HospitalInspections.org

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that many ceiling tiles were out of place throughout the facility - staff reported that this was due to construction, installation of new HVAC system, and installation of new nurse call system wiring.

There were also: holes in ceilings in the radiology data closet; a small hole in the wall in #346; and a 3" diameter hole in a laundry entry room ceiling tile.

Staff and contractors need to close up holes and replace ceiling tiles as soon as they are finished with each location - all open ceiling tiles observed during this survey were unattended by staff and/or construction employees.

These penetrations could have the possibility of affecting 50 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that numerous corridor doors throughout the facility were held open with non-approved hold open devices - cans, wedges, or chocks, including, but not limited to the following:

1.) corridor door to patient room #303 - trash and soiled linen bins impeding the door;

2.) patient room door #218 failed to latch;

3.) the waiting room door to the "same day surgery" center was held open with a chock;

4.) the corridor door to the radiology suite was held open with a chock;

5.) the electrical/data closet door in radiology was held open with a chock;

6.) the file room door in radiology had its self-closing mechanism detached;

7.) the locker/break room door in radiology had its door chocked open;

8.) the main dry goods storage room door in the kitchen was held open with a brick;

9.) the air handler/duct room door to the service corridor near the kitchen was held open with a five gallon can;

10.) a fire rated gate (pass through) assembly from the corridor to the ICU was partially open - a laptop computer was on the counter where the door would close - the laptop and its cables impeded the assembly from closing and sealing properly - staff was advised to change the location of the laptop and its wiring.

These impediments could prevent the doors from being quickly and easily closed and latched in the event of an emergency and could effect the occupants of the listed rooms, staff members in these areas and up to 20% of the patients or occupants in the corridors.

Based on observation of the physical environment, it was determined that the facility staff failed to ensure that smoke barrier walls do not have any penetrations that would allow smoke to pass through the walls in the event of a fire.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that, upon inspection of the smoke barrier wall above the corridor ceiling near patient room #309, holes and penetrations for newly installed cables and wires had not been resealed to prevent the passage of smoke - existing fire retardant caulk had been removed and was lying near the gaps..

All smoke barrier walls throughout the hospital above ceilings need to be inspected for unprotected penetrations. Open holes and penetrations need to be resealed with fire retardant caulk on both sides of each barrier wall.

These holes and penetrations could allow smoke to travel throughout the building in the event of a fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that hazardous areas are separated from other spaces by smoke resisting partitions and doors.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the corridor door to the soiled utility room in the "same day surgery" center had its strike mechanism taped with surgical tape - this prevented the door from properly latching - surgical staff was advised of this situation.

Partitions that are not smoke resisting could allow smoke to travel from hazardous areas of the facility to other sections in the event of an emergency and could effect patients and staff in the immediate area.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having stairwells free of storage.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that stairwell #C, located near the laundry suite corridor, had excessive storage in the lower level and under the stairs - this is the emergency exit for staff working in the laundry suite, and the stairwell is also an emergency exit for upper floors.

This storage (some of it combustible) fills almost the entire bottom of the stairwell and could result in a blocked emergency egress or fire in the stairwell.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having exit access so arranged that exits are readily accessible at all times.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the door from the sterile supply corridor to the exit corridor was equipped with an operating deadbolt on the inside - the door was also equipped with a key pad locking system on the outside to restrict access to the supply corridor.

This lock could cause the accidental locking-in of staff members and prevent egress from inside in the event of a fire, smoke conditions, or low light conditions if a person could not visualize the deadbolt lock or how to operate it properly. This interior lock must be removed but the exterior locking mechanism can remain on the door which will allow egress from the interior in the event of an emergency but will still limit or prevent access to residents and/or non staff members from the service corridor. NFPA 7.1.9.

Allowing such locking devices to be installed on doors in a means of egress has the potential to promote harm to occupants of the building in the event of a fire or other emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that corridors serving as exit access remain clear and unobstructed and free of storage.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) service corridors had excessive storage of old beds, discarded equipment, chairs, furniture, etc.;

2.) the operating room corridor had excessive storage along both sides, effectively reducing the width of the corridor to less than 4 ' - storage included an in-use desk and chair, shelving, racks, carts, bins, etc. - some items were wheeled and some were not.

This could obstruct the flow of people out of the building in the event of an emergency and could delay egress from these corridors. Evacuation of a patient(s) through the OR corridor while that patient is on a bed or gurney could be difficult. This could effect or delay up to 25% of the patients and staff who would use the emergency exits in case of an emergency and could delay the entry of firefighters in the event of a fire or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not installing a heat or smoke detector in all required areas of the building and in areas where Fire Alarm System control panels are located.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) There was no smoke detector in the radiology electrical/data closet which also had an alarm panel control unit;

2.) There was no smoke detector in the entry room to the commercial laundry suite - it appears to have been removed from the ceiling and not replaced.

NFPA 72 (1999 Edition as per CMS) 1-5.6 - Protection of Fire Alarm Control Units - In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

A fire in the same room as an alarm panel control unit could disable all or portions of the fire alarm system.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 pm and 4:00 pm that portions of this hospital are not protected by automatic sprinklers, including, but not limited to:

1.) The rear loading dock area;

2.) The area around the trash compacter (located off of the rear loading dock) which is covered with a metal canopy;

3.) The administrative wing including its corridor and the main board room;

4.) The kitchen walk-in refrigerators and freezers.

A fire in any one of these locations could spread since there is no automatic sprinkler coverage and could impact up to 25% of the patients and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) Two sprinkler heads over the corridor ramp near the kitchen were missing their escutcheon rings;
2.) Two low-mounted sprinkler heads in the kitchen dry goods storage room had no protective cages;
3.) Two exterior fire department connections (FDC's) had no signs indicating their locations - the side of the building near the administrative wing entrance door and the rear of the building near the main mechanical rooms - the FDC near the administrative exit door was also partially obstructed by a trash can;
4.) At least one flow/tamper switch cover in stairwell #E was not secured tightly with two tamper resistant screws - all covers must be fully secured to prevent tampering;
5.) One storage closet (#202) in the OB/GYN wing had blankets on the top shelf stored too close to the ceiling mounted sprinkler head.
These could have the possibility of affecting 25 % of the patients and staff of the facility and could result in improper operation or failure of the sprinkler heads.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the kitchen hood system in compliance with NFPA 96.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that all metal filters in the kitchen hood system were installed improperly. The filters are to be mounted so that the baffles are arranged vertically so collected grease will drain down into the trough for proper collection.

Proper alignment of the filters is required in order to assure that the system is free of flammable grease buildup.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage areas in accordance with NFPA 99.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the central medical gas storage room (located off of the loading dock) had the following:

1.) Three nitrous oxide tanks (H size) were connected to the central gas system but were unsecured on the floor;

2.) Seven "E" oxygen tanks on one side of the room were standing on the floor unprotected from falling, and more "E" oxygen tanks on the other side of the room also unprotected from falling;

3.) An entire row of assorted medical gas tanks (mostly "H" sizes) along the rear wall of the room were behind a chain that was draped too low and too loose to protect them from falling.

Note - full & empty oxygen tanks were properly marked in this location and in other locations throughout the hospital.

Unsecured oxygen tanks could lead to damage or personal injury in the event that one or more would fall.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) Second floor data processing storage room had excessive storage in front of electrical panels;

2.) Walk-in refrigerator #1 in the main kitchen had a wall mounted electrical junction box with no cover plate and wires exposed and protruding;

3.) The central medical gas storage room located off of the loading dock had a wall-mounted power strip with its power cord running up into the ceiling to an unknown location;

4.) The "general stores" storage room had an inexpensive power strip operating up to 4 high wattage appliances - coffee maker, microwave, toaster, and a laminator - staff reported that they only use one device at a time but 5 items were plugged into the strip;

5.) A small residential style washing machine in the commercial laundry room was operating off of an extension cord that was draped over pipes; the main electrical outlet (4 outlets) behind the commercial washing machines, and also the same outlet powering the small washer, was not ground fault circuit interrupter (GFCI) protected - this is a wet location;

6.) There was an open electrical junction box with protruding wires mounted on the ceiling over the commercial dryers.

These items could cause overheating or electrical short circuits resulting in fire and could increase the potential for electrical shock to residents or staff members.

NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in the ceilings.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that many ceiling tiles were out of place throughout the facility - staff reported that this was due to construction, installation of new HVAC system, and installation of new nurse call system wiring.

There were also: holes in ceilings in the radiology data closet; a small hole in the wall in #346; and a 3" diameter hole in a laundry entry room ceiling tile.

Staff and contractors need to close up holes and replace ceiling tiles as soon as they are finished with each location - all open ceiling tiles observed during this survey were unattended by staff and/or construction employees.

These penetrations could have the possibility of affecting 50 % of occupants of the facility and could allow smoke to travel above the ceiling or from one section to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that numerous corridor doors throughout the facility were held open with non-approved hold open devices - cans, wedges, or chocks, including, but not limited to the following:

1.) corridor door to patient room #303 - trash and soiled linen bins impeding the door;

2.) patient room door #218 failed to latch;

3.) the waiting room door to the "same day surgery" center was held open with a chock;

4.) the corridor door to the radiology suite was held open with a chock;

5.) the electrical/data closet door in radiology was held open with a chock;

6.) the file room door in radiology had its self-closing mechanism detached;

7.) the locker/break room door in radiology had its door chocked open;

8.) the main dry goods storage room door in the kitchen was held open with a brick;

9.) the air handler/duct room door to the service corridor near the kitchen was held open with a five gallon can;

10.) a fire rated gate (pass through) assembly from the corridor to the ICU was partially open - a laptop computer was on the counter where the door would close - the laptop and its cables impeded the assembly from closing and sealing properly - staff was advised to change the location of the laptop and its wiring.

These impediments could prevent the doors from being quickly and easily closed and latched in the event of an emergency and could effect the occupants of the listed rooms, staff members in these areas and up to 20% of the patients or occupants in the corridors.

Based on observation of the physical environment, it was determined that the facility staff failed to ensure that smoke barrier walls do not have any penetrations that would allow smoke to pass through the walls in the event of a fire.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that, upon inspection of the smoke barrier wall above the corridor ceiling near patient room #309, holes and penetrations for newly installed cables and wires had not been resealed to prevent the passage of smoke - existing fire retardant caulk had been removed and was lying near the gaps..

All smoke barrier walls throughout the hospital above ceilings need to be inspected for unprotected penetrations. Open holes and penetrations need to be resealed with fire retardant caulk on both sides of each barrier wall.

These holes and penetrations could allow smoke to travel throughout the building in the event of a fire.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that hazardous areas are separated from other spaces by smoke resisting partitions and doors.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the corridor door to the soiled utility room in the "same day surgery" center had its strike mechanism taped with surgical tape - this prevented the door from properly latching - surgical staff was advised of this situation.

Partitions that are not smoke resisting could allow smoke to travel from hazardous areas of the facility to other sections in the event of an emergency and could effect patients and staff in the immediate area.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having stairwells free of storage.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that stairwell #C, located near the laundry suite corridor, had excessive storage in the lower level and under the stairs - this is the emergency exit for staff working in the laundry suite, and the stairwell is also an emergency exit for upper floors.

This storage (some of it combustible) fills almost the entire bottom of the stairwell and could result in a blocked emergency egress or fire in the stairwell.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having exit access so arranged that exits are readily accessible at all times.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the door from the sterile supply corridor to the exit corridor was equipped with an operating deadbolt on the inside - the door was also equipped with a key pad locking system on the outside to restrict access to the supply corridor.

This lock could cause the accidental locking-in of staff members and prevent egress from inside in the event of a fire, smoke conditions, or low light conditions if a person could not visualize the deadbolt lock or how to operate it properly. This interior lock must be removed but the exterior locking mechanism can remain on the door which will allow egress from the interior in the event of an emergency but will still limit or prevent access to residents and/or non staff members from the service corridor. NFPA 7.1.9.

Allowing such locking devices to be installed on doors in a means of egress has the potential to promote harm to occupants of the building in the event of a fire or other emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that corridors serving as exit access remain clear and unobstructed and free of storage.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) service corridors had excessive storage of old beds, discarded equipment, chairs, furniture, etc.;

2.) the operating room corridor had excessive storage along both sides, effectively reducing the width of the corridor to less than 4 ' - storage included an in-use desk and chair, shelving, racks, carts, bins, etc. - some items were wheeled and some were not.

This could obstruct the flow of people out of the building in the event of an emergency and could delay egress from these corridors. Evacuation of a patient(s) through the OR corridor while that patient is on a bed or gurney could be difficult. This could effect or delay up to 25% of the patients and staff who would use the emergency exits in case of an emergency and could delay the entry of firefighters in the event of a fire or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not installing a heat or smoke detector in all required areas of the building and in areas where Fire Alarm System control panels are located.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) There was no smoke detector in the radiology electrical/data closet which also had an alarm panel control unit;

2.) There was no smoke detector in the entry room to the commercial laundry suite - it appears to have been removed from the ceiling and not replaced.

NFPA 72 (1999 Edition as per CMS) 1-5.6 - Protection of Fire Alarm Control Units - In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

A fire in the same room as an alarm panel control unit could disable all or portions of the fire alarm system.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 pm and 4:00 pm that portions of this hospital are not protected by automatic sprinklers, including, but not limited to:

1.) The rear loading dock area;

2.) The area around the trash compacter (located off of the rear loading dock) which is covered with a metal canopy;

3.) The administrative wing including its corridor and the main board room;

4.) The kitchen walk-in refrigerators and freezers.

A fire in any one of these locations could spread since there is no automatic sprinkler coverage and could impact up to 25% of the patients and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) Two sprinkler heads over the corridor ramp near the kitchen were missing their escutcheon rings;
2.) Two low-mounted sprinkler heads in the kitchen dry goods storage room had no protective cages;
3.) Two exterior fire department connections (FDC's) had no signs indicating their locations - the side of the building near the administrative wing entrance door and the rear of the building near the main mechanical rooms - the FDC near the administrative exit door was also partially obstructed by a trash can;
4.) At least one flow/tamper switch cover in stairwell #E was not secured tightly with two tamper resistant screws - all covers must be fully secured to prevent tampering;
5.) One storage closet (#202) in the OB/GYN wing had blankets on the top shelf stored too close to the ceiling mounted sprinkler head.
These could have the possibility of affecting 25 % of the patients and staff of the facility and could result in improper operation or failure of the sprinkler heads.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the kitchen hood system in compliance with NFPA 96.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that all metal filters in the kitchen hood system were installed improperly. The filters are to be mounted so that the baffles are arranged vertically so collected grease will drain down into the trough for proper collection.

Proper alignment of the filters is required in order to assure that the system is free of flammable grease buildup.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage areas in accordance with NFPA 99.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that the central medical gas storage room (located off of the loading dock) had the following:

1.) Three nitrous oxide tanks (H size) were connected to the central gas system but were unsecured on the floor;

2.) Seven "E" oxygen tanks on one side of the room were standing on the floor unprotected from falling, and more "E" oxygen tanks on the other side of the room also unprotected from falling;

3.) An entire row of assorted medical gas tanks (mostly "H" sizes) along the rear wall of the room were behind a chain that was draped too low and too loose to protect them from falling.

Note - full & empty oxygen tanks were properly marked in this location and in other locations throughout the hospital.

Unsecured oxygen tanks could lead to damage or personal injury in the event that one or more would fall.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on April 24, 2012 with the Director of Plant Operations, it was observed between 12:30 PM and 4:00 PM that:

1.) Second floor data processing storage room had excessive storage in front of electrical panels;

2.) Walk-in refrigerator #1 in the main kitchen had a wall mounted electrical junction box with no cover plate and wires exposed and protruding;

3.) The central medical gas storage room located off of the loading dock had a wall-mounted power strip with its power cord running up into the ceiling to an unknown location;

4.) The "general stores" storage room had an inexpensive power strip operating up to 4 high wattage appliances - coffee maker, microwave, toaster, and a laminator - staff reported that they only use one device at a time but 5 items were plugged into the strip;

5.) A small residential style washing machine in the commercial laundry room was operating off of an extension cord that was draped over pipes; the main electrical outlet (4 outlets) behind the commercial washing machines, and also the same outlet powering the small washer, was not ground fault circuit interrupter (GFCI) protected - this is a wet location;

6.) There was an open electrical junction box with protruding wires mounted on the ceiling over the commercial dryers.

These items could cause overheating or electrical short circuits resulting in fire and could increase the potential for electrical shock to residents or staff members.

NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.