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Based on observation, interview, and review of schematics, the facility failed to ensure a fire door on sixth floor latched and the firewall on the fifth floor was free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was completed on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a fire door to stairwell E. Observation of that door revealed it did not close completely because the latch did not work appropriately.
During the tour, Staff E5 confirmed the observation.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Review of the schematic and observation revealed a two-hour fire rated wall running north/south in front of a bank of elevators. Observation of the wall above the double doors in the fire rated wall revealed a sprinkler line with an annular space.
During the tour, Staff F6 confirmed the finding.

Based on observation and interview, the facility failed to ensure a vertical opening between the fifth and fourth floor, and a vertical opening between the third and fourth floor were enclosed with construction having a fire resistance rating of at least two hours. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. The tour revealed an electrical closet, #5111. Within the closet and to the right, a two inch floor conduit for wiring lacked fire stopping. Observation of the same conduit in the same area in the ceiling on the fourth floor also did not reveal any fire stopping material, i.e., the conduit was open between floors.
During the tour of the fifth floor, Staff E5 confirmed the finding.

Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. The tour revealed room #3143 used for information technology. Observation of the ceiling of the room revealed two three inch conduits opening into the room. The conduits were traced to open onto the space between the ceiling and the drop down ceiling on the fourth floor. There was no fire stopping observed in the conduit between the floors.
During the tour of the third floor, Staff F6 confirmed the observation.

Based on observation, interview, review of schematics, and review of posted evacuation plans, the facility failed to ensure each path of egress had an exit sign. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. and corridor 1004 was observed to have two exit signs at either end. Review of the evacuation plan posted in the corridor revealed an additional path of egress down corridor 1006, which is perpendicular to corridor 1004.
An exit sign was not observed to direct people down this path of egress.
During the tour in an interview Staff E5 and F6 confirmed the observation.

Based on observation, interview, and review of schematics, the facility failed to ensure smoke barriers on the third, fourth, fifth, and sixth floor were free of penetrations. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients. Observation of the smoke barrier that divides wing C and wing D revealed two penetrations above the south side of the double doors: a one inch conduit and a single wire.
During the tour of the sixth floor, Staff E5 verified the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above double doors in the smoke wall between wing C and D revealed a blue wire through a one inch open, unsealed conduit, located near the west side of the door.
Observation of the wall above the double doors in the smoke wall between wing B and C revealed a penetration by a two inch unsealed pipe containing blue wires.
During the tour Staff F6 confirmed the observations.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. Observation and review of the schematic revealed the floor to be separated into three smoke compartments with two smoke barriers: one between wing B and C, and one between wing C and D. Each smoke compartment contained sleeping patients.
Observation of the wall above the drop down ceiling over the north door in the smoke barrier that separated wing B and wing C, revealed a two inch conduit containing blue wires and no fire stopping. Other than the wires, it was left open to air.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 11:35 A.M. with Staff E5 and F6. The tour revealed the floor to have sleeping patients and be divided into three smoke compartments. Observation of the wall above the drop drown ceiling over the double doors in the smoke barrier that ran across from room 3234 to 3239 revealed on the north side an open, one-inch conduit with red wiring, an open two inch conduit with blue wires, and an open one inch conduit with no wiring.
During the tour, Staff F6 confirmed the observation.
Observation of the same area revealed room 3234 to be a conference room that had unrated, approximately 12 inch by 18 inch windows in the smoke wall itself.
During the tour, Staff E5 confirmed this observation.

Based on observation, interview, and review of schematics, the facility failed to ensure all hazardous areas on the sixth, fifth, fourth, and third floor were enclosed with a one hour fire-rated barrier, and all hazardous areas on the sixth and fourth floors had three-quarter fire-rated doors. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. The tour revealed a soiled utility room, #6169, in wing D. Observation of the wall above the drop down ceiling revealed three openings: a two by two foot square in the east wall, two pipes with annular spaces on the west wall in the upper left corner, and a one by one foot square in the north wall.
The tour revealed a soiled laundry room in wing B, #6127. Observation of the room revealed its door unrated and a square opening in the east wall above the drop down ceiling.
During the tour of the sixth, Staff F6 observed the findings.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor revealed soiled utility room, #5169. Observation of the wall within the room, above the drop down ceiling, and near the door, revealed a penetration through the wall revealed a one inch steel conduit with an annular space around it.
During the tour, Staff F6 confirmed the observation during an interview.
Tour of the fourth floor was conducted on 11/06/12 at 10:30 A.M. with Staff E5 and F6. The tour revealed a soiled utility room in wing D, #4169. (Wing D contains sleeping patients.) Observation of the room revealed the door to be unrated, and the north wall above the drop down ceiling to be pierced with a white plumbing line having an annular space around it.
During the tour, Staff F6 confirmed the observation.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour a soiled utility room was observed in the D wing, #3169. Observation of the north wall above the drop down ceiling revealed two white pipes with annular spaces, and two air handling conduits with annular spaces.
The tour revealed a soiled utility room in wing A, #3119. Observation above drop down ceiling above the door revealed it to be insulated only, and the north wall to have a one inch conduit with a red wire out of it connecting to a smoke detector. The opening of the conduit was not sealed.
During the tour Staff F6 confirmed the observations

Based on observation, interview, and review of schematics, the facility failed to ensure each path of egress had a paved pathway to a public area. This has the potential to affect all patients, staff, and visitors in the building.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Review of the schematic and observation revealed the in-patient sleeping area to have a path of egress leading to an outside door in the southeast corner of the unit. Observation of the area outside of the door, and, hence, outside the building revealed the path of egress lead to a concrete pad. The concrete pad was observed to not be connected to a paved pathway to a public area.
In an interview during the tour, Staff E5 confirmed the observation.

Based on observation, interview, and review of schematics, the facility failed to ensure the width off all corridors serving as exit access on the third floor were at least eight feet in width. This has the potential to affect all patients, staff, and visitors on the third floor.
Findings include:
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. During the tour, four cross-corridor, according style, unrated doors were observed in paths of egress. One was observed at the most south end of the main corridor. Behind this door were four patient sleeping rooms, rooms 3186 to 3189. The remaining three were in paths of egress within an intensive care unit. Behind one door were four patient sleeping rooms, rooms 3223 to 3229. Behind another were two sleeping patient rooms, rooms 3205 and 3207. The final one was observed to divide corridor 3016 from 3011. Corridor 3011 was observed to be in a path of egress leading from the intensive care unit to stairwell E.
Each of the doors was observed to be in the open position; however, the doors in their open position compressed the width of the corridor to six feet.
When the doors were observed in the their closed position, a red sticker on them read, " in case of emergency push to open. "
Staff E5 and F6 were observed to do this. They had difficulty pushing the doors open, taking several minutes to do so. Each door in the accordion had to be pushed out and then laterally toward the wall. The accordion door was not observed to push out as a single door in one smooth motion.
During the tour, Staff E5 and F6 confirmed the observations in an interview.

Based on observation, interview, and review of schematics, the facility failed to ensure all suites on the sixth, fifth, and third floor that were greater than 1,000 square feet in area had two remote exit access doors. This has the potential to affect all patients, staff, and visitors on the sixth, fifth, and third floors.
Findings include:
Tour of the sixth floor was conducted on 11/05/12 at 12:10 P.M. with Staff E5 and F6. Observation and review of the schematic revealed the south end of the floor to contain a suite of 1,400 square feet, containing space for sleeping patients, and one exit.
During the tour of the sixth floor, Staff E5 confirmed the finding.
Tour of the fifth floor was conducted on 11/06/12 at 8:00 A.M. with Staff E5 and F6. Observation of the floor and review of the schematic revealed wing A and wing D to be suites. Review of the schematic revealed wing A to have 1800 square feet area and wing D to have 1435 square feet area.. Observation of both the suites did not reveal two remote exits.
During the tour of the fifth floor, Staff E5 confirmed the finding.
Tour of the third floor was conducted on 11/06/12 at 1:45 P.M. with Staff E5 and F6. Observation during the tour and review of the floor ' s schematic revealed a 1600 square foot suite in wing C. The suite contained sleeping patients. The suite was not observed to have more than one remote exit.
During the tour of the third floor, Staff E5 confirmed the finding.

Based on observation during tour and staff verification it was determined this facility failed to ensure all sprinkler heads were continuously maintained in reliable operating condition. This had the potential to affect all those who were utilizing these areas of the facility. The patient census at the beginning of the survey was 170.

Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the first and second floors observation was made of sprinkler heads which had dirt, dust and/or debris on them in the following locations:
First floor:
*Within room 1179 of the vascular ultrasound department.
*Within rooms 1302, 1285, 1276 and 1278 of the emergency department.
*Multiple dirty sprinkler heads were observed in the cafeteria area.

Second floor:
*Multiple dirty sprinkler heads located in the men's surgical locker room.

These findings were verified by staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage rooms were protected with at least a one hour fire rated construction and all switches and receptacles were located at the proper distance from the floor. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 170.

Findings include:

Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the medical gas room number 0108 located in the lower level lab area, observation was made of an unrated door. This medical gas room had three H tanks of nitrogen, one H tank of argon and one small tank of argon.

During tour of the medical gas room number 136 located on the first floor adjacent to the hyperbaric room, observation was made of a light switch mounted less than five feet from the floor and a ventilation system that appeared to be tied into the hospital ventilation system due to the fact that it had a supply and return diffuser. This system was not able to be verified by this writer as a dedicated ventilation system as required.

These findings were verified by all staff present during tour. Staff A1 stated on 11/06/12 at approximately 11:15 AM that they will check to see if this ventilation system was a dedicated system. No verification was obtained by the end of the survey process.

Based on facility tour, staff interview, review of operating room relative humidity (RH) levels and verification it was determined this facility failed to ensure the relative humidity in all operating rooms was maintained to at least 35% or greater according to the National Fire Protection Association (NFPA) 99 Chapter 5.4.1.1. This had the potential to affect all those utilizing this area of the facility. The facility census was 170 at the beginning of the survey.
Findings include:
Facility tour took place on 11/05/12 through 11/06/12 with staff members A1, B2, C3 and D4. During tour of the operating rooms a question was proposed to staff A1 regarding how and what relative humidity levels are to be maintained. Staff A1 stated they are maintaining RH levels according to the ASHRAE standard which promotes 20-60% RH levels and not the NFPA standards which require a minimum of 35% RH levels in anesthetizing locations.
Documentation review of the operating room RH levels for 2012 took place on 11/07/12. It was noted that RH levels in every operating room was consistently below the required 35% level for the months of January through March. Also noted was RH levels sporadically below the required 35% in different operating rooms on varying months beyond March of 2012.
Additional documentation was provided on 11/08/12 regarding an incident in operating room # 8 on 05/16/12. This documentation revealed a reported fire during a procedure which was found to be initiated in an electrical unit for the operating table. Documentation revealed this to be smoke and not an active fire and in which no harm came to the patient or staff. Interview with staff E5 on 11/08/12 at approximately 1:15 PM reveals the unit was immediately removed and replaced and the procedure was completed without incident. This writer also reviewed the humidity level of operating room # 8 on the day of the incident 05/16/12, and was found to be documented at 25.4%, well below the required 35%. Interview with E5 on 11/08/12 at approximately 1:40 PM reveals the sensor for operating room # 8 had not been functioning correctly and felt the RH level was truly greater than what the sensor was reading. Further interview reveals this sensor had not functioned properly for at least two months prior to the incident and was not corrected until 09/16/12, four months after the incident.

These findings were verified by all staff present during interview and documentation review of operating room RH levels on 11/08/12.

LIFE SAFETY CODE 101, 2000 edition, 7.2.1.5.4: Doors shall be operable with not more than one releasing operation.
Based on observation and interview, the facility failed to ensure each door was operable with not more than one releasing operation, specifically the door on a seclusion room. This has the potential to affect any patient placed in the seclusion room.
Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch. The sliding deadbolt was observed to have holes in its frame as well as in the bolt itself. Therefore, the bolt could be held in place with both a pin in a hole as well as when the bolt is latched.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.

LIFE SAFETY CODE 101, 2000 edition, 19.2.2.2.5: Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

Based on observation and interview, the facility failed to ensure each door located in the means of egress, as defined by LIFE SAFETY CODE 101, 2000 edition, 3.3.121, had one locking device, specifically the door on the seclusion room. This has the potential to affect any patient placed in the seclusion room.

Findings include:
Tour of the psychiatric facility was conducted on 11/07/12 at 10:45 A.M. Observation of the facility revealed a room 1113. The room was observed to have two locks. One was a sliding deadbolt, and the other was a locking latch.
During the tour, Staff Z1, a member of nursing administration, explained the room was used as a seclusion room. He/she explained a staff member is always outside the room when a patient is inside. He/she stated sometimes both the deadbolt and the locking latch are used.