HospitalInspections.org

Based upon observation and interview, the facility failed to ensure that doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6, special needs locking arrangements in accordance with 19.2.2.2.5.2, delayed egress locking in accordance with 19.2.2.2.4, access-controlled egress doors in accordance with 19.2.2.2.4, or elevator lobby exit access in accordance with 19.2.2.2.4. This deficient practice could affect 321 occupants in the event of an emergency.

Findings Include:

On 04/18/18, at approximately 10:56 a.m., observed stairway door SGH-06 with delayed egress hardware, does not have the required signage. This discrepancy could potentially delay occupants from exiting the area.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 10:59 a.m., observed stairway door SGH-06 with delayed egress hardware, does not have the required signage. This discrepancy could potentially delay occupants from exiting the area.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:08 a.m., observed stairway door SGH-06 with delayed egress hardware, does not have the required signage. This discrepancy could potentially delay occupants from exiting the area.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that stairways and smoke-proof enclosures used as exits are in accordance with 7.2 as required by 19.2.2.3 and 19.2.2.4.7.2. This deficient practice could affect 321 occupants in the event of an emergency.

Findings Include:

On 04/17/18, at approximately 11:25 a.m. observed a telephone line junction box located in the west tower, 6th floor SGH Stairwell 17, for the facility fire phones. This deficiency violates Annex for Section 7.1.3.2.1.(9) in the 2012 LSC.

This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that horizontal exits were in compliance with the provisions of 7.2.4 and 19.2.2.5.1 through 19.2.2.5.4. This deficient practice could affect 321 occupants in the event of Emergency .

Findings Include:

On 04/17/18, at approximately 11:15 p.m., observed that the door to the southwest exit stairway, in the penthouse, was obstructed by mechanical equipment and storage. This deficiency could prevent timely access to the stairway and evacuation.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 11:25 a.m., observed a ½ inch unsealed penetration, located in the ceiling, and a 6-inch by ¼ inch crack located in the left corner of the west tower SGH 10 Stairway.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:43 a.m., observed fire rated door number 10175, did not close to positive latch.
This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 1:38 p.m., observed penetrations in fire rated door to Operating Room (O.R.) Suite 7, that are not sealed with a UL Listed fire resistant material. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 1:42 p.m., observed unsealed penetrations on corridor side of fire rated door labeled WG06C. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 1:51 p.m., observed penetrations in fire rated door leading into O.R. Suite 3, that are not sealed with a UL Listed fire resistant material. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9 as required by 19.2.9.1. This deficient practice could affect any staff occupying this room in the event of an emergency.

Findings Include:

On 04/18/18, at approximately 11:10 a.m., observed there is no emergency lighting in the stairway to the basement mechanical room, under radiology. This deficiency is a violation of the LSC 2012 7.9.

This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect 321 occupants in the event of an emergency.

Findings Include:

04/17/18, at approximately 11:45 a.m., observed that the door to elevator mechanical room # 12070, did not close to a positive latch. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

04/18/18, at approximately 10:40 a.m., observed that room SG 220 is being used for storage. The door does not have a self-closer and was observed in the open position. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:00 a.m., observed that the fire rated door to the mechanical basement, located under Radiology, was propped open. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 10:22 a.m., observed a ½-inch unsealed penetration in a drywall patch, above ceiling tile, in the 1st floor rehab gym closet. This discrepancy could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that a fire alarm system is installed in accordance with NFPA 70 and NFPA 72 as required by 19.3.4.1, 9.6, and 9.6.1.8. This deficient practice could affect all Staff occupants in the event of Emergency.

Findings Include:

On 04/18/18, at approximately 11:05 a.m., observed that the fire alarm manual pull station, located in the mechanical basement, under Radiology, is not located within 5 feet of the exit door. This deficiency is a violation of NFPA 72.

This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure protection throughout the hospital by an approved automatic sprinkler system in accordance with NFPA 13 as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, and 9.7.1.1(1). This deficient practice could affect 321 occupants in the event of emergency.

Findings Include:

On 04/17/18, at approximately 2:00 p.m., observed missing ceiling tiles around the automatic sprinkler heads in room E20A. This deficiency could prevent the proper operation of the sprinkler head.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 3:05 p.m., observed missing ceiling tiles around the automatic sprinkler heads in janitor's closet, across from room GLNA. This deficiency could prevent the proper operation of the sprinkler head.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.


18760



Additional Findings:

On 04/17/18, at approximately 11:20 a.m., observed that the automatic sprinkler head located in the soiled linen room, adjacent to entrance door to the penthouse, is missing its escutcheon plate. This deficiency could prevent the proper operation of the sprinkler head.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 1:20 p.m., observed that the automatic sprinkler head located in west tower room W40K is located within 4-inches of a light fixture. This deficiency could prevent the proper operation of the sprinkler head and is a violation of NFPA 13.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 10:00 a.m., observed an unlabeled automatic sprinkler system valve in room SGH 148. This deficiency is a violation of NFPA 13.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:18 a.m., observed a sprinkler head missing its escutcheon plate, in the supply chain office. This discrepancy is a violation of NFPA 13
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could affect the staff working in this area, in the event of emergency.

Findings Include:

04/18/17, at approximately 10:10 a.m., observed that the fire extinguisher located in the emergency department storage room was obstructed by a medical cart.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect 321 occupants in the event of Emergency.

Findings Include:

On 04/17/18, at approximately 10:42 a.m., observed that the door handle to patient room E6C9 was damaged and did not latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 1:28 p.m., observed that the door handle to patient room E352 was loose and did not latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 1:33 p.m., observed that the door handle to patient room E363 was damaged and did not latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor. This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.


18760


Additional Findings Include:

On 04/17/18, at approximately 11:22 a.m., observed that the fire rated door to the 6th floor west tower data room, adjacent to the elevator Lobby, did not close to a positive latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 11:23 a.m., observed that the rating label on the fire door to the 6th floor west tower data room, located by the elevator lobby, was painted over. This deficiency does not allow for confirmation of proper rating.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 12:00 p.m., observed that a corridor door (DMC-SGH # 11963) on the 6th floor west tower did not fully close and self-latch when tested. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 1:06 p.m., observed that the door to patient room # 527 was difficult to open. This deficiency could delay entry/exit from the room, in the event of an emergency.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 1:10 p.m., observed that a isolation equipment box attached to the door to patient room # 522 prevented the door to close to a positive latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:43 a.m., observed that door #10175 did not fully close and latch. This deficiency could potentially allow the spread of smoke and heat to enter the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that smoke barriers were provided to form at least 2 smoke compartments on every floor as required by 19.3.7.1 and 19.3.7.2. This deficient practice could affect 321 occupants in the event of an emergency.

Findings Include:

On 04/18/18, at approximately 10:19 a.m., observed an open ½-inch conduit above ceiling tiles, at nursing station across from stairwell SGH-06. This discrepancy would not prevent the spread of smoke and heat from entering the adjacent smoke barrier.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:37 a.m., observed the fire rated door, labeled EX-5, did not close to positive latch. Also, observed improperly sealed penetrations in the door, that are not sealed with a UL Listed fire resistant material.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:38 a.m., observed unsealed penetrations in fire rated door located at Medical Ear, Nose, Throat Office. This discrepancy would not prevent smoke and heat from entering the exit access corridor.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

Based upon observation and interview, the facility failed to ensure that equipment using gas or gas-related piping complies with NFPA 54 and electrical wiring and equipment complies with NFPA 70 as required by 19.5.1.1, 9.1.1, and 9.1.2. This deficient practice could affect 321 occupants in the event of an emergency.

Findings Include:

On 04/17/18, at approximately 1:32 p.m., observed a damaged electrical outlet in the 3rd floor staff lounge E30K. This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.


18760

Additional Findings Include:

On 04/17/18, at approximately 11:30 a.m., observed exposed electrical wires for a temporary light fixture located in an interstitial space, identified as MC706, located in stairway SGH 17. This deficiency is a violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/17/18, at approximately 12:03 a.m., observed that the electrical panel located in the west tower room 613, was obstructed by storage. This deficiency is a violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/17, at approximately 10:45 a.m., observed an open electrical panel door, located above the cross-corridor smoke barrier doors, at the main entrance sign. This deficiency is a violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 4/18/2018, at approximately 10:34 a.m., observed a junction box located above ceiling adjacent to room 108 that is missing a cover plate. This discrepancy exposes electrical wires and is in violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 10:34 a.m., observed a junction box with a missing cover plate, above ceiling tile, adjacent to room 108. This discrepancy exposes electrical wires and is in violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at 10:50 a.m., observed missing cover plate over electrical switch, in electrical closet, labeled W20P. switch plate 2n L8 11. This discrepancy exposes electrical wires and is in violation of NFPA 70.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.

On 04/18/18, at approximately 11:20 a.m., observed a junction box with a pipe penetration, located above ceiling tile, at door DMC-SGH 10316, that is not sealed with a UL Listed fire resistant material fire. This discrepancy would not prevent the spread of smoke and heat from reaching above the ceiling.
This finding was observed and confirmed in an interview with the maintenance director at the time of discovery.