HospitalInspections.org

Based on observations and interview, the hospital failed to ensure construction type and Height requirements were met.

Findings:

On 4/23/19 at 11:40 am surveyors, with the Facility Site Supervisor and Maintenance Technician observed the following:

a. Sheetrock missing from the wall assembly above the ceiling at the MRI exit.
b. Unprotected wood strapping on the exterior wall assembly above the ceiling at the MRI exit.
c. Ceiling assembly (steel) missing sprayed fire proofing above the ceiling at the MRI exit. Fire proofing
removed to accomodate new MRI canopy.

The surveyor confirmed these observations with the Facility Site Supervisor and Maintenance Technician at the time of observation.

Based on observations and interview, the hospital failed to ensure the means of egress was free from all obstructions in 2 of the 5 patient care areas.

Findings:

On 4/23/19 between 12:00 pm and 2:00 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Two straight back chairs stored in the exit corridor outside the Physical Therapy Room 116 of the Inpatient Wing. Observed at 12:24 pm.
b. Mobile nurse's station plugged in and stored across from Room 115 of the Inpatient Wing. Observed at 12:28 pm.
c. Mobile nurse's station plugged in and stored across from Room 105 of the Inpatient Wing. Observed at 1:41 pm.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.

Based on observations and interview, the hospital failed to ensure that the required signage for delayed-egress locking system was posted on the Exit doors in 1 of 5 patient care areas.

Findings:

On 4/23/19 at 12:23 pm, surveyor, with the Facilities General Manager present, observed the following:

a. Exit door by Physical Therapy lacked the required signage for special locking arrangements Signage indicating that the exit door will open 15 seconds was not attached to the exit door. Approved signage was installed prior to exit interview.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.

Based on observation the facility failed to maintain a durable surface for means of egress for one of eighteen exits.


Findings:
On April 23, 2019 between 11:00 am and 11:45 am observations during the exterior inspection of the building revealed an exterior exit access leading from Suite S-2 and the Helicopter landing pad to the public way lacked the appropriate durable surface required by NFPA 101 chapter 19 section 19.2.7, Chapter 7 section 7.7 Discharge from Exits and S & C Letter 05-38 Clarification of Life Safety Code Survey issues in Nursing Homes

Based on observations and interview, the hospital failed to ensure that 1-hour fire resistance ratings where free from penetrations in 2 of 30 hazardous areas.

Findings:

1. On 4/23/29 at 11:00 am, surveyors along with the Facility Site Supervisor and Maintenance Technician observed the following:

a. Penetration of Electrical conduit in the ceiling of Electrical Room adjacent to the Boiler room.

The above finding was confirmed at the time of the observation by surveyors, the Facility Site Supervisor and Maintenance Technician.

Findings:

2. On 4/23/19 at 12:32 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Three holes found in the interior walls of the Housekeeping Closet located across from Room 115 of the Inpatient Wing.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.

Based on observations and interviews, the hospital failed to ensure sprinkler installation in 3 of 3 canopies.

Findings:

On 4/23/19 at 11:30 am surveyors, with the Facility Site Supervisor and Maintenance Technician present observed the following:

a. No sprinkler coverage installed to protect exterior canopy located at the MRI wing exit.
b. No sprinkler coverage installed at the exterior exit canopies at A & G smoke compartments.

The surveyors confirmed these observations with the Facility Site Supervisor and Maintenance Technician at the time of the observation.

Based on observations and interview, the hospital failed to ensure sprinkler maintenance inspections in 2 of 7 smoke compartments were being completed.


Findings:

1. On 4/23/19 at 1:40 pm a surveyor, with the Facility Site Supervisor present, observed the following:

a. Sprinkler Escutcheon cap missing in the Oncology cross hallway.

The surveyor confirmed these observations with the Facility Site Supervisor the time of the observation.


Findings:

2. On 4/23/19 between 11:00 am and 2:00 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Sprinkler head escutcheon cap missing in Storage Room by Room 123 of Inpatient Wing. Observed at 12:04 pm.
b. Sprinkler head obstructed by light fixture in Nursery Storage Room of Inpatient Wing. Observed at 12:07 pm.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.

Based on observations and interview, the hospital failed to ensure that there were no impediments to the closing of the corridor doors in 1 of 5 patient care areas.

Findings:

On 4/23/19 at 12:18 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Privacy curtains to Room 118, Room 119 and 120 obstructed corridor doors from closing in the Inpatient Wing.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.

Based on observations and interview, the hospital failed to ensure the 1/2-hour fire resistance in 3 of the 7 smoke barriers.

Findings:

On 4/23/19 between 11:00 am and 2:00 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Gap and missing sheetrock above the ceiling between the ductwork and smoke barrier from the Lobby to the Inpatient Corridor. Observed at 11:40 am.
b. Hole in right smoke barrier wall above the ceiling of smoke barrier doors at Room 101 of the Inpatient Wing. Observed at 11:52 am.
c. Gap between sprinkler escutcheon cap and ceiling in the Nursery of the Inpatient Wing. Observed at 12:07 pm.
d. Multiple conduit penetrations with unsealed ends above the ceiling of smoke barrier doors at Room 122 of the Inpatient Wing. Observed at 12:14 pm.
e. Pipe penetrations above the ceiling of smoke barrier doors at Room 122 of the Inpatient Wing. Observed at 12:15 pm.

The surveyors confirmed these observations with the Facilities General Manager at the time of observation.

Based on record review and observation the facility failed properly document the required annual inspection of fire rated doors.


Findings:

1. On April 23, 2019 between 1:30 and 2:00 pm documentation was provided by the facility during record review indicating that the facility did not have a single fire rated door. The report was dated May 30, 2018 and was confirmed by Oerations manager.

2. On April 23, 2019 between 2:00 pm and 3:00 pm surveyors while in the presence of the Facilities General Manager, observed 30 Fire rated doors in 7 out of 7 smoke compartments.

1. Asset doors 77624, 77639, 77631, and 77641.
2. Rooms 145 through 147, rooms 140, 141 and 138.
3. Equipment storage room located between room 122 and 123.
4. Rooms 201, 214, 215 and A-300
5. Rooms 221, 247, 249, 250, 252, 257, and two doors located in room 259.

Based on observations and interview, the hospital failed to ensure the proper installation of re-locatable power taps in 1 of 5 patient care areas.

Findings:

On 4/23/19 at 12:32 pm, surveyors, with the Facilities General Manager present, observed the following:

a. Two improperly secured re-locatable power taps under the nurse's station of the Inpatient Wing.

The surveyors confirmed these observations with the Facilities General Manager at the time of the observation.