HospitalInspections.org

Based on observations during tour the hospital failed to have an effective Governing Body to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The finding include:

The hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross refer to 482.41 Physical Environment, Condition Tag A0700.

Based on review of facility policies and procedures, medical records and staff interview hemodialysis nursing staff failed to administer the hemodialysis treatment as per physician orders for one of four hemodialysis records reviewed (#38).

Findings include:

Review on 08/04/2011 of hemodialysis policy "Guidelines for Charting on Hemodialysis Flow Sheet" dated 07/2011 revealed "1. Scope / Purpose / Policy Statement - To provide an accurate record of patients hemodialysis treatments, and to be consistent in recording information on the Hemodialysis Flow Sheet...4. Doctors Orders...d. Settings: K+ & Ca Bath..."

Record review on 08/04/2011 for Patient #38 revealed a 70 year old male admitted 06/17/2011 for respiratory failure. Review of a physician's order written 07/19/2011 at 1200 revealed "Wednesday dialysis...3K2.5Ca (concentration of 3.0 potassium and 2.5 Calcium solution used for dialysis or dialysate bath)..." Further review of a physician's order written 7/20/2011 at 1450 revealed "Change dialysate for dialysis today to 3K2Ca bath (concentration of 3.0 potassium and 2.0 Calcium dalysate bath)..." Review of the patient's hemodialysis treatment sheet for 7/20/2011 revealed the patient dialyzed from 1555 until 1830. Further review revealed the dialysate bath recorded as used for the treatment was "K+ 3" and "Ca 2.5". Review of documentation for the hemodialysis treatment on 7/20/2011 failed to reveal any documentation the dialysate bath used was the "3K2Ca" as ordered by the physician.

Interview on 08/04/2011 at 1155 with the hemodialysis clinical manager and a hemodialysis registered nurse revealed the dialysate bath should be administered during the hemodialysis treatment as ordered by the physician. Interview revealed the dialysate bath utilized for Patient #38's hemodialysis treatment on 07/20/2011 was documented as a "3K2.5Ca" solution and not the "3K2Ca" as ordered by the physician. Interview failed to reveal any further documentation that the hemodialysis nursing staff administered the hemodialysis treatment dialysate bath as ordered by the physician.

Based on facility policy and procedure review, observations and staff interview the director of food and dietetic services failed to assure the staff complied with that established policies and procedures addressing safety practices for food handling.

The findings includeReview of facility policy #B019 revised 3/11 revealed "Cold production area...Check temperature of food before delivering to trayline or workstation. If temperature is higher than 41 degrees F, return food to cooler, or super chill, until internal temperature is 41 degrees F or less." Review of the "Food and Nutrition Test Tray Evaluation" form revealed "Standard Temperature/(Optimal)" for the tray line for a cold entree is less than or equal to 41 degrees. Review of facility policy #C031 revised 3/11 revealed "Subject: Workstation Tray Assembly Procedures And Daily Meeting...If cold food above 41 degrees, contact Director."

Observation during Test Tray assembly on 8/3/2011 at 1210 revealed banana pudding temperature on the tray line was 51 degrees ( 10 degrees above policy for cold foods). The staff assembled the test tray with the banana pudding included in the test tray.

Interview during the observation revealed the pudding should be at 41 degrees. The interview revealed the staff should remove the food item and "super chill" or assemble half of the trays then return the item to chill to ensure the temperature is at 41 degrees of lower.

Based on observations as referenced in the Life Safety Report of survey completed 08/04/2011, policy review, observations during tours, and staff interview, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710.

2. The hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709.

3. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701.

4. The hospital failed to ensure the safety of patients by failing to ensure that alcohol based hand rub units were not located above carpeted floors and/or within 6 inches of electrical switches in an unsprinklered building.

~Cross-refer to 482.41(b)(9) Physical Environment Standard Tag A-0716.

5. The hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and quality by: failing to ensure hemodialysis staff had total chlorine testing instructions available during testing of the carbon absorption for the water treatment system used for hemodialysis patients and failing to ensure dietary staff stored dry foods per the facility policy and failing to maintain a clean/sanitary environment in the food preparation area.

~Cross-refer to 482.41(c)(2) Physical Environment Standard Tag A-0724.

Based on observations as referenced in the Life Safety Report of survey completed 08/04/2011, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

A. Observations of Building 1 on 08/02/2011 - 08/04/2011 revealed the following:

1. Main Building 2nd floor - Illumination of means of egress/ exit discharge lighting in the "old dock" egress from materials management to the public way was not on the life safety branch of the emergency electrical system.
2. Main Building Illumination of means of egress/ exit discharge lighting around the perimeter of the building was on a timer and could not be verified to come on with the emergency power system during daylight hours.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045.

3. Main Building 1st floor Radiology unit - exit discharge has a single bulb light fixture for illumination of means of egress near Neuro Angio Interventional 1.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046.

4. Main building, 1st Floor, Kitchen: the hood and exhaust make-up air supply for the unit located by the baking ovens did not appear to be operational.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0069.

5. Main Building 8th floor D wing electrical outlet is not GFI protected in the greenhouse.
6. Main Building 8th floor D wing light is not on the life safety branch in the greenhouse.
7. Main Building 7th floor C wing Lights in Medx (medication preparation room) was not verified to be on emergency power.
8. Main Building 7th floor C wing room 769 red switch for nightlight not operational.
9. Main Building 7th floor F wing exposed bulbs in storage room near elevator F.
10. Main Building 7th floor North wing receptacles were loose and had dust buildup in OR2 and OR3.
11. Main Building 1st floor Radiology wing electrical outlet is not GFI protected in Inpatient Recovery Holding area.
12. Main Building 1st floor Nuclear Medicine wing 3 way switch near Nuclear Medicine 5 is not working properly.
13. Main Building 1st floor Emergency Department entrance circuit breaker FACP on normal power.
14. Main Building maintenance shop in main building EPS supplying load did not function during normal loss of power.
15. Main Building Ground floor switchboard room - The generator annunciator panel did not give an audible signal when the facility went from normal to emergency power when the emergency power system was tested.
16. Main building ground floor switchboard room -The generator annunciator panel lamp test did not give an emergency trouble visual indication of system trouble when tested during the emergency power system test.
17. Main Building 2nd floor -Confirm PACU pixus and blood bank #22 in OR on emergency power.
18. Main building 5th floor C wing. The facility has an open J box above the ceiling at double doors labeled FDO-5R-217.
19. Main building 2nd floor PICU. The facility has a medical refrigerator which was not verified to be on emergency power.
20. Main building, 1st Floor, Kitchen . The light in the cooler is missing the protective cover over the bulb.
21. Main building, 1st Floor, Kitchen. Two refrigeration units, one located on the cook line under the hood and one located next to the tray make-up area, were equipped with unapproved wiring. (Non manufactured approved wiring/cords and non approved quad receptacle box).
22. Main building, 1st Floor, Kitchen. The electrical panel located in the dishwashing area were blocked and not provided with the required clearance.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.

B. Observations of Building 2 on 08/02/2011 - 08/04/2011 revealed the following:

1. Midtown Surgery Center 3rd floor near Coffee Shop - Exit light sign is not illuminated.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046.

2. Basement of Midtown Medical Center - fire alarm control panel is not connected to the life safety branch circuit and is not identified on the fire alarm panel.

3. The surgery center electrical system is not installed as required for a type 1 essential electrical system serving a surgery center that utilizes general anesthesia.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.

4. Midtown Surgery Center 7th floor Surgery unit - only one master alarm panel for medical gas system is provided in the facility.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0140.

5. Main Building 7th floor Surgery unit - generator annunciator panel is not located within ambulatory surgery center at a supervised station.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0145.

C. Observations of Building 5 on 08/02/2011 - 08/04/2011 revealed the following:

1. 125 Baldwin 100 suite break room/ restorative kitchen room - The facility did not have the restorative range locked out mechanism installed to prevent unauthorized persons from using the range.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.

Based on observations as referenced in the Life Safety Report of survey completed 08/04/2011, the hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

The findings include:

A. Observations of Building 1 on 08/02/2011 - 08/04/2011 revealed the following:

1. Main Building 7th floor D wing - pipe penetration in employees only restroom is not firestopped to maintain rating in floor/ceiling assembly.
2. Main Building 4th floor Public Safety Command Center - DVR room of security office has several 2 inch conduits on the back wall that are not sealed on the top of the conduits.
3. Main Building 4th floor Telecom operations room -Corridor side smoke/fire wall has
¾ inch conduit going through it resulting in an unsealed penetrations just above the entry door.
4. Main Building ground floor above the E Elevators -There was unsealed penetrations above the ceiling at the cross corridor doors at the 3 inch conduit opening with the blue low voltage cable going through it.
5. Main Building ground floor D wing -There was an unsealed penetration above the ceiling at the records room the outside exit door.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012.

6. Main Building 7th floor North - room is open to corridor; located across from nourishment room.
7. Main Building 7th floor F wing - dictation room beside glass block wall is open to corridor.

8. Main Building 1st floor Ultra Sound Exam room #1 - space beside exam room is open to corridor.
9. Main Building 1st floor Ultras Sound wing - office space is open to corridor near stairwell

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0017.

10. Main Building 6th floor CCU doctor's sleep area -By-fold door in exit egress corridor.
11. Main Building 4th floor conference room, 4th floor public safety workroom, throughout hospital -Doors with card readers in corridor did not provide positive latching while engaged.
12. Main Building 3rd floor -Corridor doors and the nurses lounge for ICU Neuro & ICU suites did not have positive latching.
13. Main Building 3rd floor near room C353 & near neuroscience assistant nurse manager's office -Corridor door hardware located higher than 48" above finished floor.
14. Main Building 2nd floor -Corridor door to "casemakeup storage" in OR (operating room) suite had tape over the strike plate.
15. Main Building 2nd floor -Dutch door to the satellite pharmacy in OR had a gap between the frames and was not smoke tight. Dutch doors must comply with 19.3.6.3.6 which states that both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
16. Main Building 2nd floor -Corridor door to OR women's locker room, from the sterile side, did not have positive latching.
17. Main Building 2nd floor by freight elevator - Corridor door to "EVS" workroom had tape over the strike plate.
18. Main Building 8th floor D wing - non passage hardware on Unisex bathroom.
19. Main Building 7th floor E wing - door to room E922 does not self latch.
20. Main Building 7th floor E wing room E931 - door does not have positive latching hardware.
21. Main Building 7th floor F wing - improper air balance causing cross corridor doors to not close and latch properly near the nurses station.
22. Main Building 7th floor F wing - Exit access door near nurses station must latch with a single motion to contain fire.
23. Main Building 7th floor F wing - room 7820 not equipped with automatic flush bolt and self-closing device.
24. Main Building 7th floor North wing near the South Courtyard - the locking mechanism must open with a single motion of the hand.
25. Main Building 1st floor Radiology wing - non latching hardware on doors to Interventional Radiology Control room, Neuro Angio Interventional 1, Angio Interventional Exam room 3.
26. Main building 2nd floor wing short C hall pathology office door witch is on the corridor and did not latching hardware installed on the door.
27. Main building 5th floor wing C room C580 witch is on the egress corridor and did not have latching hardware installed on the door.
28. Main building 5th floor West wing electrical room is on the egress corridor and did not have positive latching installed the door.
29. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C455 that when opened blocks the main corridor room door from closing.
30. Main Building fourth floor, C wing - The facility has a bathroom / closet door in room C457 that when opened blocks the main corridor room door from closing.
31. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C457 that when opened blocks the main corridor room door from closing.
32. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C445 that when opened blocks the main corridor room door from closing.
33. Main Building fourth floor, C wing -The facility has a bathroom / closet door in room C447 that when opened blocks the main corridor room door from closing.
34. Main Building ground floor, C wing -The facility is utilizing an expandable gate verses a solid door in the corridor in a facility that is not fully sprinklered.
35. Main building, 3rd floor Caner Center, the clean utility room which is on the egress corridor has a door without positive latching.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018.

36. Main building ground floor outpatient soiled utility room -The Soiled utility room closet does not have a complete laundry chase installed as a plate above the chase is not secured properly.
37. Main building ground floor outpatient waiting room nurses station -The laundry chase top plate is not installed leaving the laundry chase incomplete.
38. Main building 5th floor elevator lobby, The door to the vertical chase was not-self-closing and latching during the survey.
39. Main building, 1st Floor, Kitchen. There is a duct penetrating the ceiling in the catering office/room that is not properly sealed.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0020.

40. Main Building 6th floor from 6A to mechanical room -Door in fire wall was undercut much larger than ¾ inches.
41. Main building, 3rd Floor, Stairwell 40. The stairwell door was found to be wedge open with cardboard to prevent it from closing.
42. Main building 1st floor, Stairwell 40. The stairwell door located on floor exit discharge door would not close latch and seal.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0021.

43. Main Building 2nd floor -Unsealed Penetration in the smoke wall above the ceiling at anesthesia office.
44. Main Building 6th floor near room 651 -Door in smoke wall did not close latch and seal to prevent the passage of smoke.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025.

45. Main Building 7th floor E wing smoke barrier doors did not open in opposite directions near adult behavior entrance.
46. Main Building 2nd floor PICU wing, cross corridor doors did not close smoke tight at Metroview Tower.
47. Main building 2nd floor Family Center cross corridor on left side did not close with activation of fire alarm.
48. Main building, 3rd Floor, 3A, the cross corridor door at the dietary elevator area did not close upon activation of the fire alarm system. (Door 3a-23).
49. Main building, 3rd floor, Harris Hospice. The facility has cross corridor smoke doors at H31, and H32 that had a gap grater than 1/8th of an inch when closed.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027.

50. Main Building 8th floor D wing storage room equipped louvered doors in Storage room.
51. Main Building 7th floor D wing storage room door is not a fire rated door.
52. Main Building 7th floor C wing soiled linen door not self closing and latching near the Bio Hazard room.
53. Main Building 3rd floor -Shaft to soiled linen chute was not sprinklered nor had smoke detection. Room had sprinkler piping that had been capped off, without the sprinkler head.
54. Main Building Fourth floor, B wing -The facility is utilizing a non rated door at hazardous material room B429.
55. Main building, 1st floor, Senior Administration; The ceiling in the IT room has holes that were not sealed to maintain the required rating of the room.
56. Main building, 1st floor, Kitchen Area. The doors to dry storage area witch is a hazardous area located next to catering office area are not self-closing or one hour rated.
57. Main Building, 5th floor, 5F Hall, The facility is using a soiled utility room as soiled lined room. This room will now need to be one hour or sprinkled.
58. Main Building, 1st floor, compresses gas storage room at rear exit near dietary. Room holds more than 3000 cu. ft. of compresses gas, does not have mechanical exhaust ventilation and is not sprinkled. The area is considered a sever hazard and will need to be one hour and sprinkled.
59. Main building 3rd floor, mechanical area, (open air area) next to AA elevator is used for storage and the area is not sprinkled.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029.

60. Main Building 8th floor D wing - unprotected vertical opening in stairwell 6.
61. Main Building 7th floor D wing - unprotected vertical opening in stairwell 6.
62. Main Building 1st floor Stairwell 3 - swing bar between landing and stairs to lower level obstructs stairway landing. The swing bar was not self-closing at time of survey.
63. Main Building, 2nd floor, stairwell 15, (PICU) The facility has storage in closet in stairwell.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0033.

64. Main Building 2nd floor -Door to OR storage required more than a single range of motion to exit the room.
65. Main Building 8th floor D wing - guardrail must be a minimum of 42 inches high and prevent the passage of a 6 inch spear; located near the exit access serving the elevator equipment room.
66. Main Building 7th floor D wing - locks located higher than 48 inches on rooms D793, D787, Medical director office.
67. Main Building 1st floor Radiology wing - locks located higher than 48 inches in Interventional Radiology hallway.
68. Main Building 1st floor Diagnostic Radiology - excessive hardware on door requires more than one motion of the hand to exit at Diagnostic 1.
69. Main Building 1st floor Diagnostic Radiology - door is less than 41 1/2 inches clear opening at Diagnostic 2.
70. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit.
71. Main building 5th floor E wing. The facility is utilizing more than one motion of the hand for egress at the CURY unit.
72. Main building 5th floor E wing. There is no emergency release switch located in the vicinity of the special locking doors, nor a master switch to release the doors at the nurses station.
73. Main building 5th floor E wing C unit, The facility is utilizing more than one motion of the hand for egress from this unit at both doors in the unit.
74. Main Building 5th floor E wing Cath Lab. The facility does not have a door release switch at the nurse station for the special locking doors serving that location.
75. Main building 2nd floor Hemby unit. The facility is utilizing more than one motion of the hand for egress from all office doors at this location.
76. Main building 2nd floor Pathology unit. The facility is utilizing more than one motion of the hand for egress from the vent hood room.
77. Main Building 4th floor C wing -The facility is utilizing more than one motion of the hand for egress at the staff lounge across from room C443.
78. Main Building 4th floor B wing - The facility is utilizing more than one motion of the hand for egress at room B430.
79. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services closet to fire exit.
80. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Cancer data Services near the corridor fire doors.
81. Main Building, ground floor, C wing - The facility is utilizing more than one motion of the hand for egress at occupational therapy room.
82. Main Building, ground floor, C wing -The facility is utilizing more than one motion of the hand for egress at Hydrotherapy room.
83. Main building,1st Floor, Kitchen; The means of egress outside the exit door next to cooler #1 and to the upper lever loading dock was blocked and not maintained clear and unobstructed.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038.

84. Main Building 1st floor Diagnostic Radiology wing - must have an exit directional sign at T that addresses exit path near Fluoroscopy 5.
85. Main Building 1st floor Diagnostic Radiology wing exit directional sign in nuclear medicine hallway points the wrong direction.
86. Main Building Facilities building subbasement leading up stairs -The facility did not have an exit directional sign leading form the subbasement to the required exit stairwell up to the ground floor exit.
87. Main Building 2nd and 6th floors -Exiting at B hall pediatric nurse office needs to be addressed whether exit signs are needed and/or narrowing of exit would deem horizontal exit would be required.
88. Main Building ground floor at stairwell # 4 -The facility did not have an exit directional sign leading to the required exit above from EB-1 to the public way.
89. Main building 2nd floor CUI/Cat Lab. The facility does not have proper exit discharge signage for exiting the area .
90. Main building, Sub-Basement, Gift shop storage area, Exit and directional signs are needed in the area and at the stairwell in order to direct individual from the area.
91. Main building, ground floor, stairwell 13 the facility did not have exit directional signage above door.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047.

92. Main Building 7th floor C wing smoke detector more than 15 feet from smoke barrier near E elevator.
93. Main Building 7th floor E wing smoke detector more than 15 feet from smoke barrier near room E914.
94. Main Building 1st floor G wing smoke detector covered by duct tape at entrance to G stairwell 1.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0054.

95. Main Building Ground floor pharmacy storage room -There was no sprinkler nor smoke detection at the pharmacy storage.
96. Main building ground Floor outpatient surgery -There was no sprinkler coverage nor smoke detection at the pack U and recovery area.
97. Main building 2nd floor B wing staff closet had storage within 18 inches of sprinkler head.
98. Main building 2nd floor Pathology. The facility is utilizing special locking systems and does not have sprinkler coverage in the Pathology closet.
99. Main building 7th floor IT closet. The facility is utilizing special locking systems and does not have sprinkler coverage in the IT closet.
100. Main building 7th floor Dr. sleep room, The facility is utilizing special locking systems and does not have sprinkler coverage in the doctors sleep room.
101. Main Building, ground, outside the emergency entrance -The facility is utilizing heat tape instead of electronic heating elements on the emergency power supply on back flow valves.
102. Main Building, ground floor, Kitchen walk-in cooler -The facility us utilizing special locking devices and does not have its walk-in cooler sprinklered.
103. Main building, 3rd floor, 5A area, the patient bathroom are equipped with sprinklers but the shower located in the bathroom area not protected due to the location of the sprinkler head against the bulkhead not prevent proper coverage in the area.
104. Main building 5th floor, F wing, the curtains in the patient showers do not provide the 18 inch separation at the ceiling or have the mesh top that will allow for proper coverage of the shower.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056.

105. Main Building, Ground Floor, Outside near the emergency entrance -The tamper alarm 113 did not give an audible and visual alert at an area where it was likely to be heard.
106. Main building, Ground floor parking garage maintenance room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised.
107. Main Building, Ground Floor, at Fourth Street -The facility does not have its post indicator valve on the Fourth Street location.
108. Main building ground floor Fourth Street -There is an unapproved tamper alarm at the sprinkler at the fourth street location.
109. Main building ground floor stairwell # 8 -There is an unapproved tamper alarm at the sprinkler at stairwells 3 and 8.
110. Main building, Ground floor Emergency Department Sprinkler room -The facility does not have its pressure operated flow switch on the dry pipe sprinkler system supervised.
111. Main building, Sub-Basement, Gift shop storage area, there is an unapproved tamper alarms at the sprinkler valves at this location.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061.

112. Main Building 8th floor on D wing - light fixture obstructing sprinkler in Storage room.
113. Main Building 8th floor on D wing - obstruction of sprinkler by file cabinet in File room.
114. Main Building 8th floor on D wing in Juvenile Recreation Area - obstruction of sprinkler near Unisex bathroom.
115. Main Building 7th floor on F wing in change out room - solid shower curtain obstructing sprinkler.
116. Main Building 7th floor on F wing in clean linen room - sprinkler escutheon is blocking sprinkler deflector.
117. Main Building 1st floor Admissions area - storage within 18 inches of sprinkler in office by Interview room 7.
118. Main building ground floor engineering storage -There was a blocked sprinkler head at the EV's bed storage portion of the storage room at the concrete beam and the conduit below it.
119. Main building ground floor D wing -There was a blocked sprinkler head by duct work near the records room near the outside exit door.
120. Main building, 1st floor, Outside canopy in front of the Cancer Center. The sprinkler heads were corroded and were not maintained in good condition.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0062.

121. Main Building 7th floor E wing - fire damper in electrical room is not installed in accordance with manufacturer's installation instructions. Duct penetrating floor assembly is not equipped with breakaway connections.
122. Main Building Behavioral Health Unit - there is no emergency shutdown switch for air handler serving the unit.
123. Main building 5th floor C wing short hall staff could not located shut down button for HVAC system.
124. Main Building 5th floor Cat lab and Nick U. staff could not located shut down button for HVAC system.
125. Main building, 1st Floor, Radiological Oncology, facility could not locate the HVAC emergency shutdown switch that serves the area.
126. Main building, 3rd floor, outpatient infusion, facility could not locate the HVAC emergency shutdown switch that serves the area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

127. Main Building 7th floor North wing self latching device needed on laundry chute in soiled utility # 5.
128. Main Building 6th floor -Two hour enclosure for the interstitial space at the transfer grill did not have smoke detectors on both sides for automatic closure of grills upon activation.
129. Main Building 6th floor -Two hour enclosure for the interstitial space (with the pneumatic chute) did not use both fire/smoke dampers in the transfer grill for air handling unit 24. Only fire dampers were installed.
130. Main Building the two hour enclosure for pneumatic soiled linen chute as it passes from 6th to 7th floor in the interstitial space of the 6th floor was not provided.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0071.

131. Main Building 8th floor D wing -obstruction of the means of exit egress in greenhouse.
132. Main Building 7th floor C wing -storage in 8C short hallway.
133. Main Building 7th floor C wing -wall mounted clerical pads near 764 and 767 not functioning properly.
134. Main Building 7th floor C wing -blind spot mirror mounted on corridor wall protrudes inside 6ft 8in head clearance near stairwell 8.
135. Main Building 7th floor E wing - access door to room E922 obstructs corridor.
136. Main Building 7th floor North wing - crash carts disrupt flow of corridor outside O2 room and rooms 866 and 860.
137. Main Building 1st floor Interventional Radiology - hallway lights in corridor protrude inside 6ft 8in head clearance.
138. Main Building 1st floor Radiology Wing - water fountain in hallway near Nuclear Medicine area.
139. Main Building 1st floor Radiology Wing -breakaway doors at entrance to MRI protrude further than 7 inches from the wall.
140. Main Building 6th floor near room A624 - Wall mounted charting table located near room A624 did not return to the upright position when placed down for use.
141. Main building 5th floor , D wing. The facility has items obstruction the egress corridor at C.O.W.
142. Main building 5th floor , D wing B/P has items obstructing the egress corridor at the D wing B/P area.
143. Main building 2nd floor short C hall. The janitor closet door opens into the egress corridor and does not have either a self closing device installed to close the door when opened or open 180 degrees onto the egress corridor.
144. Main building fourth floor, D wing -Charting table located near rooms D448, D494, D486, and D487 did not return to the upright position when placed down for use.
145. Main building, 5th Floor, intersection of 5A and 5F there is storage in the exit egress corridor located next to Stairwell 14, (Linen cart and stretcher).
146. Main building, 5th floor, intersection of 5A and 5C, plastic dust barrier protruding into the corridor blocking the means of egress.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0072.

147. Main Building 7th floor F wing - O2 located in equipment storage room must be stored at least 5 feet from combustibles.
148. Main Building, Sixth floor, Nurses Station -During the oxygen zone alarm testing two locations did not alarm at the required twenty percent loss of pressure.
149. Main building, liquid oxygen farm -The facility does not have the bulk storage nitrogen tanks valves covered from inclement weather at the liquid oxygen farm.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076.

150. Main building, 3rd building, HVAC unit # 12A. The smoke damper in mechanical room did not close upon activation of the fire alarm system.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0104.

151. Main Building, 5th floor, 5A, clean storage room used for oxygen storage does not have any smoking signage on the door to indicate quantities of oxygen being stored.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0141.

B. Observations of Building 2 on 08/02/2011 - 08/04/2011 revealed the following:

1. Midtown Surgery Center 2nd floor Midtown Medical Building - fire door between medical office buildings did not self close and latch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0011.

2. Midtown Surgery Center 8th floor electrical equipment room - fire proofing is missing on web of steel beam.
3. Midtown Surgery Center , all floors- The facility has rated shafts that are not complete at the mechanical rooms.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012.

4. Midtown Surgery Center 7th floor mechanical room does not self close and latch.
5. Midtown Surgery Center 7th floor Dirty utility room hardware does not self close and latch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018.

6. Midtown Surgery Center 7th floor Surgery unit - fire alarm annunciator panel is not provided in ambulatory surgery center to monitor fire alarm system.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051.

7. Midtown Surgery Center 7th floor mechanical room did not have a smoke detector in return air plenum.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0053.

8. Midtown Surgery Center Midtown Medical Office building is not fully sprinklered.
9. Midtown Surgery Center 8th floor storage closet by stairs - is not sprinklered.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056.

10. Midtown Surgery Center building, Basement, Riser room -Two tamper alarms 113 did not give an audible and visual alert at an area where it was likely to be heard.
11. Midtown Surgery Center, Basement, Dry Sprinkler riser room - The facility does not have three of its pressure operated flow switches on the dry pipe sprinkler system supervised.
12. Midtown Surgery Center, Basement, Dry Sprinkler riser room -The facility does not have three of its tamper alarms on the dry pipe sprinkler system supervised.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061.

13. Midtown Surgery Center 7th floor mechanical room upright sprinkler is closer than 4 inches to the beam and appears to have fire proofing on it.
14. Midtown Surgery Center 2nd floor Endocrinology unit - medical records rack within 18 inches of sprinkler.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0062.

15. Midtown Surgery Center 8th floor mechanical room no service access opening for duct mounted smoke detector.
16. Midtown Surgery Center 7th floor Surgery unit does not have an AHU (Air Handling Unit) shutdown switch for all units serving ambulatory surgery unit.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

17. Midtown Surgery Center 4th floor - a high temperature, exposed element portable space heater was observed in a staff office.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0070.

18. Midtown Surgery Center Basement of Midtown Medical - unsupported oxygen cylinder located in fire control room without proper support.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076.

C. Observations of Building 4 on 08/02/2011 - 08/04/2011 revealed the following:

1. Metroview, Sleep Center, 3rd floor, the soiled linen closet located in the unit is not one hour construction or sprinkled.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029.

2. Metroview, Sleep Center, Ground floor The facility has storage under the stairs in stairwell B.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0033.

3. Metroview, Sleep Center, 3rd floor, The Sleep Center was not equipped A fire alarm system in accordance with Section 9.6.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051.

D. Observations of Building 5 on 08/02/2011 - 08/04/2011 revealed the following:

1. 125 Baldwin 200 suite exit from elevator to main lobby -The facility did not have exit directional sign leading from the elevator lobby area to the main lobby exit.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047.

Based on observations as referenced in the Life Safety Report of survey completed 08/04/2011, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Observations of Building 1 on 08/02/2011 - 08/04/2011 revealed the following:

1. Main Building 6th floor stairwell 6 & 7 in ER overflow, stairwell 1, 4, & 2 in endoscopy -Delayed egress with electric strike plate, no longer in use, should be rendered no longer capable of reengaging with the turn of a key.
2. Main Building 2nd floor -Exit access blocked by vapor barriers of OR's new construction. Exit must not exceed 100 feet to stairwell.
3. Main Building 2nd floor near children's elevator -Special locking could be reengaged/relocked with fire alarm system in alarm mode.
4. Main Building 2nd floor entrance to children's wing from hospital - Special locking did not release with fire alarm or smoke head activation
5. Main Building 7th floor D wing - magnetic lock near 7D elevator must have a manual override not more than 3 feet from the door.
6. Main Building 7th floor F wing - access control egress door at ICN Entrance is a magnetic lock and has a push pad without additional features as required for access controlled egress doors in the Life Safety Code.
7. Main Building 7th floor F wing - no emergency release in ICN nurses station for special locking arrangements.
8. Main Building 7th floor North wing - egress corridor exceeds twenty feet from a point where two exits can be reached. The corridor is located near cross corridor doors between service corridor and Women's Center.
9. Main Building 1st floor Emergency Department - delayed egress doors not operating properly at the back of the Pediatric unit.
10. Main Building 1st floor Emergency Department - access control egress door push control must be within 5 feet to operate near the Pediatric unit.
11. Main Building 1st floor Emergency Department - horizontal entrance doors do not break away properly in the direction of egress.
12. 1st floor CT wing - access control egress door push control must be within 5 feet of access control doors. Located near the CT Entrance.
13. Main Building 1st floor Radiology unit - dead end corridor is more than 20 feet from point were exits may be reached. Located near MRI.

Note: Special locking arrangements are permitted only in facilities equipped throughout with a complete sprinkler or detection system. The facility on the date of this survey was not equipped with the required systems.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0032.

Based on observations as referenced in the Life Safety Report of survey completed 08/04/2011, the hospital failed to ensure the safety of patients by failing to ensure that alcohol based hand rub units were not located above carpeted floors and/or within 6 inches of electrical switches in an unsprinklered building.

The findings include:

1. Observations of Building 1 on 08/02/2011 - 08/04/2011 revealed the following:

Main building 2nd floor short C hall: the facility is not a fully sprinklered building and is utilizing alcohol based hand rub dispensers over carpet.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0211.

2. Observations of Building 4 on 08/02/2011 - 08/04/2011 revealed the following:

Sleep Center, 3rd floor, throughout the facility: alcohol rub hand sanitizers were found located within 6 inches of electrical switches and/or devices and were installed above carpet in a building that was not sprinkled.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0211.

Based on policy review, observation, and staff interview the hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and quality by failing to ensure hemodialysis staff had total chlorine testing instructions available during testing of the carbon absorption for the water treatment system used for hemodialysis patients, failing to ensure dietary staff stored dry foods per the facility policy and failing to maintain a clean/sanitary environment in the food preparation area.

Findings include:

1. A review of the hospital's policy review for the total chlorine testing revealed no policies and procedures were found to give instructions or guidance for testing of total chlorine for carbon absorption.

Observation on 08/03/2011 at 1000 during testing of total chlorine for carbon absorption in the water treatment system used for hemodialysis treatments revealed the hemodialysis nursing assistant performed the total chlorine testing without any instructions in the water treatment area. The observation revealed that the nursing assistant performed the total chlorine testing by running a stream of water from the primary carbon tank valve onto a testing strip and then reading the color change of the strip for the total chlorine level confirmed by a registered nurse that did not observe the testing procedure.

An interview on 08/03/2011 at 1015 with the nursing assistant that performed the testing for total chlorine levels revealed "I do not know of any instructions that we use for testing, We were just taught and I really do not know of any policies or procedures for chlorine checks."



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2. Review of facility policy #B006 revised 3/11 revealed "All food, non-food items and supplies in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption...Cover, label and date unused portions and open packages. Use the Morrison orange label; complete all sections on the label".

Observation during tour of the dried food storage area in the Dietary department on 8/1/2011 at 1142 revealed the following foods opened without a label indicating the expiration date or open date:
Chips, dried milk (gallon bag), gallon of dried cocoa, buttermilk biscuit mix, Bread crumbs stored in a 20 gallon container, 2 bags of lentil beans and cornmeal.

Interview with dietary administrative staff during the tour confirmed the items listed did not have a dated orange label indicating the open date or expiration date. The interview revealed with food items not labeled, the date it was opened is not known. The interview revealed the food items are good for 30 days after opening or the expiration date of the product.

Based on facility policy review, observation of care and staff interview, the hospital's infection control officer failed to provide oversight in the identification of a potential source of cross-contamination by hemodialysis staff failing to remove contaminated gloves before touching a medical record in 1 of 1 observed patients on isolation control precautions (Patient #40) and by dietary staff failing to perform hand hygiene after glove removal in 1 of 2 isolations patients observed during meal delivery.

Findings include:

1. Review of the hospital's policies and procedures for "Isolation Precautions" (reviewed 06/2011) revealed "Personal Protective Equipment...Gloves..Change gloves between tasks and procedures when indicated to prevent cross contamination of different body sites. Remove gloves promptly after use and perform hand hygiene, before touching non-contaminated items, environmental surfaces, and before going to another patient."

Observation during tour of the hospital's hemodialysis unit on 08/02/2011 at 1120 revealed patient #40 receiving hemodialysis treatment. Observation revealed that the patient was on contact isolation precautions that was indicated by signage on the bed of the patient that read as "Contact Precautions." The observation of the hospital's hemodialysis staff providing care to the patient revealed that the staff members had personal protective equipment on consisting of gloves, gowns, eyewear and masks. The observation further revealed an unidentified hemodialysis staff member wearing personal protective equipment touching the patient and the patient's hemodialysis machine without removing gloves or using hand hygiene. The staff member then touched and documented directly on the patient's paper medical record sheet leading to cross contamination of the patient's medical record sheet.

An interview during the observation on 08/02/2011 at 1140 with the hospital's Infection Control Officer revealed "The staff member did cross contaminate the patient's medical record during care of the patient. She was nervous and she knew she was supposed to remove the gloves before documenting on the record."



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2. Review of facility policy C022 revised on 11/09 revealed "Section: Patient Food Services Subject: Isolation Food Service...decontaminates hands using an alcohol-based sanitizer after removing gloves...Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. Hands must be decontaminated after glove removal".

During tour of the 7 F unit on 8/3/2011 at 1215 the dietary assistant delivered a tray to a patient in a room designated with signage on the door indicating the patient was on isolation control precautions. The staff member entered the room after putting on protective personnel equipment (gown and gloves). The staff member was observed moving the patient's bedside table, moving items on the table and placing the tray on the table. Upon exiting the room the staff member removed the gown and then the gloves. The staff member did not perform hand hygiene after glove removal. The staff member was observed returning to the dietary cart to get the next patient's tray.

Interview with administrative dietary staff during the observation revealed the staff member should have followed the hospital policy and performed hand hygiene after glove removal.

3. Observation during tour of the dietary department/food preparation areas on 8\3\2011 at 1330 revealed stained, non-secured and cracked ceiling tiles above the patient tray service line. Ceiling supply vents through out the area were covered with large amounts of dirt, dust and debris. Visible debris was observed on the floor tiles through out the area. A large amount of dirt, dust and debris was observed on the floor and wall behind equipment (out of service warmer unit stored with working units).

Interview during the observations with administrative dietary staff confirmed the areas noted had not been maintained clean and sanitary.