HospitalInspections.org

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Maintenance Lead.

The findings include but are not limited to:

1. At 1045 the door to Room 2240 Labor and Delivery failed to latch when pulled closed.
2. At 1350 the door to Surgery Equipment Room #2 failed to latch when pulled closed.

Maintenance Lead was unaware that the doors were not latching; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, at 1406, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting the vertical opening with the required fire resistive rating. This could allow movement of fire, smoke and toxic products of combustion throughout the hospital. This finding was acknowledged by the Director of Facilities.

The findings include but are not limited to:

1. Smoke strip is missing on the elevator fire door in the 1st floor east vestibule.

Director of Facilities was unaware that the smoke strip was missing; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, at 1328, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to maintain doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of rooms meant to be protected by self-closing doors, placing staff, residents and visitors at risk. This finding was acknowledged by the Director of Facilities.

The findings include but are not limited to:

Cross-Corridor Fire Doors by the Café failed to close and latch when tested.

Director of Facilities was unaware that the doors were not latching; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation and staff interview, it was discovered that the facility has failed to provide and/or maintain portable fire extinguishers per the referenced standard(s). This could result in a delay in controlling or extinguishing a fire. These findings were acknowledged by the Maintenance Lead.

Findings are, but not limited to;

1. At 0945 it was discovered that the fire extinguisher in the tower mechanical penthouse has had no monthly inspection sign-offs and that the last annual maintenance was performed 04/2013.
1. At 1010 in the Heliport Lobby, there is one Class 20A 120BC portable fire extinguisher. NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A 160-B, shall be permitted to be used to satisfy this requirement.

The Maintenance Lead stated that he was not aware of this requirement as the facility has not previously been cited for this deficiency.

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation, staff interviews and record review it was discovered that the facility has failed to has failed to protect medical gas administration areas in accordance with NFPA 99. This could result in ignition of flammable gases or oxidizers, placing staff and patients at risk. These findings were acknowledged by the Labor & Delivery Director, OR Nurse Anesthetist and the Maintenance Lead.

The findings include but are not limited to:

1. At 1055 it was discovered that the C-Section OR in L&D is utilizing general anesthesia in some cases, but has no means of monitoring nor controlling the humidity in the OR.
2. At 1330 it was discovered that the hospital ' s Policy & Procedure for ORs utilizing general anesthesia is to utilize a humidity range set for 30% - 60% vs. 35% per NFPA 99.

Follow-up discussions with the staff revealed that the Labor & Delivery Director was unaware of this requirement and that the OR staff were unaware that they are operating outside of the acceptable range. Maintenance Lead and was also not aware that the hospital is operating out of the required standard. Further discussion with the Director of Facilities revealed that he was not aware that the hospital was utilizing the wrong low end percentage per NFPA 99. He stated that engineering has the capabilities to control the humidity and that they can program the C-section OR into the system.

During the survey tour of 07/08/2015, at 1346, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Director of Facilities.
The findings include, but are not limited to:
1. Electrical UPS for CT Scan - open junction box.
Director of Facilities was unaware that the junction box was not covered.

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Maintenance Lead.

The findings include but are not limited to:

1. At 1045 the door to Room 2240 Labor and Delivery failed to latch when pulled closed.
2. At 1350 the door to Surgery Equipment Room #2 failed to latch when pulled closed.

Maintenance Lead was unaware that the doors were not latching; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, at 1406, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting the vertical opening with the required fire resistive rating. This could allow movement of fire, smoke and toxic products of combustion throughout the hospital. This finding was acknowledged by the Director of Facilities.

The findings include but are not limited to:

1. Smoke strip is missing on the elevator fire door in the 1st floor east vestibule.

Director of Facilities was unaware that the smoke strip was missing; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, at 1328, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to maintain doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of rooms meant to be protected by self-closing doors, placing staff, residents and visitors at risk. This finding was acknowledged by the Director of Facilities.

The findings include but are not limited to:

Cross-Corridor Fire Doors by the Café failed to close and latch when tested.

Director of Facilities was unaware that the doors were not latching; doors are on an annual P.M. program. Discussion with the Director of Facilities at 1530 regarding a more stringent testing program.

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation and staff interview, it was discovered that the facility has failed to provide and/or maintain portable fire extinguishers per the referenced standard(s). This could result in a delay in controlling or extinguishing a fire. These findings were acknowledged by the Maintenance Lead.

Findings are, but not limited to;

1. At 0945 it was discovered that the fire extinguisher in the tower mechanical penthouse has had no monthly inspection sign-offs and that the last annual maintenance was performed 04/2013.
1. At 1010 in the Heliport Lobby, there is one Class 20A 120BC portable fire extinguisher. NFPA 10 (Standard for Portable Fire Extinguishers) references NFPA 418 (Standard for Heliports):

3.6 Fire Protection.

A foam fire-extinguishing system shall be designed and installed to protect the rooftop landing pad.

Exception No. 1: A foam fire-extinguishing system shall not be required for heliports located on parking garages, unoccupied buildings, or other similar unoccupied structures.

Exception No. 2: For H-1 heliports, two portable foam extinguishers, each having a rating of 20-A 160-B, shall be permitted to be used to satisfy this requirement.

The Maintenance Lead stated that he was not aware of this requirement as the facility has not previously been cited for this deficiency.

During the survey tour of 07/08/2015, while accompanied by the Maintenance Lead, through observation, staff interviews and record review it was discovered that the facility has failed to has failed to protect medical gas administration areas in accordance with NFPA 99. This could result in ignition of flammable gases or oxidizers, placing staff and patients at risk. These findings were acknowledged by the Labor & Delivery Director, OR Nurse Anesthetist and the Maintenance Lead.

The findings include but are not limited to:

1. At 1055 it was discovered that the C-Section OR in L&D is utilizing general anesthesia in some cases, but has no means of monitoring nor controlling the humidity in the OR.
2. At 1330 it was discovered that the hospital ' s Policy & Procedure for ORs utilizing general anesthesia is to utilize a humidity range set for 30% - 60% vs. 35% per NFPA 99.

Follow-up discussions with the staff revealed that the Labor & Delivery Director was unaware of this requirement and that the OR staff were unaware that they are operating outside of the acceptable range. Maintenance Lead and was also not aware that the hospital is operating out of the required standard. Further discussion with the Director of Facilities revealed that he was not aware that the hospital was utilizing the wrong low end percentage per NFPA 99. He stated that engineering has the capabilities to control the humidity and that they can program the C-section OR into the system.

During the survey tour of 07/08/2015, at 1346, while accompanied by the Director of Facilities, through observation and staff interview, it was discovered that the facility has failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Director of Facilities.
The findings include, but are not limited to:
1. Electrical UPS for CT Scan - open junction box.
Director of Facilities was unaware that the junction box was not covered.