HospitalInspections.org

Based on observation, facility failed to maintain proper separation of hazardous areas from egress corridors which could allow for a fire to block egress and endanger the patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 2:32 PM while on tour with facility staff, Laboratory for Virology found fire rated doors to lab had self-closing door devices removed and doors to the egress corridor were propped open not in accordance with NFPA 101 (2000) 19.3.2.1.

Based on observation and staff interview, facility failed to maintain travel distance to exits which in a fire would endanger the staff and other building occupants.

The findings include:

On October 24, 2012 at 3:30 PM while on tour with facility staff, Laundry Facility observed, at the rear of the structure for Soiled Linen, entry/exit double doors and frame had been removed due to damage per Laundry Manager. Doors were replaced with a roll-up door assembly which does not meet requirements for egress as it is not secured in full open position with signage next to door reading, "THIS DOOR TO REMAIN OPEN WHEN THE BUILDING IS OCCUPIED". Due to the facility layout with equipment this has removed this as an acceptable exit from the rear of the building thereby requiring the travel distance to an exit to be exceeded as required in accordance with NFPA 101 (2000) 7.2.1, 7.2.1.4.1 Exception No. 2(a-e), 7.6, 19.1.1.1.7, 40.2.2.2.1, 40.2.6.

Based on observation, facility failed to maintain illumination of means of egress, including exit discharge, so as to ensure that failure of any single light fixture will not leave the area in darkness endangering patients, staff, or other building occupants.

The findings include:

On October 23, 2012 at 3:31 PM while on tour with facility staff, 3rd stairway 2nd floor to 1st floor egress by room 249 lighting in stairwell was out making it dark and hard to see not allowing for full visibility in accordance with NFPA 101 (2000) 7.8, 19.2.8.

Based on observation, facility failed to maintain cooking fire suppression equipment which could result in a fire endangering the patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 12:37 PM while on tour with facility staff, Kitchen cookline fryers and tilt skillet table were found to be out of protection coverage of the fire suppression system as required in accordance with NFPA 17A (1998) 3-5.1, NFPA 96 (1998)7-1, 7-2.2.1(d), 8-1.6, NFPA 101 (2000) 9.2.3, 19.3.2.6.

Based on observation, facility failed to maintain Laundry Chute system which could result in the fast and rapid spread of a fire endangering the patients, staff, and other building occupants.

The findings include:

On October 23, 2012 at while on tour with facility staff, bottom floor laundry collection room laundry chute fire door found being propped open against the dropped grid ceiling not allowing the fire door to self-close in accordance with NFPA 101 (2000) 19.5.4.1.

Based on observation, facility failed to maintain full instant use in the case of fire or other emergency means of egress which could endanger patients, staff, or other building occupants.

The findings include:

On October 24, 2012 at 3:15 PM while on tour with facility staff, Laundry Facility egress corridor to the west was found to be obstructed by laundry carts and storage of delivery items which did not allow for unimpeaded egress in accordance with NFPA 101 (2000) 7.1.10, 19.1.1.1.7, 40.2.1.

Based on observation, facility failed to properly store flammable and combustible liquids in approved containers which can endanger patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 2:20 PM while on tour with facility staff, Laboratory Histology Lab and Virology Lab observed 5 gallon collection containers for used lab stains, outside of flammable liquids storage cabinets, with lids off and funnel installed allowing vapors from stain residue to permeate in the room creating an flammable atmosphere not properly stored in accordance with NFPA 30 (1996) 5-3.7.1, NFPA 99 (1999) 10-7.2.1, NFPA 101 (2000) 19.3.2.2.

Based on observation, facility failed to properly store flammable and combustible liquids in approved containers which can endanger patients, staff, and other building occupants.

The findings include:

On October 25, 2012 at 3:30 PM while on tour with facility staff, Micro/Bacteriology found flammable liquids containers stored in open containers venting to the room not properly stored in accordance with NFPA 30 (1996) 5-3.7.1, NFPA 99 (1999) 10-7.2.1, NFPA 101 (2000) 19.3.2.2.

Based on observation and staff interview, facility failed to provided at time of survey procedures specific to laboratory emergencies, alarm actuations, evacuations, and equipment shutdown procedures with provisions for control of emergencies occurring in the laboratory with specific plans for control operations by emergency control group within the organization or by the public fire department endangering patients, staff, or other building occupants.

The findings include:

On October 24, 2012 at 2:25 PM while on tour with facility staff, Laboratory upon introduction with Laboratory Manager a copy of the facilities Laboratory Emergency Plan could not be produced at time of survey in accordance with NFPA 99 (1999) 10.2.1.3, NFPA 101 (2000) 19.3.2.1.

Based on observation, the facility failed to maintain electrical equipment and wiring which could endanger the patients, staff, and other building occupants.

The findings include:

On October 25, 2012 at 11:20 AM while on tour with facility staff, 3rd floor room 8329 HCS B3-10 unsecured electrical wires not in junction box in accordance with NFPA 70 (1999) Article 370-25, 370-28(c), NFPA 101 (2000) 9.1.2, 19.5.1.

On October 25, 2012 at 2:15 PM while on tour with facility staff, Micro/Bacteriology incubator machine utilizing power strip in lieu of proper outlet power in accordance with NFPA 70 (1999) Article 400-8, NFPA 101 (2000) 9.1.2, 19.5.1.

Based on observation, facility failed to maintain proper separation of hazardous areas from egress corridors which could allow for a fire to block egress and endanger the patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 2:32 PM while on tour with facility staff, Laboratory for Virology found fire rated doors to lab had self-closing door devices removed and doors to the egress corridor were propped open not in accordance with NFPA 101 (2000) 19.3.2.1.

Based on observation and staff interview, facility failed to maintain travel distance to exits which in a fire would endanger the staff and other building occupants.

The findings include:

On October 24, 2012 at 3:30 PM while on tour with facility staff, Laundry Facility observed, at the rear of the structure for Soiled Linen, entry/exit double doors and frame had been removed due to damage per Laundry Manager. Doors were replaced with a roll-up door assembly which does not meet requirements for egress as it is not secured in full open position with signage next to door reading, "THIS DOOR TO REMAIN OPEN WHEN THE BUILDING IS OCCUPIED". Due to the facility layout with equipment this has removed this as an acceptable exit from the rear of the building thereby requiring the travel distance to an exit to be exceeded as required in accordance with NFPA 101 (2000) 7.2.1, 7.2.1.4.1 Exception No. 2(a-e), 7.6, 19.1.1.1.7, 40.2.2.2.1, 40.2.6.

Based on observation, facility failed to maintain illumination of means of egress, including exit discharge, so as to ensure that failure of any single light fixture will not leave the area in darkness endangering patients, staff, or other building occupants.

The findings include:

On October 23, 2012 at 3:31 PM while on tour with facility staff, 3rd stairway 2nd floor to 1st floor egress by room 249 lighting in stairwell was out making it dark and hard to see not allowing for full visibility in accordance with NFPA 101 (2000) 7.8, 19.2.8.

Based on observation, facility failed to maintain cooking fire suppression equipment which could result in a fire endangering the patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 12:37 PM while on tour with facility staff, Kitchen cookline fryers and tilt skillet table were found to be out of protection coverage of the fire suppression system as required in accordance with NFPA 17A (1998) 3-5.1, NFPA 96 (1998)7-1, 7-2.2.1(d), 8-1.6, NFPA 101 (2000) 9.2.3, 19.3.2.6.

Based on observation, facility failed to maintain Laundry Chute system which could result in the fast and rapid spread of a fire endangering the patients, staff, and other building occupants.

The findings include:

On October 23, 2012 at while on tour with facility staff, bottom floor laundry collection room laundry chute fire door found being propped open against the dropped grid ceiling not allowing the fire door to self-close in accordance with NFPA 101 (2000) 19.5.4.1.

Based on observation, facility failed to maintain full instant use in the case of fire or other emergency means of egress which could endanger patients, staff, or other building occupants.

The findings include:

On October 24, 2012 at 3:15 PM while on tour with facility staff, Laundry Facility egress corridor to the west was found to be obstructed by laundry carts and storage of delivery items which did not allow for unimpeaded egress in accordance with NFPA 101 (2000) 7.1.10, 19.1.1.1.7, 40.2.1.

Based on observation, facility failed to properly store flammable and combustible liquids in approved containers which can endanger patients, staff, and other building occupants.

The findings include:

On October 24, 2012 at 2:20 PM while on tour with facility staff, Laboratory Histology Lab and Virology Lab observed 5 gallon collection containers for used lab stains, outside of flammable liquids storage cabinets, with lids off and funnel installed allowing vapors from stain residue to permeate in the room creating an flammable atmosphere not properly stored in accordance with NFPA 30 (1996) 5-3.7.1, NFPA 99 (1999) 10-7.2.1, NFPA 101 (2000) 19.3.2.2.

Based on observation, facility failed to properly store flammable and combustible liquids in approved containers which can endanger patients, staff, and other building occupants.

The findings include:

On October 25, 2012 at 3:30 PM while on tour with facility staff, Micro/Bacteriology found flammable liquids containers stored in open containers venting to the room not properly stored in accordance with NFPA 30 (1996) 5-3.7.1, NFPA 99 (1999) 10-7.2.1, NFPA 101 (2000) 19.3.2.2.

Based on observation and staff interview, facility failed to provided at time of survey procedures specific to laboratory emergencies, alarm actuations, evacuations, and equipment shutdown procedures with provisions for control of emergencies occurring in the laboratory with specific plans for control operations by emergency control group within the organization or by the public fire department endangering patients, staff, or other building occupants.

The findings include:

On October 24, 2012 at 2:25 PM while on tour with facility staff, Laboratory upon introduction with Laboratory Manager a copy of the facilities Laboratory Emergency Plan could not be produced at time of survey in accordance with NFPA 99 (1999) 10.2.1.3, NFPA 101 (2000) 19.3.2.1.

Based on observation, the facility failed to maintain electrical equipment and wiring which could endanger the patients, staff, and other building occupants.

The findings include:

On October 25, 2012 at 11:20 AM while on tour with facility staff, 3rd floor room 8329 HCS B3-10 unsecured electrical wires not in junction box in accordance with NFPA 70 (1999) Article 370-25, 370-28(c), NFPA 101 (2000) 9.1.2, 19.5.1.

On October 25, 2012 at 2:15 PM while on tour with facility staff, Micro/Bacteriology incubator machine utilizing power strip in lieu of proper outlet power in accordance with NFPA 70 (1999) Article 400-8, NFPA 101 (2000) 9.1.2, 19.5.1.