart with boxes filled of papers and files; the top of the small car are wood. There are 3 gallons of degreaser, small cans of aerosol paint.

3. In front of the elevators in floors 7th, 6th, and 5th there is not an evacuation sign posted in case of fire.

4.During the observational tour on 03/13/14 in the 5th floor patient ' s room # 516 and 518 is been remodeling; there are covering the existing glass on the wall with gypsum board type X but there are using a 2 " x 4 " panel of wood. Wood it is not a fire retarded material.

5. During the touring on 3/13/14 in the 5th floor the gypsum board wall it is not sealed with fire stopping material. This wall it is not finished and installed all the way up to the roof. The chairs are in clothing material.

6. The medical records department storage room on the first floor was visited on 3/12/14 at 11:00 am and was found with boxes of medical records stack over the top of the last shelves and the records touching the ceiling not permitting visibility of the sprinkler head and the smoke detector which increases the potential for a hazard.

7. During the touring on 3/14/14 at 10:00 am in the Delivery room does not have fire stopping material to seal some wall joints.

Based on observation made during the survey for life from fire with the facility ' s Engineer (employee # 11), plant manager (employee#12) and Safety Officer (employee# 28), it was determined that the facility failed to ensure placing nonsmoking sign in areas where oxygen is used or stored as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.3.2.4, 19.3.2.4 NFPA 99, 8.6.4.2.

Findings include:

1. During the tour for the life safety from fire, on 3/12/14 at 9:00 am it was observed in the medical supplies general storage seven (7) oxygen tanks (Type E ) in a wood car. Three (3) empty and four (4) full. The area does not have a non-smoking sign.

2. Two (2) Electricity Generators located between parking and entrance to the medical office does not have the appropriate protection and enough non-smoking sign posted. During the touring on 03/12/14 at 8:00 am it was observed cigarettes butts around the diesel tanks indicating that smoking occurs in the area.

3. On the entrance for the private doctors there is oxygen storage. During the tour on
3/12/2014 at 8:30 am it was observed two people smoking in the area. There are no appropriate non-smoking sign posted. Also the facility ' s engineer (employee #11) and the plant manager (employee #12) do not oriented the person of why they cannot smoke in the area.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee # 11) and Plant Manager (employee # 12), it was determined that patient's doors protecting corridors on the fifth floor #504, #506, # 507, #508 and #513 do not close completely (do not latch) , the doors locks are loose and all room doors are made of wood as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 3/13/14 through 3/13/14 from 8:30 am till 3:30 pm and it was found that patient's room doors #504, #506, #507, #508 and #513 do not latch, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

2. During the tour for life safety from fire all patients ' sleeping room doors were observed from 3/12/14 through 3/13/14 from 10:00 am and it was found that are made of wood and does not have any labeling to prove the fire protection ratings. Fire Department of PR gave the approved permit (endorsement) and inspection for the facility on October 23, 2013 until October 23, 2014. The fire department did not make any recommendation for this matter.

Based on observations made during the survey for life safety from fire and tests on doors with the facility's physical plant manager (employee # 12), it was determined that the facility failed to ensure that 1 out of 2 emergency room exit doors provides direct access as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.1.2.

Findings include:

The emergency room was visited on 3/14/14 at 4:30 pm and provided evidence that there is a door that separates the waiting area from the triage area and the rest of the emergency room. This door is opened by an electronic door release that is operated by the clerical staff. In a hurried egress of patients and staff within the treatment area, the door that separates the waiting area from the triage area and the rest of the emergency room can not be opened manually by the occupants; it has to be opened by clerical staff with an electronic door release. If clerical staff is not there to open the door, staff and patients can be trapped at this point inside of the emergency room.

Based on observations made during the survey for life safety from fire with the facility's safety officer (employee #28), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in the medical record room in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency lighting (battery operated lamps) in the medical room area as observed on 03/13/14 at 10:00 am. Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails.

Based on observation made during the survey for life from fire with the facility ' s Engineer (employee #11), plant manager and Safety Officer (employee # 28), it was determined that the facility ' s failed in the implementation of ashtray of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.4, 19.7.4.

Findings include:

1. During the tour for the life safety from fire, on 3/12/14 at 8:00 am it was observed there are no designated smoking areas. Cigarette butts shows all around.
2. During the tour for the life safety from fire on 3/12/14 at 8:00 am cigarette butts was observed all around the 10,000 diesel tank and the small diesel tanks. The non-smoking sign in the electrics generators are too small for the area.
3. During the tour for the life safety from fire on 3/12/14 at 1:00 pm it was observed in the fire escape stairs floors 7th, 5th, 4th, 3rd and 1st cigarette butts. Making this evident that people are smoking inside the building, plant manager (employee #12) and Safety Officer (employee #28 ), it was determined that the facility ' s failed in the implementation of ashtray of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.4, 19.7.4.

Based on observations made during the survey for life safety from fire with the facility ' s Safety Officer (employee 28), it was determined that the facility failed to ensure that the automatic fire suppression system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic fire suppression system above the stoves was observed on 3/14/14 at 8:30 am with the facility's Safety Officer (employee # 28) and the Engineer (employee # 11) failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the fire suppression system is activated.
b. Verification that activation of the fire suppression system activates the facility's fire alarm.
c. The kitchen's hood exhaust system six month maintenance was requested, however no evidence was found of the updated required hood/duct exhaust fan inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule. This certification should be posted on the side of the hood system visible for inspection.

Based on observations made during the survey for life safety from fire with the facility's safety officer (employee # 28), it was determined that the facility failed to maintain free from obstructions one means for egress corridor that is use as a waiting area of an Oby-Gyn private physician office, to ensure that means of egress are in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. On 3/14/14 at 2:40 pm as observed, patients sat waiting to be attended by the private doctors at the hallway on the first floor. This hallway leads to an exit access and was found with people sitting on the floor, baby strollers in the middle of the hallway and trash between the chairs. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the emergency room head nurse coordinator (employee # 32) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour in the emergency room there is not a dirty linen storage room. On 03/14/14 at 4:30 pm with the emergency room head nurse coordinator (employee#32) it was determined that personnel are using the isolation room in the pediatric area to place dirty linen, it had one large hamper full of dirty linen. The emergency room employee #32 stated during an interview on 03/14/14 at 4:40 pm that sometimes this room is used as a holding area until personnel make their rounds and remove them from the room.

Based on observation made during the survey for life from fire with the facility ' s plant manager (employee #12) , it was determined that the facility ' s failed filling penetrations of smoke barriers by ducts are protected as required by the 2000 edition of the Life Safety Code of the NFPA Section 8.3.6
Findings include:
1.During the touring on 3/12/14 at 9:35 am in the medical supplies storage on the 1st floor pipes crossing the walls and ceiling without filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
2. During the touring on 3/12/14 at 8:45 am in the mechanical room on the 1st floor pipes
crossing the walls and the ceiling without filled with a material that is capable of maintanining the smoke resistance of the smoke barrier. Two of the pipes filled with not fire resistant material.

3. During the touring on 3/12/14 at 1:45 pm in the fire stair escapes on 7th, 6th, 5th, 4th , 3rd, 2nd and 1st floor unsealed pipe crossing from ceiling through the next floor.

4. During the touring on 3/13/14 at 8:50 am in the 5th floor on the escort room the fire
suppression system pipes crossing the walls are not sealed with fire stopping material.

5. During the touring on 3/14/14 at 4:30 pm in the emergency room the fire suppression system pipe crossing the ceiling it is not sealed with a material that is capable of maintaining the smoke resistance of the smoke barrier.

6.During the touring on 3/14/14 at 4:30 pm in the isolation room of the adult emergency
room one hole in the ceiling it is not sealed with fire stopping material.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #11) and Plant Manager (employee #12), it was found that this facility ensure compliance with other Life Safety Code requirements not in CMS-2786-S related to the storage of oxygen tanks, storage of hazardous material in the kitchen, evacuation plans not posted in front elevators and unsealed wall joints.

Findings include:
1. Observations made on 3/14/14 at 9:30 am of the surgery department provided evidence that three small cylinders of oxygen (Type E) were on the floor next to the recovery room. The cylinders were not fastened to the wall or in stands to prevent them from falling. Oxygen cylinders must be secured in order to prevent them from falling and possible explosion.

2. Tools room looks like a regular storage; two wicker basket, small cart with boxes filled of papers and files; the top of the small car are wood. There are 3 gallons of degreaser, small cans of aerosol paint.

3. In front of the elevators in floors 7th, 6th, and 5th there is not an evacuation sign posted in case of fire.

4.During the observational tour on 03/13/14 in the 5th floor patient ' s room # 516 and 518 is been remodeling; there are covering the existing glass on the wall with gypsum board type X but there are using a 2 " x 4 " panel of wood. Wood it is not a fire retarded material.

5. During the touring on 3/13/14 in the 5th floor the gypsum board wall it is not sealed with fire stopping material. This wall it is not finished and installed all the way up to the roof. The chairs are in clothing material.

6. The medical records department storage room on the first floor was visited on 3/12/14 at 11:00 am and was found with boxes of medical records stack over the top of the last shelves and the records touching the ceiling not permitting visibility of the sprinkler head and the smoke detector which increases the potential for a hazard.

7. During the touring on 3/14/14 at 10:00 am in the Delivery room does not have fire stopping material to seal some wall joints.

Based on observation made during the survey for life from fire with the facility ' s Engineer (employee # 11), plant manager (employee#12) and Safety Officer (employee# 28), it was determined that the facility failed to ensure placing nonsmoking sign in areas where oxygen is used or stored as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.3.2.4, 19.3.2.4 NFPA 99, 8.6.4.2.

Findings include:

1. During the tour for the life safety from fire, on 3/12/14 at 9:00 am it was observed in the medical supplies general storage seven (7) oxygen tanks (Type E ) in a wood car. Three (3) empty and four (4) full. The area does not have a non-smoking sign.

2. Two (2) Electricity Generators located between parking and entrance to the medical office does not have the appropriate protection and enough non-smoking sign posted. During the touring on 03/12/14 at 8:00 am it was observed cigarettes butts around the diesel tanks indicating that smoking occurs in the area.

3. On the entrance for the private doctors there is oxygen storage. During the tour on
3/12/2014 at 8:30 am it was observed two people smoking in the area. There are no appropriate non-smoking sign posted. Also the facility ' s engineer (employee #11) and the plant manager (employee #12) do not oriented the person of why they cannot smoke in the area.