HospitalInspections.org

Based on observation and testing, it was determined that the facility failed to have fire doors close and latch within its frame.

The findings include:

Observation and testing on July 7, 2014 at 1:15 p.m. revealed that the fire doors that separate the 2 West wing and 2 North wing when tested did not close and latch within its frame. When the fire door is release from its hold open device, the bottom of the door drags the floor and leaves a 6 inch to 8 inch gap between the fire door.
(NFPA 101 19.3.7.6 & NFPA 80 3-4.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide hazardous areas with self-closing doors.

Observation on July 8, 2014 at 9:45 a.m. revealed the dry storage room in dietary and the storage room on the C/A back hall is not provided with self-closing doors.

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and interview, it was determined the facility failed to provide hazardous areas with self-closing doors.

The findings include:

Observation and interview on 7/8/14 at 9:30 AM revealed the storage in unit 100 and the dietary dry storage are not provided with self-closing doors.

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to maintain the sprinkler system and it components.

The findings include:

Observation on July 7, 2014 at 3:20 p.m. revealed 4 of 12 sprinklers in dietary are mixed match sprinkler heads with standard response and quick response sprinkler heads.
(NFPA 13 5-3.1.5.2)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide sprinkler coverage in all required areas.

The findings include:

Observation on July 8, 2014 at 8:45 a.m. revealed the elevator pit for the hydraulic elevator is not provided with sprinkler coverage.
(NFPA 13 5-13.6.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to maintain the automatic sprinkler systems in reliable operating condition.

The findings included:

1. Observation on 7/7/14 at 11:03 AM revealed sprinklers in the following location were filled with foreign material: Rooms 508, 509, 510, 511, Staff lounge on 4th floor, Head Nurse Office, Room 412, 410, 408, Corridor outside room 406, Room 434, 309, and Cath Lab Clinical coordinator Office. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1

2. Based on observations on 7/7/14 at 11:39 AM revealed the escutcheon plates were mising or covering the sprinklers in the following locations: Room 445, 346, 309, 314, and Cath Lab 4. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.2

3.Observation and interview on 7/7/14 at 10:30 AM revealed 7 of 7 sprinkler heads are corroded or tarnished at the overhang next to the boiler room.
NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1

4.Observation and interview on 7/7/14 at 11:00 AM revealed 1 of 10 sprinkler head deflectors bent in the main emergency room next to the bathroom and 1 of 7 sprinkler head deflectors bent in the Sarah Cannon emergency room. NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure the automatic sprinkler systems were continuously maintained in reliable operating condition.

The finding included:

Observation on 7/8/14 at 7:26 AM revealed the sprinklers in the East 3rd floor stairwell were recessed into the ceiling. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.2

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system.

The findings include:

Observation on July 7, 2014 at 3:20 p.m. revealed 8 of 12 sprinklers in dietary are corroded and tarnished.
(NFPA 25 2-2.1.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide the upblast fan for the kitchen exhaust system with the required safety components and cleaning access requirements.

The findings include:

Observation on July 7, 2014 at 10:20 a.m. revealed 3 of 3 upblast fans for the kitchen hood exhaust system is not hinged and a weather proof grease collection device is not provided on the upblast fan.
(NFPA 96 4-8.2.1)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide the upblast fan for the kitchen exhaust system with the required safety components and cleaning access requirements.

The findings include:

Observation on July 8, 2014 at 10:20 a.m. revealed the upblast fans for the kitchen hood exhaust system is not hinged and a weather proof grease collection device is not provided on the upblast fan.
(NFPA 96 4-8.2.1)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and documentation, it was determined that the facility failed to have zone valve boxes located outside of the area that it serves.

The findings include:

Observation and documentation review on July 7, 2014 revealed that the zone valve box for the piped in medical gas in the post anesthesia care unit (PACU) is located in the room that they serve.
(NFPA 99 4-3.1.2.3(d))

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to ensure smoke detectors were installed in the correct location.

The finding included:

Observation on 7/8/14 at 7:47 AM revealed a smoke detector within three feet of the air supply in the food service area. NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure smoke detectors were installed in the correct locations. NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1


The finding included:

Observation on 7/7/14 at 1:43 PM revealed smoke detectors within three feet of an air supply diffuser or return opening in the following locations:
1. Cath Lab 4.
2. Control room Cathlab 4.
3. Hallway leading to MICU by Cath Lab.
4. Dialysis Office by Ultrasound.
5. 2nd floor Hallway by Suregery Conference Room.
6. 1 of 3 on the first floor at central storage.
7. The main lobby entrance above the waiting area.


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and interview, it was determined the facility failed to ensure smoke detectors were installed at correct locations.

The findings include:

Observation and interview on 7/8/14 at 9:00 AM revealed smoke detectors within three feet of an air supply diffuser or return opening in the following locations: Laundry in unit 100, Laundry in unit 200 and Laundry in unit 400.
NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to post the proper signs at the oxygen storage locations.

The finding included:

Observation on 7/7/14 at 1:40 PM revealed the oxygen storage room in the MICU did not have the required sign, soiled utility room in the emergency room on the first floor, SICU oxygen storage room and medical room of day surgery on the second floor did not have the required signage.

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70.

The findings included:

1. Testing of the ground fault circuit interuptor in room 555 on 7/7/14 at 9:42 AM revealed the unit did not trip.

2. Observation on 7/7/14 at 1:13 PM revealed Electrical Panel TC in the waiting room on the second floor was blocked by trees and a table.

3. Observation and interview on 7/7/14 at 2:00 PM revealed the following locations are not provided with GFCI outlets:

1. Soiled utility in SICU.
2. Medical room in SICU.
3. Fluid room in Cytology.
4. Sink in the blood bank room.
5. Sink in the micro biology room.
6. Clinical lab of micro biology room.


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and testing, it was determined that the facility failed to provided ground fault current interrupter (GFCI) outlets in wet areas.

The findings include:

Observation and testing on July 7, 2014 revealed the following locations are not provided with GFCI outlets:
1. 2 west soiled utility room by the sink.
2. 2 west storage room by the sink.
3. 1 north nourishment room by the sink.
4. Day surgery soiled utility by room 102 at the sink.
(NFPA 70 210-8(a))

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and testing, it was determined that the facility failed to provided ground fault current interrupter (GFCI) outlets in wet areas.

The findings include:

Observation and testing on July 8, 2014 at 9:25 a.m. revealed the C&A Up room is not provided with a GFCI outlet and bathroom #5 GFCI outlet did not trip when tested.
(NFPA 70 210-8(a))

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on Observations, it was determined the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were installed in the correct locations.

The finding included:

Observation on 7/8/14 at 7:13 AM revealed ABHR dispensers installed over or adjacent to an ignition source in the following locations: Room 217, 212, ICU 3, 219, 221, and EEG Exam Room.

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were not installed over or adjacent to an ignition source.

The finding included:

Observation on 7/7/14 at 9:49 AM revealed ABHR dispensers installed over or adjacent to an ignition source in the following locations: Rooms 540, 539, 527, 431, Evidence Base Care Coordinator Office on 4th floor, MICU 9, MICU 11, MICU 4, MICU 3, and Cath Lab 4.

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and testing, it was determined that the facility failed to have fire doors close and latch within its frame.

The findings include:

Observation and testing on July 7, 2014 at 1:15 p.m. revealed that the fire doors that separate the 2 West wing and 2 North wing when tested did not close and latch within its frame. When the fire door is release from its hold open device, the bottom of the door drags the floor and leaves a 6 inch to 8 inch gap between the fire door.
(NFPA 101 19.3.7.6 & NFPA 80 3-4.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide hazardous areas with self-closing doors.

Observation on July 8, 2014 at 9:45 a.m. revealed the dry storage room in dietary and the storage room on the C/A back hall is not provided with self-closing doors.

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and interview, it was determined the facility failed to provide hazardous areas with self-closing doors.

The findings include:

Observation and interview on 7/8/14 at 9:30 AM revealed the storage in unit 100 and the dietary dry storage are not provided with self-closing doors.

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to maintain the sprinkler system and it components.

The findings include:

Observation on July 7, 2014 at 3:20 p.m. revealed 4 of 12 sprinklers in dietary are mixed match sprinkler heads with standard response and quick response sprinkler heads.
(NFPA 13 5-3.1.5.2)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide sprinkler coverage in all required areas.

The findings include:

Observation on July 8, 2014 at 8:45 a.m. revealed the elevator pit for the hydraulic elevator is not provided with sprinkler coverage.
(NFPA 13 5-13.6.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to maintain the automatic sprinkler systems in reliable operating condition.

The findings included:

1. Observation on 7/7/14 at 11:03 AM revealed sprinklers in the following location were filled with foreign material: Rooms 508, 509, 510, 511, Staff lounge on 4th floor, Head Nurse Office, Room 412, 410, 408, Corridor outside room 406, Room 434, 309, and Cath Lab Clinical coordinator Office. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1

2. Based on observations on 7/7/14 at 11:39 AM revealed the escutcheon plates were mising or covering the sprinklers in the following locations: Room 445, 346, 309, 314, and Cath Lab 4. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.2

3.Observation and interview on 7/7/14 at 10:30 AM revealed 7 of 7 sprinkler heads are corroded or tarnished at the overhang next to the boiler room.
NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1

4.Observation and interview on 7/7/14 at 11:00 AM revealed 1 of 10 sprinkler head deflectors bent in the main emergency room next to the bathroom and 1 of 7 sprinkler head deflectors bent in the Sarah Cannon emergency room. NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 5.2.1.1.1


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure the automatic sprinkler systems were continuously maintained in reliable operating condition.

The finding included:

Observation on 7/8/14 at 7:26 AM revealed the sprinklers in the East 3rd floor stairwell were recessed into the ceiling. NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 5.2.1.2

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system.

The findings include:

Observation on July 7, 2014 at 3:20 p.m. revealed 8 of 12 sprinklers in dietary are corroded and tarnished.
(NFPA 25 2-2.1.1*)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide the upblast fan for the kitchen exhaust system with the required safety components and cleaning access requirements.

The findings include:

Observation on July 7, 2014 at 10:20 a.m. revealed 3 of 3 upblast fans for the kitchen hood exhaust system is not hinged and a weather proof grease collection device is not provided on the upblast fan.
(NFPA 96 4-8.2.1)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined that the facility failed to provide the upblast fan for the kitchen exhaust system with the required safety components and cleaning access requirements.

The findings include:

Observation on July 8, 2014 at 10:20 a.m. revealed the upblast fans for the kitchen hood exhaust system is not hinged and a weather proof grease collection device is not provided on the upblast fan.
(NFPA 96 4-8.2.1)

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and documentation, it was determined that the facility failed to have zone valve boxes located outside of the area that it serves.

The findings include:

Observation and documentation review on July 7, 2014 revealed that the zone valve box for the piped in medical gas in the post anesthesia care unit (PACU) is located in the room that they serve.
(NFPA 99 4-3.1.2.3(d))

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to ensure smoke detectors were installed in the correct location.

The finding included:

Observation on 7/8/14 at 7:47 AM revealed a smoke detector within three feet of the air supply in the food service area. NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1

This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure smoke detectors were installed in the correct locations. NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1


The finding included:

Observation on 7/7/14 at 1:43 PM revealed smoke detectors within three feet of an air supply diffuser or return opening in the following locations:
1. Cath Lab 4.
2. Control room Cathlab 4.
3. Hallway leading to MICU by Cath Lab.
4. Dialysis Office by Ultrasound.
5. 2nd floor Hallway by Suregery Conference Room.
6. 1 of 3 on the first floor at central storage.
7. The main lobby entrance above the waiting area.


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and interview, it was determined the facility failed to ensure smoke detectors were installed at correct locations.

The findings include:

Observation and interview on 7/8/14 at 9:00 AM revealed smoke detectors within three feet of an air supply diffuser or return opening in the following locations: Laundry in unit 100, Laundry in unit 200 and Laundry in unit 400.
NFPA 72 National Fire Alarm Code 1999 Edition 2.3.5.1

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation, it was determined the facility failed to post the proper signs at the oxygen storage locations.

The finding included:

Observation on 7/7/14 at 1:40 PM revealed the oxygen storage room in the MICU did not have the required sign, soiled utility room in the emergency room on the first floor, SICU oxygen storage room and medical room of day surgery on the second floor did not have the required signage.

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observations, it was determined the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70.

The findings included:

1. Testing of the ground fault circuit interuptor in room 555 on 7/7/14 at 9:42 AM revealed the unit did not trip.

2. Observation on 7/7/14 at 1:13 PM revealed Electrical Panel TC in the waiting room on the second floor was blocked by trees and a table.

3. Observation and interview on 7/7/14 at 2:00 PM revealed the following locations are not provided with GFCI outlets:

1. Soiled utility in SICU.
2. Medical room in SICU.
3. Fluid room in Cytology.
4. Sink in the blood bank room.
5. Sink in the micro biology room.
6. Clinical lab of micro biology room.


These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and testing, it was determined that the facility failed to provided ground fault current interrupter (GFCI) outlets in wet areas.

The findings include:

Observation and testing on July 7, 2014 revealed the following locations are not provided with GFCI outlets:
1. 2 west soiled utility room by the sink.
2. 2 west storage room by the sink.
3. 1 north nourishment room by the sink.
4. Day surgery soiled utility by room 102 at the sink.
(NFPA 70 210-8(a))

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.

Based on observation and testing, it was determined that the facility failed to provided ground fault current interrupter (GFCI) outlets in wet areas.

The findings include:

Observation and testing on July 8, 2014 at 9:25 a.m. revealed the C&A Up room is not provided with a GFCI outlet and bathroom #5 GFCI outlet did not trip when tested.
(NFPA 70 210-8(a))

These findings were verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.