HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain continuous egress requirements at one of one roof-access location.

Findings include:

1. Observation on January 24, 2017, at 11:30 AM revealed the access door to the roof inside the west stair tower was unsecured against unauthorized entry.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 11:30 AM confirmed the roof access was unsecured against unauthorized entry.

Based on observation and interview, it was determined that the facility failed to maintain exit stair towers at two of two exit stair towers.

Findings include:

1. Observation on January 24, 2017, between 11:15 AM and 11:35 AM revealed the following locations had stair tower deficiencies:
A. First floor, east side stair had storage in the stair landing (11:15 AM).
B. Second floor, west side stair had an unsealed wire penetration in the stair tower above the door (11:35 AM).

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 11:35 AM confirmed the above exit stair tower deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain horizontal exits for one of one two-hour fire rated barrier.

Findings include:

1. Observation on January 24, 2017, at 10:45 AM revealed the two-hour fire rated wall between 01/02 components, inside the Intensive Care Unit waiting room, had an unsealed void between the horizontal beam and the corridor wall.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 10:45 AM confirmed the unsealed fire barrier opening.

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas in one of ten smoke compartments.

Findings include:

1. Observation on January 24, 2017, at 10:35 AM revealed the soiled linen room door #C123 lacked positive latching with the self-closure.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 10:35 AM confirmed the above door lacked positive latching with the self-closure.

Based on interview, it was determined that the facility failed to maintain cooking equipment by kitchen staff in one of one kitchen.

Findings include:

1. Interview on January 24, 2017, at 12:55 PM revealed one of one kitchen staff was unaware of the location of the manual activation for the hood suppression system.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 12:55 PM confirmed the kitchen staff shall be inserviced as to the location of the manual activation for the hood suppression system.

Based on observation and interview, it was determined that the facility failed to install fire sprinklers in one of ten smoke compartments.

Findings include:

1. Observation on January 24, 2017, at 2:00 PM revealed the electrical panel room near Central Scheduling office lacked a fire sprinkler head.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 2:00 PM confirmed the lack of a fire sprinkler head within the electrical panel room.

Based on observation and interview, it was determined that the facility failed to maintain approved portable space heater locations in one of ten smoke compartments.

Findings include:

1. Observation on January 24, 2017, at 10:10 AM revealed the nurses station at the main Medical Surgery Unit (patient sleeping smoke compartment) had a portable space heater plugged in under the desk.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 10:10 AM confirmed the space heater was located at the above nurses station within a patient sleeping smoke compartment.

Based on document review and interview, it was determined that the facility failed to maintain piped-in gas and vacuum systems for one of one medical gas system.

Findings include:

1. Review of documentation on January 24, 2017, at 8:30 AM revealed the facility lacked documentation that an annual inspection of the central supply system for medical gas was performed annually.

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 8:30 AM confirmed the lack of medical gas documentation.

Based on observation and interview, it was determined that the facility failed to maintain electrical systems in wet procedure locations in one of one rehabilitation service location:

Findings include:

1. Observation on January 24, 2017, at 11:25 AM revealed two hydrocollators within the physical therapy department were not plugged into ground fault circuit interrupters (GFCIs).

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 11:25 AM confirmed the hydrocollators were not plugged into GFCIs.

Based on observation and interview, it was determined that the facility failed to maintain power and extension cords on one of two building levels.

Findings include:

1. Observation on January 24, 2017, between 11:40 AM and 11:45 AM revealed the following locations had items plugged into an unauthorized electrical application.
A. Second floor, suite 2500, was utilizing an extension cord in the eyeglass area (11:40 AM).
B. Second floor, suite 2600, had a beverage warmer plugged into a surge protector within the consultation room (11:45 AM).

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 11:45 AM confirmed the above electrical deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain power cords in one of ten smoke compartments.

Findings include:

1. Observation on January 24, 2017, between 1:20 PM and 1:35 PM revealed the following locations had unauthorized items plugged into a surge protector:
A. Purchasing department, portable heater under the desk in the back of the room (1:20 PM).
B. Central Scheduling office, refrigerator (1:35 PM).

Interview with the Vice President of Support Services and Maintenance Supervisor on January 24, 2017, at 1:35 PM confirmed the above items shall be plugged directly into an electrical receptacle.