HospitalInspections.org

Based on observation and interview, the facility failed to maintain the building construction in accordance with LSC (00) 18.1.6.2, 18.1.6.3, 18.2.5.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the 2-hour fire wall surrounding the atrium has glass only rated for 45-minutes on the third and fourth floors.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has not maintained the corridors in accordance with NFPA 101 (2000 edition), Chapter 19, Section 19.3.6.1. This could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are numerous penetrations in the suspended ceiling tiles throughout the lower level surgical suites. This area is protected by a fire sprinkler system.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the corridor double doors leading into Room E1605 did not fully close and latch. The inactive leaf was preventing the active leaf from fully closing and latching.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observations and interview, the facility has failed to maintain smoke/fire barrier doors in accordance with LSC 19.3.7.5. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the 2-hour building separation at the third floor corridor leading from the Piper Building to Main East, which also serves as the smoke barrier, has double doors that do not latch closed and there is over an 1/8 inch gap between the doors.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that:
1. Trash room doors PB2049 and PB2009 will not close and latch,
2. Near Room PB1170, there is a storage area over 50 square feet that is open to the corridor and not enclosed,
3. Room PB2006, which is a storage room due to the roll down door, is not a properly enclosed storage room.

These deficient practices were verified by the Director of Facilities Management the time of the inspection.

Based on observation, the stairway enclosure of this facility does not meet the required one (1) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are seven exposed cables located within Stairwell 28.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the special locking arrangements on the third and fourth floor behavioral health units in the Courage Kenny building are not in compliance with the code. The special locking arrangements automatically relock upon resetting the fire alarm panel. Also, the fire alarms sound throughout the building but the special locking arrangements only unlock on the floor of incident.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility failed to have proper policies and procedures for the operating room in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients undergoing certain types of surgeries.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, staff from the Minnesota Department of Health observed electrosurgical pencils being placed on surgical drapes and not in their respective holsters during surgery in OR Room 18 in accordance with Abbott Northwestern Hospital Policy Reference # SS0037. It was observed that the electrosurgical pencil was still hot, producing smoke and/or odor and remained on the drapes in excess of 30 seconds.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on record review and interview, it was determined that the facility failed to adequately track employee participation for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 18.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that there isn't a clear means of tracking employee training and participation of the fire drills. Each department is responsible for tracking who was present but there isn't an auditing program in place to verify employee training and participation.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on record review and interview, it was determined that the facility failed to adequately track employee participation for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that there isn't a clear means of tracking employee training and participation of the fire drills. Each department is responsible for tracking who was present but there isn't an auditing program in place to verify employee training and participation.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. This deficient practice could affect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that there was no smoke detector located directly above the main fire alarm panel.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on review and interview, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. Section 9.6.1.4. This deficient practice could affect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that the fire alarm annual inspecting documentation did not have the proper NFPA documentation required.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72, (99). This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are smoke detectors within 36 inches of the HVAC diffusers near CK2792 and the third floor living room near Stairwell 22 located in Courage Kenny Building.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation, interview and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This deficient practice could effect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are smoke detectors located within 36 inches of the HVAC diffusers near Room MB4614, MB3667, Room S12 and the first floor lobby.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all patients.

Findings include:
On facility tour between 10:00 AM and 03:00 PM on 12/03/2014, it was observed that there was no wrench located, to replace a used or damaged sprinkler heads.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on observation and interview, the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that:
1) The spare sprinkler head box did not contain the full compliment of heads used for the building.
2) There was no wrench located, to replace a used or damaged sprinkler heads.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on record review and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that:
1. In Room PB5665A, the suspended ceiling is incomplete with a fire sprinkler head located below the in-place suspended ceiling tiles,
2. (2) spare fire sprinkler heads of each type are not located in the spare head box,
3. A concealed fire sprinkler head socket wrench is not provided,
4. The fire sprinkler head located in the lower level Courage Kenny Stairwell 22 is obstructed by HVAC ductwork.

These deficient practices were verified by the Director of Facilities Management the time of the inspection.

Based on observations and interviews, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) is installed in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 2-3.11. A noncompliant HVAC system could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that dampers HP-DSLL-221, HP-DSLL-261 and HP-DSLL-298 had not been inspected within the last 6 years. Test records indicate that these dampers are concealed by construction members and are inaccessible.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has failed to use the proper powerstrips in accordance with CMS-S&C 14-46. This deficient practice could affect the safety of all patients in the operating rooms.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed a yellow, non-UL complaint power strip that does not conform to CMS S&C-14-46 in use in the C-Section operating room.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility failed to maintain the building construction in accordance with LSC (00) 18.1.6.2, 18.1.6.3, 18.2.5.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the 2-hour fire wall surrounding the atrium has glass only rated for 45-minutes on the third and fourth floors.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has not maintained the corridors in accordance with NFPA 101 (2000 edition), Chapter 19, Section 19.3.6.1. This could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are numerous penetrations in the suspended ceiling tiles throughout the lower level surgical suites. This area is protected by a fire sprinkler system.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the corridor double doors leading into Room E1605 did not fully close and latch. The inactive leaf was preventing the active leaf from fully closing and latching.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observations and interview, the facility has failed to maintain smoke/fire barrier doors in accordance with LSC 19.3.7.5. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the 2-hour building separation at the third floor corridor leading from the Piper Building to Main East, which also serves as the smoke barrier, has double doors that do not latch closed and there is over an 1/8 inch gap between the doors.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that:
1. Trash room doors PB2049 and PB2009 will not close and latch,
2. Near Room PB1170, there is a storage area over 50 square feet that is open to the corridor and not enclosed,
3. Room PB2006, which is a storage room due to the roll down door, is not a properly enclosed storage room.

These deficient practices were verified by the Director of Facilities Management the time of the inspection.

Based on observation, the stairway enclosure of this facility does not meet the required one (1) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are seven exposed cables located within Stairwell 28.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that the special locking arrangements on the third and fourth floor behavioral health units in the Courage Kenny building are not in compliance with the code. The special locking arrangements automatically relock upon resetting the fire alarm panel. Also, the fire alarms sound throughout the building but the special locking arrangements only unlock on the floor of incident.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility failed to have proper policies and procedures for the operating room in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients undergoing certain types of surgeries.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, staff from the Minnesota Department of Health observed electrosurgical pencils being placed on surgical drapes and not in their respective holsters during surgery in OR Room 18 in accordance with Abbott Northwestern Hospital Policy Reference # SS0037. It was observed that the electrosurgical pencil was still hot, producing smoke and/or odor and remained on the drapes in excess of 30 seconds.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on record review and interview, it was determined that the facility failed to adequately track employee participation for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 18.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that there isn't a clear means of tracking employee training and participation of the fire drills. Each department is responsible for tracking who was present but there isn't an auditing program in place to verify employee training and participation.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on record review and interview, it was determined that the facility failed to adequately track employee participation for each shift in the last 12-month period in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that there isn't a clear means of tracking employee training and participation of the fire drills. Each department is responsible for tracking who was present but there isn't an auditing program in place to verify employee training and participation.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. This deficient practice could affect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that there was no smoke detector located directly above the main fire alarm panel.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on review and interview, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. Section 9.6.1.4. This deficient practice could affect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that the fire alarm annual inspecting documentation did not have the proper NFPA documentation required.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72, (99). This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are smoke detectors within 36 inches of the HVAC diffusers near CK2792 and the third floor living room near Stairwell 22 located in Courage Kenny Building.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation, interview and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This deficient practice could effect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that there are smoke detectors located within 36 inches of the HVAC diffusers near Room MB4614, MB3667, Room S12 and the first floor lobby.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all patients.

Findings include:
On facility tour between 10:00 AM and 03:00 PM on 12/03/2014, it was observed that there was no wrench located, to replace a used or damaged sprinkler heads.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on observation and interview, the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all patients.

Findings include:
On facility tour between 10:00 AM and 3:00 PM on 12/03/2014, it was observed that:
1) The spare sprinkler head box did not contain the full compliment of heads used for the building.
2) There was no wrench located, to replace a used or damaged sprinkler heads.

This deficiency was verified by ANW staff (AJ), at the time of discovery.

Based on record review and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice could affect the patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed that:
1. In Room PB5665A, the suspended ceiling is incomplete with a fire sprinkler head located below the in-place suspended ceiling tiles,
2. (2) spare fire sprinkler heads of each type are not located in the spare head box,
3. A concealed fire sprinkler head socket wrench is not provided,
4. The fire sprinkler head located in the lower level Courage Kenny Stairwell 22 is obstructed by HVAC ductwork.

These deficient practices were verified by the Director of Facilities Management the time of the inspection.

Based on observations and interviews, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) is installed in accordance with the LSC, Section 19.5.2.1 and NFPA 90A, Section 2-3.11. A noncompliant HVAC system could affect all patients.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, record review revealed that dampers HP-DSLL-221, HP-DSLL-261 and HP-DSLL-298 had not been inspected within the last 6 years. Test records indicate that these dampers are concealed by construction members and are inaccessible.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.

Based on observation and interview, the facility has failed to use the proper powerstrips in accordance with CMS-S&C 14-46. This deficient practice could affect the safety of all patients in the operating rooms.

Findings include:

On facility tour between 12/01/2014 and 12/04/2014, observation revealed a yellow, non-UL complaint power strip that does not conform to CMS S&C-14-46 in use in the C-Section operating room.

This deficient practice was verified by the Director of Facilities Management the time of the inspection.