HospitalInspections.org

Based on observations the facility failed to maintain vertical openings between floors as required by NFPA 101, 3.3.207, 3.3.182, 3.3.20, 8.2.5 and 19.3.1.1.

Findings include:

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, in room J415, a hazardous area as defined in NFPA 101, 19.3.2.1(4), a biomedical engineering repair shop, revealed a ceiling tile in the suspended ceiling had been cut in half and reinserted in the suspended ceiling grid. Further examination revealed a chain hoist had been installed above the suspended ceiling and when installed required the one hour fire barrier in the interstitial space above the suspended ceiling to be penetrated and the membrane had not been resealed to maintain the one hour fire resistance rating. Observation through the suspended ceiling opening and through the penetrated one hour fire barrier revealed corrugated steel supporting the roof of the Annex building. The Facility Safety Officer acknowledged the observation.

On 10/24/11, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, in room J325, a soiled utility room and a hazardous area as defined in NFPA 101, 19.3.2.1(5), revealed a four inch pipe with insulation penetrating the concrete floor to the interstitial space below the floor. Further observation revealed the insulation had separated above the floor and observation through the penetration surrounding the 4 inch pipe revealed the interstitial space above the ceiling of the floor below. The Facility Safety Officer acknowledged the observation.

On 10/24/11, on the 9th floor of the west pavilion trash chute, two tears in the steel trash chute were observed when the access door was opened. This chute also had an access door propped open on the 5th floor and a small hole approximately 3" x 5" was observed in the rated shaft wall on the second floor.

Based on observation one of three doors in a basement hazardous area was not maintained to automatically close.

Findings include:

During the Life Safety survey on October 25, 2011, one door in area E020, described as the "cart storage area" which was larger than 100 square feet and was used for receiving and storing bulk linen. The interior door when opened past 90 degrees would bind or rub on the floor and hold it in an open position.

Based on observation, the facility fire sprinkler system was not maintained for compliance with NFPA 13 and NFPA 25 as required.

Findings include:

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 2 of 2 concealed sprinkler heads in room C906 and 1 of 2 sprinkler heads in room C935, in which the sprinkler body was to be fully concealed was 1 to 1 ½ inches below the suspended ceiling tile. The Facility Safety Officer acknowledged the observation.

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 4 of 8 sprinkler heads in the Adult Discharge Department with a significant buildup of foreign material, (dust).

During the facility Life Safety survey from October 24-26, 2011 it was determined by the surveyor and the facility Administrative Staff that the following areas contained a mix of standard-response and quick-response sprinkler heads. Observed areas included: Second Floor Crossover Corridor, Main OR Corridor by #C254A and Facilities Basement Corridor between doors #15 and #16. Reference : NFPA 13 ( 2002 Edition) "Installation of Sprinkler Systems": 8.3.3.2: " Where quick-response sprinklers are installed, all sprinklers within a compartment shall be of the quick-response type." NFPA 13 ( 2002 Edition): 8.3.3.4: " When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed."

It was further observed during the facility tour that a number of sprinkler heads were debris/dust/lint laden, painted, rusted and escutcheons were missing or not securely in place in the following areas: Dietary Kitchen, Cafeteria and Food Court (loaded with debris and had rusted or missing escutcheons); OR #17 (escutcheon missing); OR #3 Hallway (escutcheon loose); Walkway by McDonalds (escutcheons missing and some loose); Laboratory (escutcheons missing and some loose); Admissions First Floor West (escutcheons missing) Administration area (escutcheons missing); Concealed head covers loose throughout property; ICU area (painted escutcheon) and NICU Waiting Area (escutcheon missing).

Based on observations and interviews, the facility failed to maintain the required portable fire extinguishers in compliance with NFPA 101 (2000 Edition) Life Safety Code and NFPA 10 (1998 Edition) Standard for Portable Fire Extinguishers.

Findings include:

It was observed that a number of fire extinguishers were fully obstructed by equipment, not allowing for immediate access in the event of a fire emergency. Obstructed extinguishers included: Dietary Kitchen area; Laboratory second floor West Pavilion; and Lab SC 2.5 area.
During the Dietary tour on October 24, 2011, it was observed that on the Cafeteria Cook's line Food Court, there was no mounted or accessible K-Series fire extinguisher or placard for the cooking area protected by the new Anusol wet chemical UL300 system. Reference NFPA 10 (1998 Edition) 4.3.2: " Class K Fire Extinguishers for Cooking Oil Fires: Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." Reference 4.3.2.2." A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher."

Based upon document review, staff interviews and observations during the survey, it was determined there was no available documentation to verify that the facility had conducted or was conducting the required monthly "Owner's Inspection" of the dietary cook line protected by a UL300 Listed fire protection system.

Findings include:

On Monday October 24, 2011, during the tour of the facility kitchen, the staff could not provide documentation that the kitchen hood system had been checked monthly. Staff interviews confirmed that this process was not in place.
Reference NFPA 17A: "Standard for Wet Chemical Extinguishing Systems" 5-2.1: " Inspection shall be conducted on a monthly basis with the manufacturer 's listed installation and maintenance manual or the owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct and protected cooking appliances have not been replaced, modified or relocated.
NFPA 17A 5-2.2: " If any deficiencies are found, appropriate corrective actions shall be taken immediately.
NFPA 17A 5.2.3: " Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. "
NFPA 17A 5-3.4: " At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. "

Based on observation and staff interview the facility failed to secure medical gas cylinders to prevent falling or being knocked over as required by NFPA 101, 19.3.2.4, and NFPA 99, 4-3.1.1.1.

Findings include:

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 2 of 2 " H " size high pressure medical gas cylinders in the MRI Equipment Room, J193, free standing, unsecured, with no device to prevent falling or being knocked over. The Facility Safety Officer acknowledged the observation.

Based on observations and staff interviews conducted during the survey from October 24-26, 2011, it was determined that this facility did not comply with the specific requirements of NFPA 101; NFPA 70- National Electrical Code and the NFPA 99 (2005 Edition).

Findings include:

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, revealed access to an electrical panel in the main corridor of the Interventional Radiology Department adjacent to room J242E blocked by furniture, a table and chair. The Facility Safety Officer acknowledged the presence of the table and chair blocking access to the electrical panel.

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, revealed a power strip plugged into a surge protector thereby creating a prohibited " Daisy Chain " that was plugged into a duplex electrical receptacle in room J-340 of the Annex building. The Facility Safety Officer acknowledged the presence of the " Daisy Chain " .

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed a power strip plugged into a power strip which is prohibited in room A971. The power strips were secured to the wall in a permanent manner and provided power for charging batteries of a patient lift and a separate chair lift.

It was observed that a number of in-use two-to-three prong adapters and extension cords failed to meet the requirements. Adapters and Extension Cords:" 8.5.2.1.7.1: Adapters and extension cords meeting the requirements of 8.4.1.2.5 shall be permitted to be used. 8.5.2.1.7.2: Three- to- two prong adapters shall not be permitted. 8.5.2.1.7.3: The wiring shall be tested for all of the following: (1) Physical integrity; (2) Polarity; and (3) Continuity of grounding at the time of assembly and periodically thereafter." Observed areas with in-use non-hospital grade multi-plugged adapters and in-use extension cords included: Dietary Ice Machine (extension cord in use as permanent power); ATM Machine Cafeteria (piggy-backed electric into surge bar in use as permanent power); Bayshore Corridor by NICU (extension cord in use as permanent power); 4th Floor Ultra sound area (multi-plug adapter in-use for decorations and piggy-backed); ); 6th Floor by A671 Storage area (piggy-backed surge bar) and OB/LDR Area OR#1 (double-plugged hospital grade Tripp-Lite surge bars piggy-backed).

Based on observations the facility failed to maintain vertical openings between floors as required by NFPA 101, 3.3.207, 3.3.182, 3.3.20, 8.2.5 and 19.3.1.1.

Findings include:

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, in room J415, a hazardous area as defined in NFPA 101, 19.3.2.1(4), a biomedical engineering repair shop, revealed a ceiling tile in the suspended ceiling had been cut in half and reinserted in the suspended ceiling grid. Further examination revealed a chain hoist had been installed above the suspended ceiling and when installed required the one hour fire barrier in the interstitial space above the suspended ceiling to be penetrated and the membrane had not been resealed to maintain the one hour fire resistance rating. Observation through the suspended ceiling opening and through the penetrated one hour fire barrier revealed corrugated steel supporting the roof of the Annex building. The Facility Safety Officer acknowledged the observation.

On 10/24/11, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, in room J325, a soiled utility room and a hazardous area as defined in NFPA 101, 19.3.2.1(5), revealed a four inch pipe with insulation penetrating the concrete floor to the interstitial space below the floor. Further observation revealed the insulation had separated above the floor and observation through the penetration surrounding the 4 inch pipe revealed the interstitial space above the ceiling of the floor below. The Facility Safety Officer acknowledged the observation.

On 10/24/11, on the 9th floor of the west pavilion trash chute, two tears in the steel trash chute were observed when the access door was opened. This chute also had an access door propped open on the 5th floor and a small hole approximately 3" x 5" was observed in the rated shaft wall on the second floor.

Based on observation one of three doors in a basement hazardous area was not maintained to automatically close.

Findings include:

During the Life Safety survey on October 25, 2011, one door in area E020, described as the "cart storage area" which was larger than 100 square feet and was used for receiving and storing bulk linen. The interior door when opened past 90 degrees would bind or rub on the floor and hold it in an open position.

Based on observation, the facility fire sprinkler system was not maintained for compliance with NFPA 13 and NFPA 25 as required.

Findings include:

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 2 of 2 concealed sprinkler heads in room C906 and 1 of 2 sprinkler heads in room C935, in which the sprinkler body was to be fully concealed was 1 to 1 ½ inches below the suspended ceiling tile. The Facility Safety Officer acknowledged the observation.

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 4 of 8 sprinkler heads in the Adult Discharge Department with a significant buildup of foreign material, (dust).

During the facility Life Safety survey from October 24-26, 2011 it was determined by the surveyor and the facility Administrative Staff that the following areas contained a mix of standard-response and quick-response sprinkler heads. Observed areas included: Second Floor Crossover Corridor, Main OR Corridor by #C254A and Facilities Basement Corridor between doors #15 and #16. Reference : NFPA 13 ( 2002 Edition) "Installation of Sprinkler Systems": 8.3.3.2: " Where quick-response sprinklers are installed, all sprinklers within a compartment shall be of the quick-response type." NFPA 13 ( 2002 Edition): 8.3.3.4: " When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed."

It was further observed during the facility tour that a number of sprinkler heads were debris/dust/lint laden, painted, rusted and escutcheons were missing or not securely in place in the following areas: Dietary Kitchen, Cafeteria and Food Court (loaded with debris and had rusted or missing escutcheons); OR #17 (escutcheon missing); OR #3 Hallway (escutcheon loose); Walkway by McDonalds (escutcheons missing and some loose); Laboratory (escutcheons missing and some loose); Admissions First Floor West (escutcheons missing) Administration area (escutcheons missing); Concealed head covers loose throughout property; ICU area (painted escutcheon) and NICU Waiting Area (escutcheon missing).

Based on observations and interviews, the facility failed to maintain the required portable fire extinguishers in compliance with NFPA 101 (2000 Edition) Life Safety Code and NFPA 10 (1998 Edition) Standard for Portable Fire Extinguishers.

Findings include:

It was observed that a number of fire extinguishers were fully obstructed by equipment, not allowing for immediate access in the event of a fire emergency. Obstructed extinguishers included: Dietary Kitchen area; Laboratory second floor West Pavilion; and Lab SC 2.5 area.
During the Dietary tour on October 24, 2011, it was observed that on the Cafeteria Cook's line Food Court, there was no mounted or accessible K-Series fire extinguisher or placard for the cooking area protected by the new Anusol wet chemical UL300 system. Reference NFPA 10 (1998 Edition) 4.3.2: " Class K Fire Extinguishers for Cooking Oil Fires: Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." Reference 4.3.2.2." A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher."

Based upon document review, staff interviews and observations during the survey, it was determined there was no available documentation to verify that the facility had conducted or was conducting the required monthly "Owner's Inspection" of the dietary cook line protected by a UL300 Listed fire protection system.

Findings include:

On Monday October 24, 2011, during the tour of the facility kitchen, the staff could not provide documentation that the kitchen hood system had been checked monthly. Staff interviews confirmed that this process was not in place.
Reference NFPA 17A: "Standard for Wet Chemical Extinguishing Systems" 5-2.1: " Inspection shall be conducted on a monthly basis with the manufacturer 's listed installation and maintenance manual or the owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct and protected cooking appliances have not been replaced, modified or relocated.
NFPA 17A 5-2.2: " If any deficiencies are found, appropriate corrective actions shall be taken immediately.
NFPA 17A 5.2.3: " Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. "
NFPA 17A 5-3.4: " At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. "

Based on observation and staff interview the facility failed to secure medical gas cylinders to prevent falling or being knocked over as required by NFPA 101, 19.3.2.4, and NFPA 99, 4-3.1.1.1.

Findings include:

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed 2 of 2 " H " size high pressure medical gas cylinders in the MRI Equipment Room, J193, free standing, unsecured, with no device to prevent falling or being knocked over. The Facility Safety Officer acknowledged the observation.

Based on observations and staff interviews conducted during the survey from October 24-26, 2011, it was determined that this facility did not comply with the specific requirements of NFPA 101; NFPA 70- National Electrical Code and the NFPA 99 (2005 Edition).

Findings include:

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, revealed access to an electrical panel in the main corridor of the Interventional Radiology Department adjacent to room J242E blocked by furniture, a table and chair. The Facility Safety Officer acknowledged the presence of the table and chair blocking access to the electrical panel.

On 10/24/11, the first day of survey, observation during the interior tour conducted from 1:15 to 3:30 p.m., accompanied by the Facility Safety Officer, revealed a power strip plugged into a surge protector thereby creating a prohibited " Daisy Chain " that was plugged into a duplex electrical receptacle in room J-340 of the Annex building. The Facility Safety Officer acknowledged the presence of the " Daisy Chain " .

On 10/25/11, the second day of survey, observation during the interior tour conducted from 9:45 a.m. to 2:30 p.m., accompanied by the Facility Safety Officer, revealed a power strip plugged into a power strip which is prohibited in room A971. The power strips were secured to the wall in a permanent manner and provided power for charging batteries of a patient lift and a separate chair lift.

It was observed that a number of in-use two-to-three prong adapters and extension cords failed to meet the requirements. Adapters and Extension Cords:" 8.5.2.1.7.1: Adapters and extension cords meeting the requirements of 8.4.1.2.5 shall be permitted to be used. 8.5.2.1.7.2: Three- to- two prong adapters shall not be permitted. 8.5.2.1.7.3: The wiring shall be tested for all of the following: (1) Physical integrity; (2) Polarity; and (3) Continuity of grounding at the time of assembly and periodically thereafter." Observed areas with in-use non-hospital grade multi-plugged adapters and in-use extension cords included: Dietary Ice Machine (extension cord in use as permanent power); ATM Machine Cafeteria (piggy-backed electric into surge bar in use as permanent power); Bayshore Corridor by NICU (extension cord in use as permanent power); 4th Floor Ultra sound area (multi-plug adapter in-use for decorations and piggy-backed); ); 6th Floor by A671 Storage area (piggy-backed surge bar) and OB/LDR Area OR#1 (double-plugged hospital grade Tripp-Lite surge bars piggy-backed).