HospitalInspections.org

Based on observation it was discovered that the facility failed to properly maintain the required separation from hazardous areas to the rest of the hospital.

Findings were:

On Dec. 11, 2012 at 12:55 PM while accompanied by the Assistant Maintenance Director the door to the soiled utility room on the 2nd floor, in Respitory Therapy, was found damaged and would not properly close and latch.

Based on observation it was discovered that the facility failed to properly maintain the means of egress and improperly locking of doors in this path.

On Dec. 11th and 12th, 2012 while accompanied by the Assistant Maintenance Director, who informed me that these following locked doors were delayed egress locks. They had no info to let the occupant know these doors would open upon action of delayed lock. Delayed Egress Locked exit doors are required instructional sign was missing from several delayed egress locked doors:
1) by Rm 161
2)near TBI
3)Pharmacy
4) 3rd floor Peds

The requirement per section 7.2.1.6 is for ----On the door adjacent to release device, there shall be a visible sign in letters not less than 1 inch high that reads as follows" PUSH UNTIL ALARM SOUNDS-- DOOR CAN BE OPENED IN 15 SECONDS."

Based on observation it was discovered that the facility failed to properly maintain the smoke detectors for the fire alarm system.

On Dec. 12, 2012 at 11:30 till noon while accompanied by the Assistant Maintenance Director several smoke detectors (areas by Rms. OB186,&189, TBI core by locker Rm.) were found mounted too close to the ceiling vents. The code calls for the Smoke detectors to be at least 3 feet away from these vents. This is to assure that smoke could actually reach the detectors with out being dispersed by the air currents and to prevent the smoke detectors from getting dirty and losing the required sensitivity.

Based on observation, and conversation it was discovered that the facility failed to properly maintain the sprinkler protection as required by NFPA 13.

Findings were:

On Dec 11, 2012 at noon while accompanied by the Assistant Maintenance Director it was discovered that there are many places in the West Wing Penthouse that are not properly equipped with sprinkler coverage under a duct that is more than 4 feet wide. The Asst. Maintenance Director stated that the new duct was recently added to supply ventilation for a new Pharmacy renovation on the ground floor-- Note a Certificate of Use and Occupancy from the local authority had been issued for this completed renovation project .

On Dec. 11, 2012 at 13:10 while accompanied by the Assistant. Maintenance Director it was discovered that there was an area in the Pharmacy that had obstructed sprinkler protection due to a new shelving unit, the area was designed for the storing of the crash carts. This area on a plans review would not have shown the furniture layout and was missed during plans review by the local authority- NOTE the local authority has issued a Certificate of Use and Occupancy for this completed renovation project

Based on observation and record review it was discovered that the facility failed to properly maintain the monitoring of the sprinkler control valves.

Findings were:

On Dec 13, 2012 while doing the record review with the Assistant Maintenance Director, the paperwork from the sprinkler contractor showed that a 1st floor tamper valve was found on Nov 12, 2012 to not be working properly and the valve was secured in the open position by a locked chain, NOTE-while this is an acceptable method per NFPA 13, CMS requires that all sprinkler protection valves be supervised electronically and an alarm sound if valves are closed. This had the potential to affect 100% of the occupants.

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system.

Findings were:

On Dec 12, 2012 at 8:18 AM while accompanied by the Assistant Maintenance Director,
1) a hanger was found disconnected from the sprinkler piping that it was intended to support( by air handler unit #8 in penthouse)
2) an antenna cable/ wiring was found rapped around and hanging from sprinkler piping near AHU #8 in penthouse
3) several sprinkler head eschusions covers were observed missing from at least but not limited to M-221, M-274, PSU-2313, PSU 2nd PIXA Rm., PEDS ER across from Rm. 10, Back door to OR36, dishwasher machine in kitchen, dinning Rm., TBI main comm closet ....etc.

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components.

Findings were:

On Dec 11, 2012 at 12:13 PM while accompanied by the Assistant Maintenance Director, an open space was discovered in the electrical panel ( LPWW1) located in the west wing penthouse electrical room.

On Dec. 12, at 9:15 AM while accompanied by the Assistant Maintenance Director, power strips were found connected in series at the Switch Board room.

Based on observation it was discovered that the facility failed to properly maintain the required separation from hazardous areas to the rest of the hospital.

Findings were:

On Dec. 11, 2012 at 12:55 PM while accompanied by the Assistant Maintenance Director the door to the soiled utility room on the 2nd floor, in Respitory Therapy, was found damaged and would not properly close and latch.

Based on observation it was discovered that the facility failed to properly maintain the means of egress and improperly locking of doors in this path.

On Dec. 11th and 12th, 2012 while accompanied by the Assistant Maintenance Director, who informed me that these following locked doors were delayed egress locks. They had no info to let the occupant know these doors would open upon action of delayed lock. Delayed Egress Locked exit doors are required instructional sign was missing from several delayed egress locked doors:
1) by Rm 161
2)near TBI
3)Pharmacy
4) 3rd floor Peds

The requirement per section 7.2.1.6 is for ----On the door adjacent to release device, there shall be a visible sign in letters not less than 1 inch high that reads as follows" PUSH UNTIL ALARM SOUNDS-- DOOR CAN BE OPENED IN 15 SECONDS."

Based on observation it was discovered that the facility failed to properly maintain the smoke detectors for the fire alarm system.

On Dec. 12, 2012 at 11:30 till noon while accompanied by the Assistant Maintenance Director several smoke detectors (areas by Rms. OB186,&189, TBI core by locker Rm.) were found mounted too close to the ceiling vents. The code calls for the Smoke detectors to be at least 3 feet away from these vents. This is to assure that smoke could actually reach the detectors with out being dispersed by the air currents and to prevent the smoke detectors from getting dirty and losing the required sensitivity.

Based on observation, and conversation it was discovered that the facility failed to properly maintain the sprinkler protection as required by NFPA 13.

Findings were:

On Dec 11, 2012 at noon while accompanied by the Assistant Maintenance Director it was discovered that there are many places in the West Wing Penthouse that are not properly equipped with sprinkler coverage under a duct that is more than 4 feet wide. The Asst. Maintenance Director stated that the new duct was recently added to supply ventilation for a new Pharmacy renovation on the ground floor-- Note a Certificate of Use and Occupancy from the local authority had been issued for this completed renovation project .

On Dec. 11, 2012 at 13:10 while accompanied by the Assistant. Maintenance Director it was discovered that there was an area in the Pharmacy that had obstructed sprinkler protection due to a new shelving unit, the area was designed for the storing of the crash carts. This area on a plans review would not have shown the furniture layout and was missed during plans review by the local authority- NOTE the local authority has issued a Certificate of Use and Occupancy for this completed renovation project

Based on observation and record review it was discovered that the facility failed to properly maintain the monitoring of the sprinkler control valves.

Findings were:

On Dec 13, 2012 while doing the record review with the Assistant Maintenance Director, the paperwork from the sprinkler contractor showed that a 1st floor tamper valve was found on Nov 12, 2012 to not be working properly and the valve was secured in the open position by a locked chain, NOTE-while this is an acceptable method per NFPA 13, CMS requires that all sprinkler protection valves be supervised electronically and an alarm sound if valves are closed. This had the potential to affect 100% of the occupants.

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system.

Findings were:

On Dec 12, 2012 at 8:18 AM while accompanied by the Assistant Maintenance Director,
1) a hanger was found disconnected from the sprinkler piping that it was intended to support( by air handler unit #8 in penthouse)
2) an antenna cable/ wiring was found rapped around and hanging from sprinkler piping near AHU #8 in penthouse
3) several sprinkler head eschusions covers were observed missing from at least but not limited to M-221, M-274, PSU-2313, PSU 2nd PIXA Rm., PEDS ER across from Rm. 10, Back door to OR36, dishwasher machine in kitchen, dinning Rm., TBI main comm closet ....etc.

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components.

Findings were:

On Dec 11, 2012 at 12:13 PM while accompanied by the Assistant Maintenance Director, an open space was discovered in the electrical panel ( LPWW1) located in the west wing penthouse electrical room.

On Dec. 12, at 9:15 AM while accompanied by the Assistant Maintenance Director, power strips were found connected in series at the Switch Board room.