HospitalInspections.org

Based upon observation and interview, it was determined the building construction type and height does not meet regulations on one of six floors.

Findings include:

Observation on November 13, 2013, between 1:20 pm and 1:27 pm revealed the facility had unprotected steel beams at the following locations:
1. Second floor new C Wing addition Mechanical Room.
2. Second floor new C Wing addition Library Storage Room.
3. Second floor new C Wing addition Gift Shop Storage Room.

Interview with Director of Plant Operations (DPO) on November 13, 2013, at 1:27 pm confirmed the unprotected steel beams at the above listed locations.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in one of six floors.

Findings include:

1. Observation on November 14, 2013, at 10:15 am revealed the first floor Linen Room door lacked positive latching with the closure.

Interview with DPO on November 14, 2013, at 10:15 am confirmed the door lacked positive latching.

2. Observation on November 12, 2013, between 11:30 am and 1:55 pm revealed the facility had corridor doors that lacked positive latching at the following locations:
A. Fifth floor patient room 5207/5208
B. Fifth floor Administrative Office Center for Women and Children suite corridor door lacked positive latching.
C. Fifth floor Family Birth patient room 5804 corridor door lacked positive latching.

Interview with the Electrical Supervisor on November 12, 2013, at 11:30 am confirmed the above listed corridor doors lacked positive latching.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of six floors.

Findings include:

1. Observation on November 13, 2013, at 11:15 am revealed the second floor B Wing Linen Chute Terminal room door lacked positive latching.

Interview with DPO on November 13, 2013, at 11:15 am confirmed the door lacked positive latching.

2. Observation on November 14, 2013, at 10:45 am revealed the first floor Material Management double corridor doors lacked positive latching.

Interview with the Electrical Supervisor on November 14, 2013, at 10:45 am confirmed the double corridors lacked positive latching.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination and also served by the emergency lighting system on one of six floors.

Findings include:

Observation on November 13, 2013, at 12:40 pm revealed the old Boiler Room lacks an exit sign. This entire room needs evaluated to determine placement of exit signs throughout the room.

Interview with DPO on November 13, 2013, at 12:40 pm confirmed the Boiler Room lacked exit signs.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 1:40 pm revealed the fourth floor patient room 4407 had a fire sprinkler escutcheon missing.

Interview with DPO on November 12, 2013, at 1:40 pm confirmed the sprinkler escutcheon missing.

2. Observation on November 12, 2013, at 1:40 pm revealed the fourth floor patient room 4407 had a fire sprinkler deflector located above the lay-in ceiling tile.

Interview with DPO on November 12, 2013, at 1:40 pm confirmed the fire sprinkler deflector above the ceiling.

3. Observation on November 13, 2013, at 10:30 am revealed the second floor Suite 213 Exam Room 1 had a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 10:30 am confirmed the fire sprinkler escutcheon missing.

4. Observation on November 13, 2013, at 10:30 am revealed the second floor Suite 213 Exam Room 1 had a fire sprinkler deflector located above the lay-in ceiling tile.

Interview with DPO on November 13, 2013, at 10:30 am confirmed the sprinkler deflector above the ceiling.

5. Observation on November 13, 2013, at 11:20 am revealed the second floor Nuclear Medicine Mechanical Room Telephone closet had a ceiling tile missing and a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 11:20 am confirmed the missing ceiling tile and missing escutcheon.

6. Observation on November 13, 2013, at 1:15 pm revealed the second floor new C Wing addition old IV Solution Room had a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 1:15 pm confirmed the fire sprinkler escutcheon missing.

7. Observation on November 12, 2013, at 1:15 pm revealed the fifth floor Pediatrics soiled utility room had a fire sprinkler escutcheon missing.

Interview with the Electrical Supervisor on November 12, 2013, at 1:15 pm confirmed the fire sprinkler escutcheon was missing.

8. Observation on November 12, 2013, at 1:25 pm revealed the fire sprinkler head outside the fifth floor Clinical Supervisor's office by elevator 5R had the sprinkler deflector above the suspended ceiling.

Interview with the Electrical Supervisor on November 12, 2013, at 1:25 pm confirmed the sprinkler deflector was above the suspended ceiling.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on one of six floors.

Findings include:

1. Observation on November 13, 2013, at 11:00 am revealed the second floor Care Management area had a fire extinguisher that was not clearly visible for immediate use in case of fire.

Interview with DPO on November 13, 2013, at 11:00 am confirmed the fire extinguisher was not visible.

2. Observation on November 13, 2013 , at 11:35 am revealed the third floor Nuclear Medicine hallway fire extinguisher was blocked from immediate use by an ultra-sound machine.

Interview with the Electrical Supervisor on November 13, 2013, at 11:35 am confirmed the fire extinguisher was not immediately accessible.

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 12:52 pm revealed the following deficiencies in the second floor Kitchen:
1. Bake Shop - hood filters missing above the steam kettle.
2. Cook Isle 1 - hood filters have gaps and an unsealed penetration in the hood.
3. Cook Isle 1 - hood filters have gaps above the griddle.
4. Cook Isle 1 - excessive grease build up on fire suppression nozzles above the griddle.

Interview with DPOA on November 13, 2013, at 12:52 pm confirmed the above listed deficiencies in the Kitchen.

Based upon observation and interview, it was determined the facility failed to monitor the portable space heating devices in accordance with regulations on two of six floors.

Findings include:

1. Observation on November 12, 2013, between 11:22 am and 11:30 am revealed the facility was utilizing unauthorized portable space heaters at the following locations:
A. Fourth floor Director's office.
B. Fourth floor Revenue Cycle Manager office.
C. Fourth floor Senior Accountant office.
D. Fourth floor Business Office.

Interview with DPO on November 12, 2013, at 11:30 am confirmed the use of unauthorized portable heating devices at the above listed locations.

2. Observation on November 13, 2013, at 10:35 am revealed the facility was utilizing an unauthorized portable space heater on the second floor Clinical Educator office.

Interview with DPO on November 13, 2013, at 10:35 am confirmed the use of an unauthorized portable space heater.

3. Observation on November 13, 2013, at 11:15 am revealed the third floor Radiology Doctor's Dictation room was utilizing an unapproved portable electric heater.

Interview with the Electrical Supervisor on November 13, 2013, at 11:15 am confirmed the unapproved portable was being utilized.

Based upon observation and interview, it was determined that the facility failed to properly maintain the fire protection for trash chutes and laundry chutes on one of six floors.

Findings include:

Observation on November 13, 2013, at 11:15 am revealed the B Wing second floor Linen Chute Terminal room had a cart blocking the chute door.

Interview with DPO on November 13, 2013, at 11:15 am confirmed the cart was blocking the chute door.

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 10:50 am revealed the facility was charging Computers on Wheels in the exit corridor which impedes on the clear and unobstructed corridor width on the sixth floor.

Interview with DPO on November 12, 2013, at 10:50 am confirmed the computers in the exit corridor.

2. Observation on November 13, 2013, at 11:30 am revealed the facility had storage (drums and carts with x-ray film) stored in the second floor Nuclear Medicine exit corridor.

Interview with DPOA on November 13, 2013, at 11:30 am confirmed the storage in the exit corridor.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 10:30 am revealed unsecured carbon dioxide cylinders in the third floor Lab Microbiology department.

Interview with the Electrical Supervisor on November 13, 2013, at 10:30 am confirmed the carbon dioxide cylinders were not secured.

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 11:25 am revealed emergency medical gas shut-off valves accessibility was blocked by a lead vest carousel by Special Procedure Room 10 in third floor radiology.

Interview with the Electrical Supervisor on November 13, 2013, at 11:25 am confirmed the emergency shut-off valves accessibility was blocked.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 10:52 am revealed the sixth floor Manager's office (6F) had an electrical outlet cover plate that was broke.

Interview with DPO on November 12, 2013, at 10:52 am confirmed the broken electrical outlet cover plate.

2. Observation on November 12, 2013, at 11:20 am revealed the fourth floor Finance office had a portable space heater plugged into a surge protector.

Interview with DPO on November 12, 2013, at 11:20 am confirmed the space heater plugged into a surge protector.

3. Observation on November 12, 2013, at 11:55 am revealed the fourth floor Library Reference room had a microwave oven plugged into a surge protector.

Interview with DPO on November 12, 2013, at 11:55 am confirmed the microwave plugged into a surge protector.

4. Observation on November 12, 2013, at 1:20 pm revealed the fourth floor Medical Director office (4B) had a microwave oven plugged into an extension cord.

Interview with DPO on November 12, 2013, at 1:20 pm confirmed the microwave plugged into and extension cord.

5. Observation on November 13, 2013, at 10:10 am revealed that a microwave oven was plugged into a surge protector in the third floor Screening Office.

Interview with the Electrical Supervisor on November 13, 2013, at 10:10 am confirmed the microwave oven was plugged into a surge protector.

Based upon observation and interview, it was determined the building construction type and height does not meet regulations on one of six floors.

Findings include:

Observation on November 13, 2013, between 1:20 pm and 1:27 pm revealed the facility had unprotected steel beams at the following locations:
1. Second floor new C Wing addition Mechanical Room.
2. Second floor new C Wing addition Library Storage Room.
3. Second floor new C Wing addition Gift Shop Storage Room.

Interview with Director of Plant Operations (DPO) on November 13, 2013, at 1:27 pm confirmed the unprotected steel beams at the above listed locations.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in one of six floors.

Findings include:

1. Observation on November 14, 2013, at 10:15 am revealed the first floor Linen Room door lacked positive latching with the closure.

Interview with DPO on November 14, 2013, at 10:15 am confirmed the door lacked positive latching.

2. Observation on November 12, 2013, between 11:30 am and 1:55 pm revealed the facility had corridor doors that lacked positive latching at the following locations:
A. Fifth floor patient room 5207/5208
B. Fifth floor Administrative Office Center for Women and Children suite corridor door lacked positive latching.
C. Fifth floor Family Birth patient room 5804 corridor door lacked positive latching.

Interview with the Electrical Supervisor on November 12, 2013, at 11:30 am confirmed the above listed corridor doors lacked positive latching.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of six floors.

Findings include:

1. Observation on November 13, 2013, at 11:15 am revealed the second floor B Wing Linen Chute Terminal room door lacked positive latching.

Interview with DPO on November 13, 2013, at 11:15 am confirmed the door lacked positive latching.

2. Observation on November 14, 2013, at 10:45 am revealed the first floor Material Management double corridor doors lacked positive latching.

Interview with the Electrical Supervisor on November 14, 2013, at 10:45 am confirmed the double corridors lacked positive latching.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination and also served by the emergency lighting system on one of six floors.

Findings include:

Observation on November 13, 2013, at 12:40 pm revealed the old Boiler Room lacks an exit sign. This entire room needs evaluated to determine placement of exit signs throughout the room.

Interview with DPO on November 13, 2013, at 12:40 pm confirmed the Boiler Room lacked exit signs.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 1:40 pm revealed the fourth floor patient room 4407 had a fire sprinkler escutcheon missing.

Interview with DPO on November 12, 2013, at 1:40 pm confirmed the sprinkler escutcheon missing.

2. Observation on November 12, 2013, at 1:40 pm revealed the fourth floor patient room 4407 had a fire sprinkler deflector located above the lay-in ceiling tile.

Interview with DPO on November 12, 2013, at 1:40 pm confirmed the fire sprinkler deflector above the ceiling.

3. Observation on November 13, 2013, at 10:30 am revealed the second floor Suite 213 Exam Room 1 had a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 10:30 am confirmed the fire sprinkler escutcheon missing.

4. Observation on November 13, 2013, at 10:30 am revealed the second floor Suite 213 Exam Room 1 had a fire sprinkler deflector located above the lay-in ceiling tile.

Interview with DPO on November 13, 2013, at 10:30 am confirmed the sprinkler deflector above the ceiling.

5. Observation on November 13, 2013, at 11:20 am revealed the second floor Nuclear Medicine Mechanical Room Telephone closet had a ceiling tile missing and a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 11:20 am confirmed the missing ceiling tile and missing escutcheon.

6. Observation on November 13, 2013, at 1:15 pm revealed the second floor new C Wing addition old IV Solution Room had a fire sprinkler escutcheon missing.

Interview with DPO on November 13, 2013, at 1:15 pm confirmed the fire sprinkler escutcheon missing.

7. Observation on November 12, 2013, at 1:15 pm revealed the fifth floor Pediatrics soiled utility room had a fire sprinkler escutcheon missing.

Interview with the Electrical Supervisor on November 12, 2013, at 1:15 pm confirmed the fire sprinkler escutcheon was missing.

8. Observation on November 12, 2013, at 1:25 pm revealed the fire sprinkler head outside the fifth floor Clinical Supervisor's office by elevator 5R had the sprinkler deflector above the suspended ceiling.

Interview with the Electrical Supervisor on November 12, 2013, at 1:25 pm confirmed the sprinkler deflector was above the suspended ceiling.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on one of six floors.

Findings include:

1. Observation on November 13, 2013, at 11:00 am revealed the second floor Care Management area had a fire extinguisher that was not clearly visible for immediate use in case of fire.

Interview with DPO on November 13, 2013, at 11:00 am confirmed the fire extinguisher was not visible.

2. Observation on November 13, 2013 , at 11:35 am revealed the third floor Nuclear Medicine hallway fire extinguisher was blocked from immediate use by an ultra-sound machine.

Interview with the Electrical Supervisor on November 13, 2013, at 11:35 am confirmed the fire extinguisher was not immediately accessible.

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 12:52 pm revealed the following deficiencies in the second floor Kitchen:
1. Bake Shop - hood filters missing above the steam kettle.
2. Cook Isle 1 - hood filters have gaps and an unsealed penetration in the hood.
3. Cook Isle 1 - hood filters have gaps above the griddle.
4. Cook Isle 1 - excessive grease build up on fire suppression nozzles above the griddle.

Interview with DPOA on November 13, 2013, at 12:52 pm confirmed the above listed deficiencies in the Kitchen.

Based upon observation and interview, it was determined the facility failed to monitor the portable space heating devices in accordance with regulations on two of six floors.

Findings include:

1. Observation on November 12, 2013, between 11:22 am and 11:30 am revealed the facility was utilizing unauthorized portable space heaters at the following locations:
A. Fourth floor Director's office.
B. Fourth floor Revenue Cycle Manager office.
C. Fourth floor Senior Accountant office.
D. Fourth floor Business Office.

Interview with DPO on November 12, 2013, at 11:30 am confirmed the use of unauthorized portable heating devices at the above listed locations.

2. Observation on November 13, 2013, at 10:35 am revealed the facility was utilizing an unauthorized portable space heater on the second floor Clinical Educator office.

Interview with DPO on November 13, 2013, at 10:35 am confirmed the use of an unauthorized portable space heater.

3. Observation on November 13, 2013, at 11:15 am revealed the third floor Radiology Doctor's Dictation room was utilizing an unapproved portable electric heater.

Interview with the Electrical Supervisor on November 13, 2013, at 11:15 am confirmed the unapproved portable was being utilized.

Based upon observation and interview, it was determined that the facility failed to properly maintain the fire protection for trash chutes and laundry chutes on one of six floors.

Findings include:

Observation on November 13, 2013, at 11:15 am revealed the B Wing second floor Linen Chute Terminal room had a cart blocking the chute door.

Interview with DPO on November 13, 2013, at 11:15 am confirmed the cart was blocking the chute door.

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 10:50 am revealed the facility was charging Computers on Wheels in the exit corridor which impedes on the clear and unobstructed corridor width on the sixth floor.

Interview with DPO on November 12, 2013, at 10:50 am confirmed the computers in the exit corridor.

2. Observation on November 13, 2013, at 11:30 am revealed the facility had storage (drums and carts with x-ray film) stored in the second floor Nuclear Medicine exit corridor.

Interview with DPOA on November 13, 2013, at 11:30 am confirmed the storage in the exit corridor.

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 10:30 am revealed unsecured carbon dioxide cylinders in the third floor Lab Microbiology department.

Interview with the Electrical Supervisor on November 13, 2013, at 10:30 am confirmed the carbon dioxide cylinders were not secured.

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of six floors.

Findings include:

Observation on November 13, 2013, at 11:25 am revealed emergency medical gas shut-off valves accessibility was blocked by a lead vest carousel by Special Procedure Room 10 in third floor radiology.

Interview with the Electrical Supervisor on November 13, 2013, at 11:25 am confirmed the emergency shut-off valves accessibility was blocked.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of six floors.

Findings include:

1. Observation on November 12, 2013, at 10:52 am revealed the sixth floor Manager's office (6F) had an electrical outlet cover plate that was broke.

Interview with DPO on November 12, 2013, at 10:52 am confirmed the broken electrical outlet cover plate.

2. Observation on November 12, 2013, at 11:20 am revealed the fourth floor Finance office had a portable space heater plugged into a surge protector.

Interview with DPO on November 12, 2013, at 11:20 am confirmed the space heater plugged into a surge protector.

3. Observation on November 12, 2013, at 11:55 am revealed the fourth floor Library Reference room had a microwave oven plugged into a surge protector.

Interview with DPO on November 12, 2013, at 11:55 am confirmed the microwave plugged into a surge protector.

4. Observation on November 12, 2013, at 1:20 pm revealed the fourth floor Medical Director office (4B) had a microwave oven plugged into an extension cord.

Interview with DPO on November 12, 2013, at 1:20 pm confirmed the microwave plugged into and extension cord.

5. Observation on November 13, 2013, at 10:10 am revealed that a microwave oven was plugged into a surge protector in the third floor Screening Office.

Interview with the Electrical Supervisor on November 13, 2013, at 10:10 am confirmed the microwave oven was plugged into a surge protector.