HospitalInspections.org

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @ 13:10 (a) The 2 hour wall located in corridor 592 had penetrations with no fire stopping material present.

(b) No documentation could be provided to indicate that the doubled pieces of gypsum board located at the upper 2' of the 2 hour wall meet the requirements for a 2 hr assembly (no fire stopping present as well)

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. No documentation could be provided to indicate that doors were being inspected in accordance with 2012 NFPA 101-7.2.1.15

2. The 2 hour fire wall located in corridor 592 near operating room entrance (above the ceiling) there is exposed foam board insulation that does not have the required thermal barrier/covering per Title 25 section 2447-B of the state statue.

Based on observation of surveyors 16732, 16776, 35163 and 37696 on June 13, 2017:

The exit that leads to the outside of the building where the MRI trailer is parked was blocked with the MRI trailer platform and steps. There was no to evacuate out of the exit.



The maintenance director and quality director confirmed this finding at the site.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @11:24 Emergency department exit to main entrance requires additional signs. There is no visible exit sign when standing at opposite end of corridor.

Based on observation of surveyors 16732, 16776, 35163 and 37696 on June 13, 2017:

The exit enclosure that goes out where the MRI trailer is parked has a IT area on the left that is exposed to the enclosure with plastic strips protecting the area and chain link wall. The area is the entire length of the exit enclosure. In the area are computer servers, phone machines and wiring.


The maintenance director and quality director confirmed this finding at the site.




35163

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @11:44 (a) Elevator control room located near patient registration had penetrations in the 1 hour wall with no fire stopping material present and would not stop the passage of smoke/fire.

2. @ 12:13 upstairs mechanical room (2 hr rated space) had spray urethane insulation used to seal penetrations and additional penetrations with no fire stopping material present.

3. The old sleep study suite now used for storage shall have a self-closing and positive latching door

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met by the lack of smoke detection in the elevator "lobby" on the main level.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. Supply closet located in performance improvement office has exposed CPVC sprinkler piping running from floor to ceiling. No documentation could be provided that the piping did not need to be enclosed/protected per the manufacturer.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @ 12:05 Physical file room located across from conference room had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

2. @ 13:46 The janitors closet located in back of station had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

3. @ 15:10 Janitor closet (#128) located near vending, had storage within 18" of the sprinkler head that would not allow for proper sprinkler pattern development.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @11:38 Patient registration corridor had a electrical panel room with penetrations that would not prevent the passage of smoke.

2. @11:58 Server/IT room had penetrations and missing ceiling tiles that would not prevent the passage of smoke.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @ 11:49 Zone 3 stairwell located near human resources had a painted door/frame tag and the rating it could not be determined.

2. @ 13:40 The nursing I/T office

3. @ 14:23 Health information office door (door#70) had holes in the door that would not prevent the passage of smoke.

4. @14:26 Support services locker room door (#67) does not have a latch on the door or any means of keeping the door closed.

5. @ 14:41 Environmental services storage rooms do not have a self closing device.

6. @ 15:10 Janitor closet (#128) located near vending, had vent in door that would not prevent the passage of smoke.

7. @ 15:15 Cardio-pulmonary testing room is also being used as a storage room and does not have a self closing device on the door.

8. Staff restroom in ED department has a louvered door

9. ED exam room doors do not have latching devices

10. ED exam room door has a measure 3/4" gap at the top of the door. A glove holder bracket and blue FRP on the door prevent the door from closing properly

11. Unisex bathroom door, frame label 258 has a gap that measures over 1"

12. Door 36 staff breakroom (locker room) corridor door to be latching

13. door to nurses station to be latching

On 6-13-2017 During our regular inspection Surveyors 16776 / 16732 with Nursing Supervisor for Environmental Services observed:

1- In the Boiler Room; Hole penetrations from pipes at the ceiling / wall areas need to be filled to maintained fire resistance rating.

2- In the 2nd floor Mechanical Room; Missing fire proofing from ceiling "Steel I Beams" ; Need to be coved with fire rated material.
Area of question, In the Middle of the room and on the outside wall going to the roof exit door.

Based on records review and observation surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

The following deficiencies were listed on the medical testing and evaluation report conducted by a third party on June 1, 2016 and no documentation could be provided to indicate that the corrections were made.

1. Emergency Department/Radiology
(a) room #252 oxygen outlet leaks
(b) X-ray 1 oxygen outlet leaks
(c) X-ray 2 vacuum inlet leaks
(d) Treatment room 6 vacuum inlet leaks

2. Admin/Radiology room # 101 vacuum inlet leaks

3. ICU (a) The oxygen zone valve located left of the ICU entrance leaks when in the off position.
(b) ICU C-3rd vacuum leaks

4. Surgical Services-Operating room # 2 (173)
(a) 1st vacuum inlet on ceiling leaks at the end of the hose.
(b) 2nd inlet on ceiling leaks at the end of the hose.
(c) 3rd inlet on ceiling leaks at the end of the hose.

5. Radiology-zone valves located around the corner from Bone Density
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has no threaded connections to the piping

6. Emergency Department/Radiology
(a) The zone valve box located left of nuclear medicine has no pressure indicators on the station outlet/inlet side of the valves
(b)The zone valve box located left of nuclear medicine has threaded connections to the piping
(c) Needs to be relabeled to say Nuclear Medicine

7. The zone valve box located inside file room (120B)
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has threaded connections to the piping
(c) Needs to be relabeled to say Trauma Rooms 5-6, X-ray 2

8. The zone valve box located right side of stress testing
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has threaded connections to the piping
(c)The vacuum valve needs to relabeled to say Stress Testing (125), Trauma rooms 5-6, X-ray 2, Nuclear medicine (126)
(d) The oxygen valve needs to be relabeled to say Stress testing (125)

9. The zone valve box located right of room 247
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has threaded connections to the piping
(c) Needs to be relabeled to say Trauma room 1, Cardiac Rehab, X-ray 1, Rooms 247, 251, 252

10. Admin/Radiology-The zone valve boxes located left of room 133 have no pressure indicators on the station outlet/inlet side of the valves.

11. Medical Surgical
(a) The zone valve box located across from nurses station has no pressure indicators on the station outlet/inlet side of the valves
(b) The zone valve box located left of room 121 has no pressure indicators on the station outlet/inlet side of the valves
(c) The zone valve box located right of room 102 has no pressure indicators on the station outlet/inlet side of the valves and has threaded connections to piping

12. Old Birthing-the oxygen zone valve located right of room 37
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has threaded connections to the piping
(c) Is located behind a door/concealed

13. Old Birthing vacuum zone valve located right of room 37
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) Has threaded connections to the piping

14. ICU-The zone valve box located left of the ICU entrance
(a) Has no pressure indicators on the station outlet/inlet side of the valves
(b) The oxygen valve has the wrong colored pipe label

15. Surgical Services- The vacuum inlet in the endoscopy scope room is being used for non-patient care

16. Sources ( Vacuum Pump)
(a) Final line gauge and pressure switch are not located immediately after the source valve
(b) The final line gauge cannot be seen from a standing position

17. Sources (Manifold Room)
(a) The vent lines for all manifolds need to be labeled to distinguish them from the main line piping
(b) The source valves for nitrous oxide, medical air, carbon dioxide and nitrogen need to be relabeled with names for specific medical gas, rooms or areas served, and caution to not close or open the valve except in emergency

18. Oxygen system piping to the oxygen pressure switch is soft copper

19. The existing Melco oxygen outlets throughout the facility do not meet current NFPA criteria for operational pressure tests.

20. Zone valve box near stress testing room-piping has wrong color for vacuum piping

Based on observations and records review surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

The following deficiencies were listed on the medical testing and evaluation report conducted by a third party on June 1, 2016 and no documentation could be provided to indicate that the corrections were made.

1. Medical Surgical-the area alarm panel that monitors Medical Surgical rooms 122-124, Day room
(a) The oxygen low pressure alarm sounds at 48 psig
(b) The vacuum low pressure alarm sounds at -7Hg
(c)The panel will not reinitiate if a signal is already in alarm
(d) The vacuum indicator light does not function.
2. Emergency Department/Radiology
(a) There are no area alarms monitoring the medical gases in this department

3. Old Birthing- there is no area alarm monitoring the medical gases in this department

4. ICU has no area alarm monitoring the medical gases in this department.

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director an electrical switch just inside the door of room 277 in cardio pulmonary testing did not "turn on" anything apparent in the room

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @11:04 Radiology office had a power strip/multi outlet device that was powering coffee pot and the multi outlet device was hanging down creating tension on the plug

2. ED breakroom had coffee pot & microwave plugged into power strips

Based on observations surveyors 35163, 16776, and 37696 on 05/13/17, in the presence of the maintenance director the following was not met:

1. @ 11:31 Oxygen storage room located in cardio-pulmonary room has vent that is open to the corridor and would not prevent the passage of smoke.