HospitalInspections.org

Based on observation and interview it was determined that the facility failed to notify the Department of Health Plan Review of room occupancy type changes, for one of six levels.

Findings include:

Observation on August 26, 2019, at 10:15 a.m., revealed the sixth floor storage room, had been converted to a Meditech computer training room. The facility failed to notify Plan Review of the occupancy type change for the room.

Interview with the maintenance supervisor on August 26, 2019, at 10:15 a.m., confirmed the sixth floor storage room, had been converted to a Meditech computer training room.

Based on observation and interview, the facility failed to maintain the two-hour fire resistance barrier, between multiple building construction types, on one of seven building levels.

Findings include:

1. Observation on August 27, 2019, at 9:35 a.m., revealed the second floor, Cardiology supervisor office door (fire barrier door between main and "X" buildings) lacked a self-closure device.

Interview with the director of facilities on August 27, 2019, at 9:35 a.m., confirmed the above fire barrier door lacked a self-closure.

Based on observation and interview, the facility failed to maintain the two-hour fire resistance barrier, between multiple building construction types, on one of seven floors.

Findings include:

1. Observation on August 26, 2019, at 9:25 a.m., revealed the fifth floor fire barrier, between 5 Tower and 5 Main Buildings, had an unsealed hole in the wall above the fire doors.

Interview with the director of facilities on August 26, 2019, at 9:25 a.m., confirmed the above unsealed hole in the above fire barrier wall.

2. Observation on August 26, 2019, at 9:30 a.m., revealed the fifth floor fire barrier door, between 5 Tower and 5 Surge Buildings, lacked positive latching (right side door).

Interview with the director of facilities on August 26, 2019, at 9:30 a.m., confirmed the above fire door lacked positive latching.

Based on observation and interview, the facility failed to maintain means of egress, to be free of all obstructions to full use in case of emergency, in one of over ten smoke compartments.

Findings include:

1. Observation on August 26, 2019, at 9:00 a.m., revealed a large, wooden rehabilitation ramp, was stored in the sixth floor corridor with Rehabilitation Services unit.

Interview with the director of facilities on August 26, 2019, at 9:00 a.m., confirmed the above corridor obstruction.

Based on observation and interview, the facility failed to maintain means of egress, to be free of all obstructions to full use in case of emergency, on four of seven building levels.

Findings include:

1. Observation on August 27, 2019, between 8:10 a.m. and 11:30 a.m., revealed the following corridor obstructions:
a. (8:10 a.m.) sixth floor, east corridor, near M6101D, nurse charting station desk did not self-close completely;
b. (9:15 a.m.) fifth floor, south corridor, near treatment room #12, nurse charting station desk did not self-close;
c. (9:17 a.m.) fifth floor, south corridor, near treatment room #3, nurse charting station desk did not self-close;
d. (9:20 a.m.) second floor corridor, outside of Palliative Care offices, stored stretchers;
e. (11:30 a.m.) ground floor corridor, at main entrance waiting area, round table.

Interview with the director of facilities on August 27, 2019, at 11:30 a.m., confirmed the above corridor obstructions.

Based on observation and interview it was determined that the facility failed to maintain the path of egress free and unobstructed, on one of six levels.

Findings include:

Observation on August 26, 2019, at 12:40 p.m., revealed the X-wing, rear stair tower # 4XBLDG07, had four potted plants on the stairwell landing, obstructing the path of egress from the stairs.

Interview with the maintenance supervisor on August 26, 2019, at 12:40 p.m., confirmed the X-wing stair tower was obstructed with four potted plants.

Based on observation and interview, the facility failed to maintain stair towers at two of six emergency exit stair towers.

Findings include:

1. Observation on August 27, 2019, at 11:40 a.m., revealed the ground floor, stair tower door frame (located at facilities 1-8-4), had an illegible fire rated label.

Interview with the director of facilities on August 27, 2019, at 11:40 a.m., confirmed the above exit stair tower door frame label was illegible.

Based on observation and interview, the facility failed to maintain stair towers at two of two emergency exit stair towers.

Findings include:

1. Observation on August 26, 2019, between 8:45 a.m. and 12:40 p.m., revealed the following exit stair tower doors lacked a label to indicate that the attached hardware is "fire exit hardware":
a. (8:45 a.m.) sixth floor, B stair T6035;
b. (9:10 a.m.) sixth floor stair, near resident room T6201;
c. (9:20 a.m.) fifth floor, stair T5033;
d. (10:10 a.m.) second floor, stair #2;
e. (12:40 p.m.) third floor, O.R. stair, across from O. R. #5.

Interview with the director of facilities on August 26, 2019, at 12:40 p.m., confirmed the above exit stair tower doors lacked labels on the hardware to indicate it is "fire exit hardware".

Based on observation and interview it was determined that the facility failed to install "No Exit" signage on exterior doors that fail to lead to an unobstructed path of egress, on one of six levels.

Findings include:

Observation on August 27, 2019, at 11:20 a.m. revealed the first floor, mechanical room, had an exterior door leading to an obstructed path of egress, that lacked a "No Exit" sign.

Interview with the maintenance supervisor on August 27, 2019, at 11:20 a.m., confirmed the mechanical room exterior door, lacked a "No Exit" sign.

Based on observation and interview, the facility failed to maintain vertical openings at two of over ten vertical enclosures.

Findings include:

1. Observation on August 27, 2019, between 9:45 a.m. and 11:35 a.m., revealed the following vertical opening deficiencies:
a. (9:45 a.m.) second floor, medical office "back stair" to fitness room, had combustibles stored within the vertical enclosure;
b. (9:47 a.m.) second floor, medical office "back stair" door to fitness room, had a fire rated label on the door that was illegible;
c. (11:35 a.m.) ground floor, vertical shaft penetration, near elevators 12 and 13, had construction storage stored within the vertical enclosure (doors, plaster, boxes, etc.).

Interview with the director of facilities on August 27, 2019, at 11:35 a.m., confirmed the above vertical opening deficiencies.

Based on observation and interview, the facility failed to maintain hazardous areas on three of seven building levels.

Findings include:

1. Observation on August 27, 2019, between 8:05 a.m. and 11:05 a.m., revealed the following hazardous area deficiencies:
a. (8:05 a.m.) sixth floor, Physical Therapy soiled utility room door, lacked positive latching;
b. (9:10 a.m.) fourth floor, south storage room door, across from treatment room #9, lacked a self-closure device;
c. (10:10 a.m.) second floor, soiled utility room door frame fire rated label, across from
C.D.I. manager office, was illegible;
d. (11:00 a.m.) second floor, storage room door, near Imaging Reading room, lacked a self-closure device;
e. (11:05 a.m.) second floor, Facilities Air Handler #2 room door, across from C.T. scan, lacked consistent positive latching.

Interview with the director of facilities on August 27, 2019, at 11:05 a.m., confirmed the above hazardous area deficiencies.

2. Observation on August 27, 2019, at 10:55 a.m., revealed the second floor, Radiology electrical room, near Imaging #4, had combustible items stored inside the room. This room was not constructed to store combustible items, and the use of this room has changed. If this room is intended to be used for combustible storage, the facility shall obtain approved drawings from State Plan Review, and a granted occupancy from the Division of Life Safety, before using this room.

Interview with the director of facilities on August 27, 2019, at 10:55 a.m., confirmed the above change in use of a room to a hazardous area.

Based on observation and interview, the facility failed to maintain hazardous areas within one of over ten smoke compartments.

Findings include:

1. Observation on August 26, 2019, at 12:45 p.m., revealed the third floor, Operating Room suite soiled utility room T3076 door, lacked positive latching in the frame.

Interview with the director of facilities on August 26, 2019, at 12:45 p.m., confirmed the soiled utility room door lacked positive latching.

Based on observation and interview it was determined that the facility failed to inspect and maintain hazardous storage areas, on one of six levels.

Findings include:

1. Observation on August 26, 2019, between 12:46 p.m. and 12:47 p.m., revealed the following deficiencies with the fourth floor, 4X nursing staff only storage room:
A. (12:26 p.m.) right side wall, had an unsealed penetration around a sprinkler pipe;
B. (12:47 p.m.) the corridor door, equipped with a door closure, failed to close and latch into the frame.

Interview with the maintenance supervisor on August 26, 2019, at 12:47 p.m., confirmed the deficiencies listed above existed.

Based on observation, document review and interview, the facility failed to maintain cooking equipment within two of two cooking areas.

Findings include:

1. Observation on August 27, 2019, at 10:25 a.m., revealed the second floor, main kitchen serving area, lacked a sign for the K-type fire extinguisher, stating that the extinguisher shall be used after the activation of the hood suppression system.

Interview with the director of facilities on August 27, 2019, at 10:25 a.m., confirmed the above extinguisher lacked a corresponding sign for correct usage.

2. Document review on August 27, 2019, at 11:20 a.m., revealed the "To Your Health Cafe" hood suppression system, did not have a monthly owner's inspection ("quick-check"), in compliance with the manufacturers maintenance manual.

Interview with the director of facilities on August 27, 2019, at 11:20 a.m., confirmed the lack of "quick-check" documentation.

Based on observation and interview, the facility failed to maintain fire alarm systems for all fire alarm systems covering the entire building.

Findings include:

1. Observation on August 26, 2019, at 10:00 a.m., revealed all fire alarm panels indicated trouble mode.

Interview with the director of facilities on August 26, 2019, at 10:00 a.m., confirmed all fire alarm panels indicated trouble mode.

Based on document review, observation and interview it was determined that the facility failed to maintain the fire sprinkler suppression system, on one of one system.

Findings include:

1. Document review on August 26, 2019, between 8:55 a.m. and 8:56 a.m., revealed the following fire hydrant deficiencies existed:
A. (8:55 a.m.) hydrant #1, indicated right side 2 1/2 inch threaded connection is loose;
B. (8:56 a.m.) hydrant #6, should have an 18 inch clearance from streamer connection.

Interview with the maintenance supervisor on August 26, 2019, at 8:56 a.m., confirmed the fire hydrant deficiencies listed above existed.

2. Observation on August 27, 2019, between 9:47 a.m. and 11:30 a.m., revealed the following fire suppression system deficiencies:
A. (9:47 a.m.) third floor, west stairwell "C", had a sprinkler valve that lacked a UL approved metal or rigid plastic sign, attached with a wire or chain;
B. (10:00 a.m.) third floor, corridor outside the Nursery, by the breast feeding room, above the lay-in ceiling, had grey wires laying on the sprinkler pipe;
C. (10:04 a.m.) third floor, Birthing Suite soiled utility room, had a missing sprinkler escutcheon;
D. (11:30 a.m.) first floor, one south, outside the switchboard office, at the fire doors, above the lay-in ceiling, had grey wires attached to the sprinkler pipe.

Interview with the maintenance supervisor on August 27, 2019, at 11:30 a.m., confirmed the sprinkler system deficiencies listed above existed.

3. Observation on August 27, 2019, between 11:10 a.m. and 11:45 a.m., revealed the following fire sprinkler deficiencies:
A. (11:10 a.m.) second floor, Radiology hall electrical/data closet fire sprinkler head, is not designed for the correct application (sprinkler is a concealed-type, instead of an upright-type for use in areas without ceiling tile);
B. (11:15 a.m.) ground floor, "To Your Health Cafe" storage room shelving unit, was placed within 18 inches of the fire sprinkler head;
C. (11:25 a.m.) ground floor O.S.&Y. (outside screw and yoke), outside of the building at the main fire alarm panel room, had sediment inside the piping behind the end caps;
D. (11:45 a.m.) ground floor, unexcavated crawl space, had combustibles stored inside (this area is not a sprinklered location).

Interview with the director of facilities on August 27, 2019, at 11:45 a.m., confirmed the above sprinkler deficiencies.

Based on document review, observation and interview it was determined that the facility failed to maintain the fire suppression system, on one of one systems.

Findings include:

1. Document review on August 26, 2019, between 8:55 a.m. and 8:56 a.m., revealed the following fire hydrant deficiencies existed:
A. (8:55 a.m.) hydrant #1, indicated right side 2 1/2 inch threaded connection is loose;
B.. (8:56 a.m.) hydrant #6, should have 18 inch clearance from streamer connection.

Interview with the maintenance supervisor on August 26, 2019, at 8:56 a.m., confirmed the fire hydrant deficiencies listed above existed.

2. Observation on August 26, 2019, at 10:30 a.m., revealed the sixth floor, 6X biomed work room, had a sprinkler head loaded with dust in the main work area.

Interview with the maintenance supervisor on August 26, 2019, at 10:30 a.m., confirmed the biomed work area had a sprinkler head loaded with dust.

3. Observation on August 27, 2019, between 8:50 a.m. and 9:30 a.m., revealed the following fire suppression system deficiencies:
A. (8:50 a.m.) first floor, loading dock corridor, had two missing sprinkler escutcheons;
B. (9:02 a.m.) fifth floor, South building, Family Intervention office, had a missing sprinkler escutcheon;
C. (9:30 a.m.) third floor, at the fire doors by Geriatric Behavior Health entrance, above the lay-in ceiling, had a fire suppression system valve that lacked a UL approved sign

Interview with the maintenance supervisor on August 27, 2019, at 9:30 a.m., conformed the fire suppression system deficiencies listed above existed.

Based on document review, observation and interview it was determined that the facility failed to maintain the fire suppression system, on one of one systems.

Findings include:

1. Document review on August 26, 2019, between 8:55 a.m. and 8:56 a.m., revealed the following fire hydrant deficiencies existed:
A. (8:55 a.m.) hydrant #1, indicated right side 2 1/2 inch threaded connection is loose;
B.. (8:56 a.m.) hydrant #6, should have an 18 inch clearance from streamer connection.

Interview with the maintenance supervisor on August 26, 2019, at 8:56 a.m., confirmed the fire hydrant deficiencies listed above existed.

Based on document review and interview it was determined that the facility failed to provide current certification for the fire extinguisher service technicians, for two of three technicians, per NFPA 10-7.1.2.

Findings include:

Document review on August 26, 2019, at 8:45 a.m., revealed that certifications for two of three fire extinguisher technicians had expired in June 2019.

Interview with the maintenance supervisor on August 26, 2019, at 8:45 a.m., confirmed two of three fire extinguisher technicians had expired in June 2019.

Based on document review, observation and interview, it was determined that the facility failed to maintain fire extinguishers at two of over fifty portable fire extinguishers.

Findings include:

1. Document review on August 26, 2019, at 8:45 a.m., revealed that certifications for two of three fire extinguisher technicians had expired in June 2019 (per NFPA 10-7.1.2).

Interview with the maintenance supervisor on August 26, 2019, at 8:45 a.m., confirmed two of three fire extinguisher technicians certifications had expired in June 2019.

2. Observation on August 26, 2019, at 11:00 a.m., revealed the ground floor, fire extinguisher, located at the elevator lobby, was blocked by large carts.

Interview with the director of facilities on August 26, 2019, at 11:00 a.m., confirmed the above fire extinguisher was blocked.

3. Observation on August 26, 2019, at 1:15 p.m., revealed the third floor, fire extinguisher housing case door handle, was missing (broken off), located at the Endoscopy and stair tower area.

Interview with the director of facilities on August 26, 2019, at 1:15 p.m., confirmed the above fire extinguisher housing case door handle was damaged.

Based on observation and interview, the facility failed to maintain corridor doors at two of over 100 corridor doors.

Findings include:

1. Observation on August 26, 2019, between 9:15 a.m. and 9:40 a.m., revealed the following corridor doors lacked positive latching in the frame:
a. (9:15 a.m.) sixth floor, resident room T6225;
b. (9:40 a.m.) fifth floor, I.C.U. resident room T5209.

Interview with the director of facilities on August 26, 2019, at 9:40 a.m., confirmed the above corridor doors lacked positive latching.

Based on observation and interview it was determined that the facility failed to maintain and inspect corridor doors, on two of six levels.

Findings include:

1. Observation on August 26, 2019, between 10:25 a.m. and 12:33 p.m., revealed the following corridor doors failed to close and latch into the frames:
A. (10:25 a.m.) sixth floor, door # 6, North 61, right leaf;
B. (12:33 p.m.) fourth floor, Sue E. storage room, corridor door.

Interview with the maintenance supervisor on August 26, 2019, at 12:33 p.m., confirmed the corridor doors listed above failed to close and latch into the frames.

2. Observation on August 27, 2019, at 10:20 a.m., revealed the second floor addition corridor electrical closet door, right leaf, failed to close and latch.

Interview with the maintenance supervisor on August 27, 2019, at 10:20 a.m., confirmed the second floor addition dorridor electrical closet door, right leaf, failed to close and latch.

Based on observation and interview it was determined that the facility failed to maintain smoke barriers to resist the passage of smoke, on one of six levels.

Findings include:

Observation on August 26, 2019, at 10:17 a.m., revealed the sixth floor, room 6N1115, had two unsealed penetrations on the left side wall, at two abandoned electric outlet boxes.

Interview with the maintenance supervisor on August 26, 2019, at 10:17 a.m., confirmed the two unsealed penetrations listed above existed.

Based on observation and interview it was determined that the facility failed to maintain smoke partitions to resist the passage of smoke, on one of six levels.

Findings include:

Observation on August 27, 2019, at 9:50 a.m., revealed the third floor, 3 Main nurse station, had an unsealed penetration in the wall next to the tube delivery system unit.

Interview with the maintenance supervisor on August 27, 2019, at 9:50 a.m., confirmed the third floor, 3 Main nurse station, had an unsealed penetration in the wall next to the tube delivery system unit.

Based on observation and interview, the facility failed to maintain vertical chutes at one of two chutes.

Findings include:

1. Observation on August 26, 2019, at 9:45 a.m., revealed the second floor access door to the trash chute, lacked positive latching.

Interview with the director of facilities on August 26, 2019, at 9:45 a.m., confirmed the trash chute door lacked positive latching.

Based on observation and interview it was determined that the facility failed to test and inspect trash chutes, on one of six levels.

Findings include:

Observation on August 26, 2019, at 12:45 p.m,. revealed the fourth floor, 4X nursing wing trash chute, located in the facilities room, failed to close and latch.

Interview with the maintenance supervisor on August 26, 2019, at 12:45 p.m., confirmed the trash chute failed to close and latch.

Based on document review and interview it was determined that the facility failed to conduct fire drills at unexpected times under varying conditions, on one of three shifts.

Findings include:

Document review on August 26, 2019, at 8:15 a.m., revealed the third shift fire drills for the previous four quarters, had been conducted between the hours of 6:17 a.m. and 7:00 a.m.

Interview with the maintenance supervisor on August 26, 2019, at 8:15 a.m., confirmed the third shift fire drills for the previous twelve months, had been conducted within the same hour each quarter.

Based on observation and interview it was determined that the facility failed to test and inspect fire rated doors, on one of six levels.

Findings include:

Observation on August 26, 2019, at 10:45 a.m., revealed the fifth floor, cross corridor fire doors, 5 North 51, by room # N5301W, failed to close and latch.

Interview with the maintenance supervisor on August 26, 2019, at 10:45 a.m., confirmed the fifth floor, cross corridor fire doors, 5 North 51, by room # N5301W, failed to close and latch.

Based on observation and interview, the facility failed to maintain the medical gas, vacuum, or support systems in one of one piped-in medical gas system.

Findings include:

1. Observation on August 27, 2019, between 10:30 a.m. and 10:40 a.m., revealed the following second floor, Radiology areas, had piped-in medical gas lines that had incorrectly colored labeling:
a. (10:30 a.m.) assessment room #3;
b. (10:40 a.m.) ultrasound room #5.

Interview with the director of facilities on August 27, 2019, at 10:40 a.m., confirmed the above piped-in medical gas labels are not labeled in accordance with the Compressed Gas Association regulations.

Based on observation and interview it was determined that the facility failed to maintain electrical outlets, on one of six levels.

Findings include:

Observation on August 26, 2019, at 1:23 p.m., revealed the third floor, 3X Education Suite, had a broken red electrical outlet cover, located at the right rear of the suite.

Interview with the maintenance supervisor on August 26, 2019, at 1:23 p.m., confirmed the red electrical outlet cover was broken.

Based on observation and interview, the facility failed to maintain extension cords in two of over 100 rooms.

Findings include:

1. Observation on August 26, 2019, between 10:15 a.m. and 10:30 a.m., revealed the following areas were utilizing extension cords for computers:
a. (10:15 a.m.) second floor, Nursing Training classroom B & C;
b. (10:30 a.m.) first floor, Heating Ventilation and Air Conditioning/Chiller room.

Interview with the director of facilities on August 26, 2019, at 10:30 a.m., confirmed the extension cord use in the above locations.

Based on observation and interview it was determined that the facility failed to inspect and maintain electrical extension and power cords, on three of six levels.

Findings include:

1. Observation on August 27, 2019, between 9:51 a.m. and 11:50 a.m., revealed the following:
A. (9:51 a.m.) third floor, nurse station, rear office by the tube delivery unit, had a surge protector power supply, suspended by the electrical power cord;
B. (10:04 a.m.) third floor, OR scheduling office, had a surge protector plugged into a surge protector;
C. (11:15 a.m.) first floor, One South, IS cubicle, Gary K., had a surge protector plugged into a surge protector;
D. (11:50 a.m.) first floor, Electrophysiology office, across from the restroom, had a surge protector hanging by the electrical power cord.

Interview with the maintenance supervisor on August 27, 2019, at 11:50 a.m., confirmed the deficiencies listed above existed.

2. Observation on August 27, 2019, between 10:20 a.m. and 10:50 a.m., revealed the following:
A. (10:20 a.m.) second floor, cafeteria serving line, had an extension cord behind the soda machine;
B. (10:50 a.m.) second floor, Radiology pod, had a refrigerator plugged into a surge protector.

Interview with the director of facilities on August 27, 2019, at 10:50 a.m., confirmed the deficiencies listed above existed.

Based on observation and interview it was determined that the facility failed to inspect power cords and extension cords, on two of six levels.

Findings include:

1. Observation on August 26, 2019, between 11:00 a.m. and 12:49 p.m., revealed the following:
A. (11:00 a.m.) fifth floor, Purchasing Agent office, by the restroom, had a computer power supply hanging by the electrical cord;
B. (12:49 p.m.) fourth floor, nursing wing library, had a surge protector suspended by a television electrical power cord.

Interview with the maintenance supervisor on August 26, 2019, at 12:49 p.m., confirmed the electrical cord deficiencies listed above existed.

2. Observation on August 27, 2019, between 8:10 a.m. and 11:05 a.m., revealed the following:
A. (8:10 a.m.) second floor, Triage room #2, had a computer power supply hanging by the electrical power cord, below the desk;
B. (11:05 a.m.) first floor, Human Resources break room, had a three to one electrical extension cord, with a refrigerator and coffee pot plugged into the extension cord.

Interview with the maintenance supervisor on August 27, 2019, at 11:05 a.m., confirmed the electrical cord deficiencies listed above existed.

Based on observation and interview, the facility failed to maintain medical gas cylinder storage on two of seven floors.

Findings include:

1. Observation on August 26, 2019, at 8:25 a.m., revealed an unsecured oxygen cylinder in the seventh floor oxygen storage room, near room T7214.

Interview with the director of facilities on August 26, 2019, at 8:25 a.m., confirmed the above oxygen storage room contained an unsecured oxygen cylinder.

2. Observation on August 26, 2019, at 1:00 p.m., revealed third floor, Operating Room suite storage room, had greater than 300 cubic feet of oxygen (over 12 e-sized cylinders) used as "operational supply".

Interview with the director of facilities on August 26, 2019, at 1:00 p.m., confirmed the oxygen stored in the above location was over the required amount used as "operational supply".