HospitalInspections.org

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Based on observation and interview the facility failed to ensure exit signage was appropriately installed and/or displayed. This failed practice had the potential to delay egress during an emergency situation for occupants inhabiting the first and second floors of the facility. Findings:

Observation on 8/28/15 at 2:10 pm revealed no exit signage were in place indicating a means of egress at the west side exit corridor intersection outside the acute care unit. In addition, further observation revealed no exit signage indicating means of egress through to the dietary service hall once through the west side exit corridor intersection outside of the acute care unit.

Review of the posted emergency evacuation plan on 8/28/15 at 2:10 pm revealed the identified egress lacking exit signage was a dedicated means of egress.

During an interview on 8/28/15 at 2:10 pm the Director of Engineering confirmed the identified egress pathway was a dedicated means of egress and the lacked exit signage.

Observation of ambulatory surgical center on 8/28/15 at 3:25 revealed an exit sign with paper arrows taped to the face plate indicating inappropriate direction. Further observation revealed multiple points within the area that lacked directional exit signage. Additional observation revealed room B106 with a printed sign that said " do not enter exit only. " Room B106 was observed as the sterile process area and did not serve as an exit.

Observation on 8/28/15 at 3:35 pm revealed no exit sign was in place to direct occupants from the pharmacy corridor to the facility maintenance corridor.

During an interview on 8/28/15 at 3:35 pm the Director of Engineering confirmed lack of an exit sign and stated the corridor was used as a means of egress during an emergency evacuation.

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Based on observation and interview the facility failed to ensure; 1) a self-closing door protecting a hazardous area was free from being held open while unattended; and 2) penetrations in a fire barrier were protected. These failed practices had the potential to expedite the exposure of facility occupants to a fire and smoke environment. Findings:

Observation of room D315 (equipment storage) on 8/28/15 at 1:48 pm revealed a self-closing 45-minute rated door was propped open. Room D315 was unattended at the time of observation.

Observation of room G213 (dietary storage) on 8/28/15 at 2:46 pm revealed an unprotected penetration in a fire barrier.

Observation of room 115 (biohazardous waste) on 8/28/15 at 3:41 pm revealed an unprotected penetration in a fire barrier.

Observation of room 123 (electrical service) on 8/28/15 at 3:52 pm revealed two self-closing fire-rated doors propped open by a chair and ladder. The two doors were located in a fire barrier wall that separated the room into two sections. Room 123 was unoccupied at the time of observation.

The Director of Engineering acknowledged the findings at their time of discovery.

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Based on observation and interview the facility failed to ensure a smoke detector was properly mounted and maintained. This failed practice had the potential to cause a lack of functionality or delay in response to a smoke and fire environment. As a result, this placed all occupants at risk for a delayed fire alarm response and notification potentially resulting in a prolonged exposure to a smoke and fire environment. Findings:

Observation of room H235 on 8/25/15 at 2:15 pm revealed a smoke detector suspended approximately six inches from the ceiling by two red wires.

During an interview on 8/25/15 at 2:15 pm the Director of Engineering acknowledged the finding and confirmed the smoke detector should not be suspended by wires.

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Based on observation, interview and document review the facility failed to ensure the hood systems above the cooking areas in the central kitchen and serve line were free from grease build up. This failed practice heightened the risk of a grease fire and had the potential to expose occupants of the facility to a smoke and fire environment. Findings:

Observation on 8/28/15 revealed the hood system over the central kitchen contained a moderate amount of grease build up. Additional observation revealed the hood system over the serve line cooking area contained a large amount of grease build up.
During an interview on 8/28/15 the kitchen staff stated the hood system is cleaned every week.

During an interview on 8/28/15 Maintenance Staff #1 stated the hoods were self-cleaning but the self-cleaning mechanisms were out of service since July.

Review of the document "Daily Cleaning of Equipment" on 8/28/15 revealed "Hoods/ Vents/ Walls" were to be cleaned at the end of each shift.

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Based on observation and interview the facility failed to ensure a corridor serving as a means of egress was clear and free of obstructions. This failed practice decreased the width of the corridor; as a result this placed occupants of the facility at risk for delayed egress during an emergency and could extend exposure time to a less than desirable environment. Finding:

Observation of the dietary service hall on 8/28/15 at 2:09 pm revealed two storage devices used to harbor chairs was located in the corridor.

During an interview on 8/28/15 at 2:09 pm the Director of Engineering stated the storage devices are continuously kept in that location. In addition, the Director confirmed the corridor was a dedicated means of exit egress and the storage devices significantly decreased the width of the corridor.
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Based on observation and interview the facility failed to ensure privacy curtains were in compliance with NFPA 701. The facility was unable to ensure privacy curtains were appropriately rated and fire resistant per NFPA 701 standards in the acute care unit. This failed practice placed occupants of the smoke compartment containing the acute care unit at risk for an accelerated exposure to a fire and smoke environment. Findings:

Random observations during the facility tour on 8/28/15 revealed multiple privacy curtains in the acute care unit with an illegible identification tag or completely lacked an identification tag.

The Director of Engineering confirmed the findings at the time of discovery and stated the facility could not ensure the curtains were compliant with NFPA 701.
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Based on observation and interview the facility failed to ensure: 1) a fire-rated door functioned as designed; 2) penetrations in a fire barrier were protected; and 3) appropriate signage was displayed outside of a medical gas generator room. These failed practices placed the occupants of the facility at risk for a fire and smoke environment. In addition, these failed practices placed the patients at risk for loss of medical gas services. Findings:

Observation of the oxygen manifold room on 8/28/15 at 1:08 pm revealed a 45-minutes fire entry door that would not shut and latch.

Observation of the oxygen generator room on 8/28/15 at 1:10 pm revealed eight unprotected penetrations through the fire-barrier walls and ceiling. In addition, the entry door did not contain signage identifying the purpose and contents of the oxygen generator room.

The Director of Engineering acknowledged the findings at their time of discovery.

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Based on interview and observation the facility failed to ensure staff were knowledgeable of how to respond during a fire emergency. This failed practice placed occupants of the facility at risk for delay in response to a fire emergency and potentially prolonged exposure to a fire and smoke environment. Findings:

During an interview on 8/28/15 at 2:36 pm the charge nurse of the acute care unit was unaware of the locations of the medical gas shut off values.

During an interview on 8/28/15 at 2:36 pm the Director of Engineering stated the charge nurse should have been aware of the medical gas shut off valves.

During an interview on 8/28/15 at 2:39 Cook #1 was asked how to activate the fire alarm system in case of a fire in cafeteria. Cook #1 responded he or she would pull a lever device located in the serve line grill area. When asked what happens when the lever device is pulled, Cook #1 stated it activated only the strobe lights of the fire alarm system and not the audible alarm.

During an interview on 8/28/15 at 2:41 pm the Dietary Supervisor was asked if the hood suppression systems could be manually activated. The Dietary Supervisor stated he or she was not aware of a method to manually activate the hood suppression system.

Observation on 8/28/15 of the level device indicated by Cook #1 revealed it was intended to manually activate the hood suppression system in the serve line grill area.

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Based on observation and interview the facility failed to ensure: 1) electrical/service control panels were free from obstructions and impediments; 2) an electrical outlet near a water source was ground-fault interrupter protected; and 3) a power strips was used safe and appropriately. These failed practices had the potential to expose occupants of the facility to a smoke and fire environment and/or loss of services. Findings:
Observations in the mechanical penthouse on 8/25/15 from 1:21 pm to 1:29 pm revealed 6 electrical/service control access panels obstructed and impeded by tables, boxes, equipment and various other storage items. The panels included: VLX-VENTW1-1; VLX-VENTW1-2; VLX-VENTW2-1; VLX-VENTW2-2; VLX-VETE-1; and VLX-VETE-2.

Observation of the central soiled laundry on 8/25/15 at 1:30 pm revealed a non-ground fault interrupter protected electrical outlet (Label: 3CN21-39) adjacent to a washing sink.

Observation of an office in the laboratory on 8/28/15 at 3:04 pm revealed an extension cord plugged directly into a power strip.

The Director of Engineering acknowledged the findings at their time of discovery.

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Based on observation and interview the facility failed to ensure exit signage was appropriately installed and/or displayed. This failed practice had the potential to delay egress during an emergency situation for occupants inhabiting the first and second floors of the facility. Findings:

Observation on 8/28/15 at 2:10 pm revealed no exit signage were in place indicating a means of egress at the west side exit corridor intersection outside the acute care unit. In addition, further observation revealed no exit signage indicating means of egress through to the dietary service hall once through the west side exit corridor intersection outside of the acute care unit.

Review of the posted emergency evacuation plan on 8/28/15 at 2:10 pm revealed the identified egress lacking exit signage was a dedicated means of egress.

During an interview on 8/28/15 at 2:10 pm the Director of Engineering confirmed the identified egress pathway was a dedicated means of egress and the lacked exit signage.

Observation of ambulatory surgical center on 8/28/15 at 3:25 revealed an exit sign with paper arrows taped to the face plate indicating inappropriate direction. Further observation revealed multiple points within the area that lacked directional exit signage. Additional observation revealed room B106 with a printed sign that said " do not enter exit only. " Room B106 was observed as the sterile process area and did not serve as an exit.

Observation on 8/28/15 at 3:35 pm revealed no exit sign was in place to direct occupants from the pharmacy corridor to the facility maintenance corridor.

During an interview on 8/28/15 at 3:35 pm the Director of Engineering confirmed lack of an exit sign and stated the corridor was used as a means of egress during an emergency evacuation.

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Based on observation and interview the facility failed to ensure; 1) a self-closing door protecting a hazardous area was free from being held open while unattended; and 2) penetrations in a fire barrier were protected. These failed practices had the potential to expedite the exposure of facility occupants to a fire and smoke environment. Findings:

Observation of room D315 (equipment storage) on 8/28/15 at 1:48 pm revealed a self-closing 45-minute rated door was propped open. Room D315 was unattended at the time of observation.

Observation of room G213 (dietary storage) on 8/28/15 at 2:46 pm revealed an unprotected penetration in a fire barrier.

Observation of room 115 (biohazardous waste) on 8/28/15 at 3:41 pm revealed an unprotected penetration in a fire barrier.

Observation of room 123 (electrical service) on 8/28/15 at 3:52 pm revealed two self-closing fire-rated doors propped open by a chair and ladder. The two doors were located in a fire barrier wall that separated the room into two sections. Room 123 was unoccupied at the time of observation.

The Director of Engineering acknowledged the findings at their time of discovery.

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Based on observation and interview the facility failed to ensure a smoke detector was properly mounted and maintained. This failed practice had the potential to cause a lack of functionality or delay in response to a smoke and fire environment. As a result, this placed all occupants at risk for a delayed fire alarm response and notification potentially resulting in a prolonged exposure to a smoke and fire environment. Findings:

Observation of room H235 on 8/25/15 at 2:15 pm revealed a smoke detector suspended approximately six inches from the ceiling by two red wires.

During an interview on 8/25/15 at 2:15 pm the Director of Engineering acknowledged the finding and confirmed the smoke detector should not be suspended by wires.

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Based on observation, interview and document review the facility failed to ensure the hood systems above the cooking areas in the central kitchen and serve line were free from grease build up. This failed practice heightened the risk of a grease fire and had the potential to expose occupants of the facility to a smoke and fire environment. Findings:

Observation on 8/28/15 revealed the hood system over the central kitchen contained a moderate amount of grease build up. Additional observation revealed the hood system over the serve line cooking area contained a large amount of grease build up.
During an interview on 8/28/15 the kitchen staff stated the hood system is cleaned every week.

During an interview on 8/28/15 Maintenance Staff #1 stated the hoods were self-cleaning but the self-cleaning mechanisms were out of service since July.

Review of the document "Daily Cleaning of Equipment" on 8/28/15 revealed "Hoods/ Vents/ Walls" were to be cleaned at the end of each shift.

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Based on observation and interview the facility failed to ensure a corridor serving as a means of egress was clear and free of obstructions. This failed practice decreased the width of the corridor; as a result this placed occupants of the facility at risk for delayed egress during an emergency and could extend exposure time to a less than desirable environment. Finding:

Observation of the dietary service hall on 8/28/15 at 2:09 pm revealed two storage devices used to harbor chairs was located in the corridor.

During an interview on 8/28/15 at 2:09 pm the Director of Engineering stated the storage devices are continuously kept in that location. In addition, the Director confirmed the corridor was a dedicated means of exit egress and the storage devices significantly decreased the width of the corridor.
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Based on observation and interview the facility failed to ensure privacy curtains were in compliance with NFPA 701. The facility was unable to ensure privacy curtains were appropriately rated and fire resistant per NFPA 701 standards in the acute care unit. This failed practice placed occupants of the smoke compartment containing the acute care unit at risk for an accelerated exposure to a fire and smoke environment. Findings:

Random observations during the facility tour on 8/28/15 revealed multiple privacy curtains in the acute care unit with an illegible identification tag or completely lacked an identification tag.

The Director of Engineering confirmed the findings at the time of discovery and stated the facility could not ensure the curtains were compliant with NFPA 701.
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Based on observation and interview the facility failed to ensure: 1) a fire-rated door functioned as designed; 2) penetrations in a fire barrier were protected; and 3) appropriate signage was displayed outside of a medical gas generator room. These failed practices placed the occupants of the facility at risk for a fire and smoke environment. In addition, these failed practices placed the patients at risk for loss of medical gas services. Findings:

Observation of the oxygen manifold room on 8/28/15 at 1:08 pm revealed a 45-minutes fire entry door that would not shut and latch.

Observation of the oxygen generator room on 8/28/15 at 1:10 pm revealed eight unprotected penetrations through the fire-barrier walls and ceiling. In addition, the entry door did not contain signage identifying the purpose and contents of the oxygen generator room.

The Director of Engineering acknowledged the findings at their time of discovery.

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Based on interview and observation the facility failed to ensure staff were knowledgeable of how to respond during a fire emergency. This failed practice placed occupants of the facility at risk for delay in response to a fire emergency and potentially prolonged exposure to a fire and smoke environment. Findings:

During an interview on 8/28/15 at 2:36 pm the charge nurse of the acute care unit was unaware of the locations of the medical gas shut off values.

During an interview on 8/28/15 at 2:36 pm the Director of Engineering stated the charge nurse should have been aware of the medical gas shut off valves.

During an interview on 8/28/15 at 2:39 Cook #1 was asked how to activate the fire alarm system in case of a fire in cafeteria. Cook #1 responded he or she would pull a lever device located in the serve line grill area. When asked what happens when the lever device is pulled, Cook #1 stated it activated only the strobe lights of the fire alarm system and not the audible alarm.

During an interview on 8/28/15 at 2:41 pm the Dietary Supervisor was asked if the hood suppression systems could be manually activated. The Dietary Supervisor stated he or she was not aware of a method to manually activate the hood suppression system.

Observation on 8/28/15 of the level device indicated by Cook #1 revealed it was intended to manually activate the hood suppression system in the serve line grill area.

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Based on observation and interview the facility failed to ensure: 1) electrical/service control panels were free from obstructions and impediments; 2) an electrical outlet near a water source was ground-fault interrupter protected; and 3) a power strips was used safe and appropriately. These failed practices had the potential to expose occupants of the facility to a smoke and fire environment and/or loss of services. Findings:
Observations in the mechanical penthouse on 8/25/15 from 1:21 pm to 1:29 pm revealed 6 electrical/service control access panels obstructed and impeded by tables, boxes, equipment and various other storage items. The panels included: VLX-VENTW1-1; VLX-VENTW1-2; VLX-VENTW2-1; VLX-VENTW2-2; VLX-VETE-1; and VLX-VETE-2.

Observation of the central soiled laundry on 8/25/15 at 1:30 pm revealed a non-ground fault interrupter protected electrical outlet (Label: 3CN21-39) adjacent to a washing sink.

Observation of an office in the laboratory on 8/28/15 at 3:04 pm revealed an extension cord plugged directly into a power strip.

The Director of Engineering acknowledged the findings at their time of discovery.