HospitalInspections.org

Based on observation and interview, the facility failed to protect structural steel maintaining the fire resistive construction of the building in two areas on two of eight floors.

Findings include:

1. Observation on September 14, 2009, at 10:03 AM, revealed there were several locations of an exposed structural steel beam where the fire resistive coating was removed in the 8th Floor Elevator Penthouse.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:03 AM confirmed the exposed structural steel beam where the fire resistive coating was removed.

2. Observation on September 15, 2009, at 9:11 AM, revealed there were numerous locations of an exposed structural steel beam where the fire resistive coating was removed in the 3rd Floor Equipment Room.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:11 AM confirmed the exposed structural steel beam where the fire resistive coating was removed.

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 several locations throughout the building..

Findings include:

Observation on September 14, 2010 revealed the following:
a. At 09:55 a.m. the door to the utility room across from the electric panels next to room 601 did not positively latch.
b. At 12:40 p.m. the door to room 403 was incapable of closing and latching due to the placement of the bed.
c. At 12:40 p.m. the door to the clean linen closet across from the Nourishment room on the 4th floor surgical wing was not capable of closing and latching.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in four locations, on three of eight floors.

Findings include:

1. Observation on September 14, 2010, at 10:21 AM revealed an unsealed penetration inside a 2-inch conduit on the 7th floor smoke barrier wall above the double corridor doors near room 705.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:21 AM confirmed there was an unsealed smokewall penetration.

2. Observation on September 15, 2010, between 12:43 PM and 2:11 PM revealed unsealed penetrations at the following times and locations:

a) 12:43 PM, there was a large unsealed penetration above the 1st floor corridor door between PETSCAN entrance and Laundry.

b) 1:37 PM, there were unsealed penetrations above the 2nd floor corridor double doors at the Outpatient Laband along the smoke barrier wall to the outside wall.

c) 2:11 PM, there was an unsealed penetration around a sprinkler pipe above the 2nd floor smokewall double corridor doors near the Center for Diabetes Care.

Interview with the Maintenance Journeyman on September 15, 2010, at 2:11 PM confirmed there were unsealed smokewall penetrations.

Based on observation and interview, the facility failed to maintain the one hour fire rated construction in accordance with 8.4.1 and/or 19.3.5.4, protecting hazardous areas on four of eight floors.

Findings include:

1. Observation on September 14, 2010, between 10:51 AM and 1:03 PM revealed unsealed penetrations during the following times and and at the following locations:
a) 10:51 AM, numerous unsealed penetrations in the 6th floor Equipment Storage Room across from room 622.
b) 11:01 AM, numerous unsealed penetrations in the 6th floor Soiled Utility Room.
c) 11:11 AM, numerous unsealed penetrations in the 5th floor Soiled Utility Room.
d) 11:15 AM, 3-foot by 3-foot unsealed penetration in the 5th floor Storage Room on west side near the exit door.
e) 12:49 PM, unsealed penetrations above the circuit breaker panel in the 4th floor Surgery Wing Storage Room between the clean linen closet and the drinking fountain.
f) 12:55 PM, unsealed penetrations above the call box and corridor door in the 4th floor Surgery Wing Equipment Storage Room across from the Staff Lounge.
g) 1:03 PM, 2-foot by 3-foot unsealed penetration above the door in the 4th floor Bed Storage Room.

Interview with the Maintenance Journeyman on September 14, 2010, at 1:03 PM confirmed the above conditions exist.

2. Observation on September 15, 2010, between 9:11 AM and 9:17 AM revealed unsealed penetrations during the following times and and at the following locations:
a) 9:11 AM, unsealed penetrations inside two conduits and around HVAC duct in 3rd floor storage room near rooms 319 and 320.
a) 9:17 AM, 3rd floor ADL Bedroom used for storage and requires a closure on the corridor door.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:17 AM confirmed the above conditions exist.

Based upon observation the exit access doors do not comply with regulations in 1 instance on the 1st floor.

Findings include:

Observation on September 15, 2010 @ 1300 hours revealed the west exit door in the storeroom was difficult to open.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on documentation review and interview, the facility failed to properly maintain exit and directional signs for the entire facility.

Findings include:

Documentation review on September 16, 2010, between 8:00 AM and 12:00 PM revealed that the facility lacked documentation verifying that exit signs were visually inspected on a monthly basis during February, June and July 2010.

Interview with the Assistant Director, Facilities Management on September 16, 2010, at 12:00 PM confirmed the lack of monthly inspections.

Based on observation and interview the fire alarm systems with approved components, devices or equipment is installed and maintained in accordance with regulations throughout the building.

Findings include:

Observation on September 14, 2010 between the hours of 08:00 a.m. thru 15:00 p.m. revealed that the entire fire alarm system was placed on a bypass mode for more than a four hour period without providing an approved fire watch or notifying the Department of Health, Division of Safety Inspection.

Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on observation and interview, the facility failed to properly maintain the sprinkler system by ensuring automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically throughout the entire facility. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Findings include:

1. Observation on September 15, 2010, at 9:39 AM revealed the 3rd floor Lab Storage Room, near the elevator, has wires secured to sprinkler pipe.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:39 AM confirmed the wires secured to the sprinkler pipe.

2. Observation on September 15, 2010, at 9:51 AM revealed the 3rd floor Chemistry Room has ceiling tile supported by sprinkler pipe.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:51 AM confirmed ceiling tile supported by sprinkler pipe.

Based on documentation review and interview, the facility failed to provide documentation reflecting that cooking facilities for the entire facility are protected in accordance with 9.2.3., 19.3.2.6, NFPA 96

Findings include:

Document review on September 16, 2010, between 8:00 AM and 12:00 PM revealed that facility lacked documentation that monthly "quick checks" were being performed on the kitchen suppression system.

Interview with the Assistant Director, Facilities Management on September 16, 2010, at 12:00 PM confirmed that monthly "quick checks" were not performed on the kitchen suppression system.

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in 2 areas throughout the hospital.

Findings include:

Observation of medical gas storage and/or cylinders on September 14 -26, 2010 revealed the following:

a. At 0930 The oxygen storage room across from room 714 did not meet the requirements for a medical gas storage location. (The cylinders were not separated full & empty, there were combustibles being stored with the O2, and the electric was not installed at least 60 inches above the floor.
b. At 1348 The utility room in the respiratory therapy area on the 2nd flooor did not meet the requirements for a medical gas storage location. (The cylinders were not separated full & empty, there were combustibles being stored with the O2, and the electric was not installed at least 60 inches above the floor.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based upon observation and interview, it was determined the electrical wiring and/or equipment does not comply with NFPA 70, the National Electrical Code in three locations on two of eight floors.

Findings include:

1. Observation on September 14, 2010 at 0940 a.m. revealed an open junction box with exposed wiring in the closet of the playroom by the nurse's station across from room # 725.

Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

2. Observation on September 14, 2010 at 10:33 AM. revealed a coffee pot and a microwave plugged into a surge protector in the 7th floor Pediatric Staff Lounge.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:33 AM confirmed the existence of the above finding.

3. Observation on September 14, 2010 at 1:29 PM. revealed numerous medical equipment plugged into a surge protector in the 4th floor OR Cysto Room.

Interview with the Maintenance Journeyman on September 14, 2010, at 1:29 PM confirmed the existence of the above finding.

Based on observation and interview, it was determined the facility failed to install the alcohol hand sanitizer dispensers in the approved manner per the CMS directives in 2 locations on the 6th floor.

Findings include:

Observation on September 14, 2010 @ 09:50 a.m. revealed alcohol based hand sanitizer installed above a light switch in rooms 607 & 614.

Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on observation and interview, the facility failed to protect structural steel maintaining the fire resistive construction of the building in two areas on two of eight floors.

Findings include:

1. Observation on September 14, 2009, at 10:03 AM, revealed there were several locations of an exposed structural steel beam where the fire resistive coating was removed in the 8th Floor Elevator Penthouse.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:03 AM confirmed the exposed structural steel beam where the fire resistive coating was removed.

2. Observation on September 15, 2009, at 9:11 AM, revealed there were numerous locations of an exposed structural steel beam where the fire resistive coating was removed in the 3rd Floor Equipment Room.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:11 AM confirmed the exposed structural steel beam where the fire resistive coating was removed.

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 several locations throughout the building..

Findings include:

Observation on September 14, 2010 revealed the following:
a. At 09:55 a.m. the door to the utility room across from the electric panels next to room 601 did not positively latch.
b. At 12:40 p.m. the door to room 403 was incapable of closing and latching due to the placement of the bed.
c. At 12:40 p.m. the door to the clean linen closet across from the Nourishment room on the 4th floor surgical wing was not capable of closing and latching.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in four locations, on three of eight floors.

Findings include:

1. Observation on September 14, 2010, at 10:21 AM revealed an unsealed penetration inside a 2-inch conduit on the 7th floor smoke barrier wall above the double corridor doors near room 705.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:21 AM confirmed there was an unsealed smokewall penetration.

2. Observation on September 15, 2010, between 12:43 PM and 2:11 PM revealed unsealed penetrations at the following times and locations:

a) 12:43 PM, there was a large unsealed penetration above the 1st floor corridor door between PETSCAN entrance and Laundry.

b) 1:37 PM, there were unsealed penetrations above the 2nd floor corridor double doors at the Outpatient Laband along the smoke barrier wall to the outside wall.

c) 2:11 PM, there was an unsealed penetration around a sprinkler pipe above the 2nd floor smokewall double corridor doors near the Center for Diabetes Care.

Interview with the Maintenance Journeyman on September 15, 2010, at 2:11 PM confirmed there were unsealed smokewall penetrations.

Based on observation and interview, the facility failed to maintain the one hour fire rated construction in accordance with 8.4.1 and/or 19.3.5.4, protecting hazardous areas on four of eight floors.

Findings include:

1. Observation on September 14, 2010, between 10:51 AM and 1:03 PM revealed unsealed penetrations during the following times and and at the following locations:
a) 10:51 AM, numerous unsealed penetrations in the 6th floor Equipment Storage Room across from room 622.
b) 11:01 AM, numerous unsealed penetrations in the 6th floor Soiled Utility Room.
c) 11:11 AM, numerous unsealed penetrations in the 5th floor Soiled Utility Room.
d) 11:15 AM, 3-foot by 3-foot unsealed penetration in the 5th floor Storage Room on west side near the exit door.
e) 12:49 PM, unsealed penetrations above the circuit breaker panel in the 4th floor Surgery Wing Storage Room between the clean linen closet and the drinking fountain.
f) 12:55 PM, unsealed penetrations above the call box and corridor door in the 4th floor Surgery Wing Equipment Storage Room across from the Staff Lounge.
g) 1:03 PM, 2-foot by 3-foot unsealed penetration above the door in the 4th floor Bed Storage Room.

Interview with the Maintenance Journeyman on September 14, 2010, at 1:03 PM confirmed the above conditions exist.

2. Observation on September 15, 2010, between 9:11 AM and 9:17 AM revealed unsealed penetrations during the following times and and at the following locations:
a) 9:11 AM, unsealed penetrations inside two conduits and around HVAC duct in 3rd floor storage room near rooms 319 and 320.
a) 9:17 AM, 3rd floor ADL Bedroom used for storage and requires a closure on the corridor door.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:17 AM confirmed the above conditions exist.

Based upon observation the exit access doors do not comply with regulations in 1 instance on the 1st floor.

Findings include:

Observation on September 15, 2010 @ 1300 hours revealed the west exit door in the storeroom was difficult to open.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on documentation review and interview, the facility failed to properly maintain exit and directional signs for the entire facility.

Findings include:

Documentation review on September 16, 2010, between 8:00 AM and 12:00 PM revealed that the facility lacked documentation verifying that exit signs were visually inspected on a monthly basis during February, June and July 2010.

Interview with the Assistant Director, Facilities Management on September 16, 2010, at 12:00 PM confirmed the lack of monthly inspections.

Based on observation and interview the fire alarm systems with approved components, devices or equipment is installed and maintained in accordance with regulations throughout the building.

Findings include:

Observation on September 14, 2010 between the hours of 08:00 a.m. thru 15:00 p.m. revealed that the entire fire alarm system was placed on a bypass mode for more than a four hour period without providing an approved fire watch or notifying the Department of Health, Division of Safety Inspection.

Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based on observation and interview, the facility failed to properly maintain the sprinkler system by ensuring automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically throughout the entire facility. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Findings include:

1. Observation on September 15, 2010, at 9:39 AM revealed the 3rd floor Lab Storage Room, near the elevator, has wires secured to sprinkler pipe.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:39 AM confirmed the wires secured to the sprinkler pipe.

2. Observation on September 15, 2010, at 9:51 AM revealed the 3rd floor Chemistry Room has ceiling tile supported by sprinkler pipe.

Interview with the Maintenance Journeyman on September 15, 2010, at 9:51 AM confirmed ceiling tile supported by sprinkler pipe.

Based on documentation review and interview, the facility failed to provide documentation reflecting that cooking facilities for the entire facility are protected in accordance with 9.2.3., 19.3.2.6, NFPA 96

Findings include:

Document review on September 16, 2010, between 8:00 AM and 12:00 PM revealed that facility lacked documentation that monthly "quick checks" were being performed on the kitchen suppression system.

Interview with the Assistant Director, Facilities Management on September 16, 2010, at 12:00 PM confirmed that monthly "quick checks" were not performed on the kitchen suppression system.

Based on observation and interview it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition in 2 areas throughout the hospital.

Findings include:

Observation of medical gas storage and/or cylinders on September 14 -26, 2010 revealed the following:

a. At 0930 The oxygen storage room across from room 714 did not meet the requirements for a medical gas storage location. (The cylinders were not separated full & empty, there were combustibles being stored with the O2, and the electric was not installed at least 60 inches above the floor.
b. At 1348 The utility room in the respiratory therapy area on the 2nd flooor did not meet the requirements for a medical gas storage location. (The cylinders were not separated full & empty, there were combustibles being stored with the O2, and the electric was not installed at least 60 inches above the floor.


Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

Based upon observation and interview, it was determined the electrical wiring and/or equipment does not comply with NFPA 70, the National Electrical Code in three locations on two of eight floors.

Findings include:

1. Observation on September 14, 2010 at 0940 a.m. revealed an open junction box with exposed wiring in the closet of the playroom by the nurse's station across from room # 725.

Interview with the Director of Maintenance and the CEO on September 16, 2010 at 13:00 confirmed the existence of the above findings.

2. Observation on September 14, 2010 at 10:33 AM. revealed a coffee pot and a microwave plugged into a surge protector in the 7th floor Pediatric Staff Lounge.

Interview with the Maintenance Journeyman on September 14, 2010, at 10:33 AM confirmed the existence of the above finding.

3. Observation on September 14, 2010 at 1:29 PM. revealed numerous medical equipment plugged into a surge protector in the 4th floor OR Cysto Room.

Interview with the Maintenance Journeyman on September 14, 2010, at 1:29 PM confirmed the existence of the above finding.