HospitalInspections.org

Based on observation on Wed , 4/6/2011

1) The exit corridor on 3rd floor was not constructed smoke tight. (Exit Corridor between the two mechanical rooms)

2) The inside corridor wall of the storage closet located next to the large clean linen room was not maintained in order to provide a one hour fire resistance rating for the area.(Ground Floor West)

Based on observation on Wed , 4/6/2011,

1) (Behavioral Health)The findings include the door to the medical perpetration room in the behavioral health portion of the 5th floor did not have a door closure for the top portion of the door that can be opened by the staff.

2) (Fifth Floor)The findings include the door to the office next to the Oncology office had unsealed holes near the door hardware that were not properly sealed

3) The corridor door to patient room 135 did not close, latch and seal when checked.(1st floor)

4) The corridor doors to the mechanical room near the elevators were not smoke tight when closed. (3rd floor)

5) The first set of corridor door to the mechanical room on the left side of hall on 3rd floor were not self-closing.

6) Corridor Door to the second floor nursing lounge, near room 271, does not have positive latching. (11:00 AM)

Based on observation on Wed , 4/6/2011,

1) Access to the exit, in the stairwell from OR & Outpatient, did not have a hinge on the directional barrier or a sign that says " no exit " . The way to reach the exit is not readily apparent to the occupants. 7.10.1.4 (2:45 PM)

Based on observation on Wed , 4/6/2011

(1) ( ADON ' s office area) The findings include the smoke wall above the cross corridor smoke doors had unsealed penetrations at the area where the smoke wall meets the door frame. (This area is located where the new MRI was brought through the corridor)

Based on observation on Wed , 4/6/2011

1) (ICU) The findings include both sets of cross corridor smoke doors to enter and exit the ICU had gaps greater than 1/8 of an inch.

2) The Fire/Smoke door from ground floor PACU to ER, in the four hour wall, did not have positive latching. (2:00 PM)

Based on observation on Wed , 4/6/2011

1) The Supply Room corridor door for the Laboratory was not self closing. (Ground Floor West)

2) There was soiled linen stored in alcoves across from room 463 and room 475. (10:20 AM)

Based on observation on Wed , 4/6/2011,

1. Lower Level, Out-Patient- Same Day Surgery, Numerous doors to Baths, storage , etc required 2 hand motion to exit the rooms.

2. Lower Level, Out-Patient- Same Day Surgery, Exit discharge - There was no hard surface discharge path to a safe public way.





26594

Based on observation on Wed , 4/6/2011

(1) (Behavioral Health) The findings include the key lock door release for the egress from that space is not located in the vicinity of the locked door. The key lock is at the door nearest to the nurse ' s station.

(2) (Fifth Floor) The findings include not all staff that are assigned to the fifth floor carry keys for egress through the behavioral health area.

(3) (Dietary) The findings include the exit discharge path from the required exit on the North wall did not have a solid path (easily maintained in inclement weather) other than grass or soil to the public way.

(4) (Dietary) The findings include the freezer, cooler and produce cooler did not have a means of egress from each space that could be found from inside in all levels of light.

(5) (Loading dock) The findings include the loading dock did not have fall protection installed at the truck loading and unloading area.

(6) (Dietary) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the freezer, cooler and produce cooler.

(7) (Fifth Floor) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the closet of the Oncology office.

(8) (Decontamination room) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the hopper room.

(9) (Dietary) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the freezer, cooler and produce cooler.

(10) (First Floor) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the Viewing room

(11) (Behavioral Health) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the closet in room 565.

Based on observation on Wed , 4/6/2011,

1. Stairwell from Outpatient Clinic - Lower Level to 1st Floor : There was no Exit Direction Sign to the exit Discharge.


26594

Based on observation on Wed , 4/6/2011,

(1) (Dietary) The findings include the exit sign located on the south wall did not give the proper direction for exiting. The exit sign directed persons in that space to the right where there was no required exit.

(2) (Behavioral Health)The findings include there was no exit directional sign leading from the nurses station door to the required exit at the stairwell in the locked unit.

3) An exit directional sign was not provided for in the hall outside the laboratory storage room to the exit corridor. (Ground Floor West)

Based on observation on Wed , 4/6/2011

1) During the inspection and testing of the facility fire alarm system, that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure, located in the main electrical room, did not send a trouble signal to the fire alarm control panel (FACP) located at the ER main communications. The main electrical room, where the automatic dialer component was located, gave an audible trouble signal, however, the main fire alarm control panel (FACP), located at the ER main communications, showed all systems were normal. There was not a visual and audible signal at the main communications area.

Based on observation on Wed , 4/6/2011,

1. Lower Level - Outpatient - Same Day Surgery Clinic- Two Electrical/ IT closets had no sprinkler coverage as required.

Based on observation on Wed , 4/6/2011

1) Access Doors to the smoke duct detectors for visual inspection was not provided for to several of the smoke duct detectors installed in the HVAC units on the 3rd floor mechanical area.

Based on observation on Wed , 4/6/2011

1) (Behavioral Health) The findings include that the residential dryer in the laundry area did not have a noncombustible dryer vent.

Based on observation on Wed , 4/6/2011

1) (Fifth Floor) The findings include there was an unapproved space heater being utilized in the office next to the oncology.

Based on observation on Wed , 4/6/2011,

(1) (Behavioral Health) The findings include the door to the nurse's station opened into the egress corridor neither without opening 180 degrees to the wall nor had a door closure installed to keep the door closed after being opened.

(2) Labor and Delivery Room (LDR) The findings include the improper storage of wheel chair in alcove that were protruding into the egress corridor.

(3) (LDR) The findings include the storage of two planters in the egress corridor.

(4) (LDR) The findings include the keypad/bio readers that were protruding into the corridor more that seven inches.

Based on observation on Wed , 4/6/2011

1) Oxygen cylinders stored in the clean works room 1st floor near the nurse station were not separated, full from empty and did not have signage posted for full or empty.

2) H-size tanks stored in the bulk oxygen area were not individually secured or cover in order to be protected from the environment.

3) Full and Empty signage was not posted in oxygen storage areas on fourth and second floors. (Fourth floor across from room 467 & second floor clean utility room)

Based on observation on Wed , 4/6/2011,

1. Type 1 EES Emergency Power Generators did not crank and Transfer load within the required 10 Seconds. (Gen 1,2,and 4)

Based on observation on Wed , 4/6/2011

1) (Labor and Delivery Room) The findings include the soiled utility room had an alcohol based hand rub that was installed above the light receptacle which is an ignition source.

Based on observation on Wed , 4/6/2011

1) The exit corridor on 3rd floor was not constructed smoke tight. (Exit Corridor between the two mechanical rooms)

2) The inside corridor wall of the storage closet located next to the large clean linen room was not maintained in order to provide a one hour fire resistance rating for the area.(Ground Floor West)

Based on observation on Wed , 4/6/2011,

1) (Behavioral Health)The findings include the door to the medical perpetration room in the behavioral health portion of the 5th floor did not have a door closure for the top portion of the door that can be opened by the staff.

2) (Fifth Floor)The findings include the door to the office next to the Oncology office had unsealed holes near the door hardware that were not properly sealed

3) The corridor door to patient room 135 did not close, latch and seal when checked.(1st floor)

4) The corridor doors to the mechanical room near the elevators were not smoke tight when closed. (3rd floor)

5) The first set of corridor door to the mechanical room on the left side of hall on 3rd floor were not self-closing.

6) Corridor Door to the second floor nursing lounge, near room 271, does not have positive latching. (11:00 AM)

Based on observation on Wed , 4/6/2011,

1) Access to the exit, in the stairwell from OR & Outpatient, did not have a hinge on the directional barrier or a sign that says " no exit " . The way to reach the exit is not readily apparent to the occupants. 7.10.1.4 (2:45 PM)

Based on observation on Wed , 4/6/2011

(1) ( ADON ' s office area) The findings include the smoke wall above the cross corridor smoke doors had unsealed penetrations at the area where the smoke wall meets the door frame. (This area is located where the new MRI was brought through the corridor)

Based on observation on Wed , 4/6/2011

1) (ICU) The findings include both sets of cross corridor smoke doors to enter and exit the ICU had gaps greater than 1/8 of an inch.

2) The Fire/Smoke door from ground floor PACU to ER, in the four hour wall, did not have positive latching. (2:00 PM)

Based on observation on Wed , 4/6/2011

1) The Supply Room corridor door for the Laboratory was not self closing. (Ground Floor West)

2) There was soiled linen stored in alcoves across from room 463 and room 475. (10:20 AM)

Based on observation on Wed , 4/6/2011,

1. Lower Level, Out-Patient- Same Day Surgery, Numerous doors to Baths, storage , etc required 2 hand motion to exit the rooms.

2. Lower Level, Out-Patient- Same Day Surgery, Exit discharge - There was no hard surface discharge path to a safe public way.





26594

Based on observation on Wed , 4/6/2011

(1) (Behavioral Health) The findings include the key lock door release for the egress from that space is not located in the vicinity of the locked door. The key lock is at the door nearest to the nurse ' s station.

(2) (Fifth Floor) The findings include not all staff that are assigned to the fifth floor carry keys for egress through the behavioral health area.

(3) (Dietary) The findings include the exit discharge path from the required exit on the North wall did not have a solid path (easily maintained in inclement weather) other than grass or soil to the public way.

(4) (Dietary) The findings include the freezer, cooler and produce cooler did not have a means of egress from each space that could be found from inside in all levels of light.

(5) (Loading dock) The findings include the loading dock did not have fall protection installed at the truck loading and unloading area.

(6) (Dietary) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the freezer, cooler and produce cooler.

(7) (Fifth Floor) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the closet of the Oncology office.

(8) (Decontamination room) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the hopper room.

(9) (Dietary) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the freezer, cooler and produce cooler.

(10) (First Floor) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the Viewing room

(11) (Behavioral Health) The findings include the facility is utilizing special locking arrangements but did not have full sprinkler coverage nor detection in the closet in room 565.

Based on observation on Wed , 4/6/2011,

1. Stairwell from Outpatient Clinic - Lower Level to 1st Floor : There was no Exit Direction Sign to the exit Discharge.


26594

Based on observation on Wed , 4/6/2011,

(1) (Dietary) The findings include the exit sign located on the south wall did not give the proper direction for exiting. The exit sign directed persons in that space to the right where there was no required exit.

(2) (Behavioral Health)The findings include there was no exit directional sign leading from the nurses station door to the required exit at the stairwell in the locked unit.

3) An exit directional sign was not provided for in the hall outside the laboratory storage room to the exit corridor. (Ground Floor West)

Based on observation on Wed , 4/6/2011

1) During the inspection and testing of the facility fire alarm system, that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure, located in the main electrical room, did not send a trouble signal to the fire alarm control panel (FACP) located at the ER main communications. The main electrical room, where the automatic dialer component was located, gave an audible trouble signal, however, the main fire alarm control panel (FACP), located at the ER main communications, showed all systems were normal. There was not a visual and audible signal at the main communications area.

Based on observation on Wed , 4/6/2011,

1. Lower Level - Outpatient - Same Day Surgery Clinic- Two Electrical/ IT closets had no sprinkler coverage as required.

Based on observation on Wed , 4/6/2011

1) Access Doors to the smoke duct detectors for visual inspection was not provided for to several of the smoke duct detectors installed in the HVAC units on the 3rd floor mechanical area.

Based on observation on Wed , 4/6/2011

1) (Behavioral Health) The findings include that the residential dryer in the laundry area did not have a noncombustible dryer vent.

Based on observation on Wed , 4/6/2011

1) (Fifth Floor) The findings include there was an unapproved space heater being utilized in the office next to the oncology.

Based on observation on Wed , 4/6/2011,

(1) (Behavioral Health) The findings include the door to the nurse's station opened into the egress corridor neither without opening 180 degrees to the wall nor had a door closure installed to keep the door closed after being opened.

(2) Labor and Delivery Room (LDR) The findings include the improper storage of wheel chair in alcove that were protruding into the egress corridor.

(3) (LDR) The findings include the storage of two planters in the egress corridor.

(4) (LDR) The findings include the keypad/bio readers that were protruding into the corridor more that seven inches.

Based on observation on Wed , 4/6/2011

1) Oxygen cylinders stored in the clean works room 1st floor near the nurse station were not separated, full from empty and did not have signage posted for full or empty.

2) H-size tanks stored in the bulk oxygen area were not individually secured or cover in order to be protected from the environment.

3) Full and Empty signage was not posted in oxygen storage areas on fourth and second floors. (Fourth floor across from room 467 & second floor clean utility room)

Based on observation on Wed , 4/6/2011,

1. Type 1 EES Emergency Power Generators did not crank and Transfer load within the required 10 Seconds. (Gen 1,2,and 4)