HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to ensure the two hour common wall and/or doors on one of six floors.

Findings include:

Observation on December 5, 2016 at 1:00 PM revealed the common wall doors between Three X and Three South buildings lacked positive latching with the self-closer.

Interview with the Maintenance Supervisor on December 5, 2016 at 1:00 PM confirmed the common wall doors lacked positive latching with the self-closer.

Based on observation and interview it was determined that the facility failed to maintain the common wall, two hour separation between components on three of six levels.

Findings include:

1. Observation on December 6, 2016 at 8:52 AM revealed the Sixth Floor, common wall corridor fire rated doors, between components, by the John Kirk Office, had a gap greater than 1/8 inch at the leading edge, on the bottom half of the doors.

Interview with the Director of Facilities (DF) on December 6, 2016 at 8:52 AM confirmed the fire rated door gap existed.

2. Observation on December 6, 2016 at 9:20 AM revealed the Third Floor common wall between Three South and the Connecting Corridor had an unsealed penetration above the common wall doors at the blue wire bundle.

Interview with the Maintenance Supervisor on December 6, 2016 at 9:20 AM confirmed the unsealed penetration of the common wall.

3. Observation on December 6, 2016 at 8:40 AM revealed the Fifth Floor common wall doors between Med Surge and Tower lacked positive latching with the self-closer.

Interview with the Maintenance Supervisor on December 6, 2016 confirmed the common wall doors lacked positive latching with the self-closer.

Based on observation and interview it was determined that the facility failed to maintain the fire protection rating for a Type II (222) fire resistant building on two of seven levels.

Findings include:

1. Observation on December 6, 2016 at 10:20 AM revealed the Ground Floor, Emergency Disconnect Room had orange spray foam in two unsealed penetrations in the deck above, located in the left rear of the room. (10:20 AM)

Interview with the Director of Facilities (DF) on December 6, 2016 at 10:20 AM confirmed the orange spray foam existed in the deck penetrations.

2. Second Floor Electric Room had unsealed floor penetrations:
A. A rectangular unsealed penetration on the right side of the room. (10:47 AM)
B. Four 6" unsealed conduit through the floor behind the rear electrical cabinet. (10:47 AM)

Interview with the DF on December 6, 2016 at 10:47 AM confirmed the deck penetrations existed.

Based on observation and interview it was determined that the facility failed to maintain means of egress free of all obstructions to full use in case of emergency on one of six levels.

Findings include:

Observation on December 6, 2016 at 9:18 AM revealed the Radiology Corridor by Imaging Room #4 had radiology equipment and a linen cart stored in the exit corridor.

Interview with the DF on December 6, 2016 at 9:18 AM confirmed the items listed above were stored in the exit corridor.

Based on observation and interview it was determined that the facility failed to maintain the means of egress continuously free of all obstructions to full use in case of emergency on one of seven levels.

Findings include:

Observation on December 6, 2016 at 11:15 AM revealed the Stairway A Level 3 had storage in the stairway.

Interview with the DF on December 6, 2016 at 11:15 AM confirmed the storage in the stairway existed.

Based on observation and interview it was determined that the facility failed to install exit and directional signage as required in stairways, five stories or greater, throughout the entire building.

Findings include:

Observation on December 5, 2016 from 10:55 AM - 2:31 PM revealed the facility lacked the required stairway identification inside all stairways at every level.

Interview with the Director of Facilities (DF) on December 5, 2016 at 2:31 PM confirmed the lack of stairway identification.

Based on observation and interview it was determined that the facility failed to install exit and directional signage as required in stairways, five stories or greater, throughout the entire building.

Findings include:

Observation on December 6, 2016 at 9:55 AM revealed the facility lacked the required stairway identification inside all stairways at every level.

Interview with the DF on December 6, 2016 at 9:55 AM confirmed the lack of stairway identification.

Based on observation and interview it was determined that the facility failed to maintain the means of egress continuously free of all obstructions to full use in case of emergency on one of seven levels.

Findings include:

Observation on December 6, 2016 at 11:15 AM revealed the Stairway A Level 3 had storage in the stairway.

Interview with the DF on December 6, 2016 at 11:15 AM confirmed the storage in the stairway existed.

Based on observation and interview it was determined that the facility failed to maintain building protection on one of seven levels.

Findings include:

Observation on December 6, 2016 at 10:15 AM revealed the Ground Floor, Elevator Pit Room had combustible materials stored in the elevator pit.

Interview with the DF on December 6, 2016 at 10:15 AM confirmed the elevator pit room had combustible materials stored in the pit.

Based on observation and interview it was determined that the facility failed to maintain building protection requirements on one of six levels.

Findings include:

Observation on December 6, 2016 at 8:50 AM revealed the Sixth Floor, Rehab, Data Closet had unsealed penetrations above a bundle of blue wires penetrating the back wall.

Interview with the DF on December 6, 2016 at 8:50 AM confirmed the unsealed penetration existed.

Based on observation and interview it was determined that the facility failed to maintain building protection on one of seven levels.

Findings include:

Observation on December 6, 2016 at 10:15 AM revealed the Ground Floor, Elevator Pit Room had combustible materials stored in the elevator pit.

Interview with the DF on December 6, 2016 at 10:15 AM confirmed the elevator pit room had combustible materials stored in the pit.

Based on observation and interview it was determined that the facility failed to maintain vertical openings - enclosures between floors with construction having a fire resistance rating of at least one hour on one of six levels.

Findings include:

Observation on December 5, 2016 at 11:55 AM revealed the Fourth Floor, North 1 Level 4 stairway had unsealed vertical penetrations between the wall and fluted deck above.

Interview with the DF on December 5, 2016 at 11:55 AM confirmed the unsealed penetration existed.

Based on observation and interview it was determined that the facility failed to maintain hazardous areas with a separation from other spaces by smoke resisting partitions on one of six levels.

Findings include:

1. Observation on December 6, 2016 between 9:22 AM and 9:30 AM revealed:
A. Second Floor, Imaging Admin Electric Room had multiple unsealed penetrations in the back wall by the electrical panels. (9:22 AM)
B. Second Floor, Electrical Room by sign "Main 1 Level 2" had:
1. Two unsealed penetrations at a metal conduit on the corridor. (9:28 AM)
2. One penetration at the top of the wall with exposed mineral wool which lacked rated fire stop material. (9:28 AM)
C. Second Floor, Imaging Mechanical Room, had:
1. An unsealed penetration in the deck above. (9:30 AM)
2. Unsealed penetration around a sprinkler pipe penetrating the right wall. (930 AM)
3. Unsealed penetration around a drain pipe penetrating the floor. (9:30 AM)

Interview with the DF on December 6, 2016 at 9:30 AM confirmed the deficiencies listed above existed.

2. Observation on December 6, 2016 at 10:00 AM revealed the soiled utility room in the third floor Birthing Suite lacked positive latching with the self-closer.

Interview with the Maintenance Supervisor on December 6, 2016 at 10:00 AM confirmed the soiled utility room lacked positive latching with the self-closer.

Based on observation and interview it was determined that the facility failed to maintain hazardous areas with a separation from other spaces by smoke resisting partitions on one of six levels.

Findings include:

1. Observation on December 5, 2016 at 2:10 PM revealed the Fourth Floor, Triage Corridor, Soiled Utility room had two unsealed penetrations around conduit penetrating the wall.

Interview with the DF on December 5, 2016 at 2:10 PM confirmed the unsealed penetrations existed.

2. Observation on December 5, 2016 at 1:40 PM revealed the First Floor Mechanical Room across from soiled utility room had an unsealed conduit penetrations into the corridor above the suspended ceiling.

Interview with the Maintenance Supervisor on December 5, 2016 at 1:40 PM confirmed the unsealed conduits of the First Floor Mechanical Room into corridor.

Based on observation and interview it was determined that the facility failed to maintain hazardous areas with a separation from other spaces by smoke resisting partitions on three of seven levels.

Findings include:

1. Observations on December 6, 2016 between 10:35 AM and 11:20 AM revealed:
A. First Floor Electric Room, located off the mechanical room, had unsealed penetrations between the fluted deck above and the rear wall. (10:35 AM)
B. Third Floor, Pre-OP IT Room had three unsealed penetrations. (11:20 AM)

Interview with the DF on December 6, 2016 at 11:20 AM confirmed the deficiencies listed above existed.

Based on observation and interview it was determined that the facilty failed to provide required cooking equipment protection in one of one kitchens.

Findings include:

1. Observation on December 6, 2016 between 9:45 AM and 9:50 AM revealed the Ground Floor Kitchen:
A. Lacked a Class K-Type fire extinguisher placard located above the fire extinguisher. (945 AM)
B. Staff lacked knowledge on the manual operation of the hood fire suppression system. (9:50 AM)

Interview with the DF on December 6, 2016 at 9:50 AM confirmed the deficiencies listed above existed.

Based on observation and interview it was determined that the facilty failed to provide required cooking equipment protection in one of one kitchens.

Findings include:

Observation on December 5, 2016 at 2:30 PM revealed the Second Floor, Main Kitchen lacked a Class K-Type fire extinguisher placard located above the fire extinguisher.

Interview with the DF on December 5, 2016 at 2:30 PM confirmed the K-Type extinguisher lacked the required placard.

Based on observation and interview it was determined that the facility failed to maintain and inspect the automatic sprinkler system on four of six levels.

Findings include:

1. Observation on December 5, 2016 between 10:56 AM and 1:30 PM revealed the following:
A. Sixth Floor, Janitor Closet # 6N1113 had a gap around the sprinkler escutcheon and the ceiling assembly that would delay the operation of the sprinkler. (10:56 AM)
B. Sixth Floor, Paint Shop Sink Room had a missing sprinkler escutcheon. (11:04 AM)
C. Sixth Floor, Biomed Small Storage Closet had storage within 18" of the sprinkler. (11:20 AM)
D. Fourth Floor, Nursing Administration, X Wing, Staff Only Room had a metal cabinet stored within 18 inches of the sprinkler. (1:12 PM)
E. Fourth Floor, X Building Main Stairway (North 1 Level 4) sprinkler valve lacked a metal sign. (1:21 PM)
F. Fourth Floor, South Building corridor by Physician Office lacked a sprinkler escutcheon. (1:30 PM)
G. Second Floor, Main Kitchen lacked multiple sprinkler escutcheons throughout the kitchen area. (2:00 PM)

Interview with the DF on December 5, 2016 at 1:30 PM confirmed the sprinkler deficiencies listed above existed.

2. Observation on December 6, 2016 at 8:30 AM revealed the Basement IT Department main store room had a wireless antenna attached to the sprinkler pipe.

Interview with the DF on December 6, 2016 at 8:30 AM confirmed the wireless antenna was attached to the sprinkler pipe.

Based on observation and interview it was determined that the facility failed to maintain the automatic sprinkler system on one of six levels.

Findings include:

1. Observation on December 6, 2016 between 8:51 AM and 9:00 AM revealed:
A. Sixth Floor, Corridor by the Waiting Room had paint on the sprinkler head. (8:51 AM)
B. Sixth Floor, Storage Room had a gap between the sprinkler escutcheon and the ceiling assembly that may affect the operation of the sprinkler. (9:00 AM)

Interview with the DF on December 6, 2016 at 9:00 AM confirmed the sprinkler deficiencies listed above existed.

2. Observation on December 6, 2016 at 9:45 AM revealed the facility had fire sprinklers that lacked escutcheons creating a gap in the suspended ceiling tile, which may affect the operation of the sprinkler at the following locations.
A. Third floor patient room 3106. (9:45 AM)
B. Third floor corridor throughout. (9:45 AM)

Interview with the Maintenance Supervisor on December 6, 2016 at 9:45 AM confirmed the above listed locations lacked sprinkler escutcheons.

Based on observation and interview, it was determined the portable fire extinguishers were not inspected or maintained on three of six floor levels.

Findings include:

Observation on December 5, 2016 between 12:00 PM and 1:53 PM revealed the facility had portable fire extinguishers that did not receive a monthly "quick check" inspection at the following locations for the month indicated.
A. Third floor fire extinguisher across from Room 3415 lacked a monthly "quick check" inspection for April 2016. (12:00 PM)
B. First floor fire extinguisher in the First Floor Data Room lacked a monthly "quick check inspection for May 2016. (1:53 PM)

Interview with the Maintenance Supervisor on December 5, 2016 at 1:55 PM confirmed the portable fire extinguishers listed above lacked monthly "quick checks" as indicated.

Based on observation and interview, the facility failed to insure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on two of six levels.

Findings include:

1. Observation on December 6, 2016 at 10:05 AM revealed the portable fire extinguisher at the Third Floor Birthing Suite nurse station access was blocked by IV poles and a stool.

Interview with the Maintenance Supervisor on December 6, 2016 at 10:05 AM confirmed that the portable fire extinguisher access was blocked.

2. Observation on December 6, 2016 at 10:45 AM revealed the portable fire extinguisher in the First Floor Histology Lab did not receive a monthly "quick check" for the month of April 2016.

Interview with the Maintenance Supervisor on December 6, 2016 at 10:45 AM confirmed the portable fire extinguisher lacked a monthly "quick check" for April 2016.

Based on observation and interview it was determined that the facility failed to maintain corridor doors that are smoke tight and provide a means suitable for keeping the door latched on two of six levels.

Findings include:

1. Observation on December 5, 2016, between 10:55 AM and 1:25 PM revealed the following corridor doors, equipped with automatic door closer failed to closed and latch into the frames:
A. Sixth Floor Door # 6N1115. (10:55 AM)
B. Fourth Floor, TCF Activity Store Room. (1:25 PM)

Interview with the DF on December 5, 2016 at 1:25 PM confirmed the corridor doors failed to close and latch into the frames.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier wall on one of six levels.

Findings include:

Observation on December 6, 2016 at 9:55 AM revealed an unsealed smoke barrier penetration above the suspended ceiling at the Three Main and Three Main Addition smoke barrier doors.

Interview with the Maintenance Supervisor on December 6, 2016 at 9:55 AM confirmed the unsealed smoke barrier wall penetration.

Based on observation and interview, the smoke barriers are constructed to provide at least a one hour fire resistance rating per regulation on one of seven floor levels.

Findings include:

Observation on December 6, 2016 at 12:55 PM revealed the Sixth Floor Data Closet had an unsealed penetration of the smoke barrier at a large conduit on the one hour fire rated wall.

Interview with the Maintenance Supervisor on December 6, 2016 at 12:55 PM confirmed the unsealed conduit penetration of the one hour smoke barrier wall.

Based on observation and interview, the smoke barrier door assemblies do not comply with regulations on one of six levels.

Findings include:

Observation on December 6, 2016 at 9:00 AM revealed the fifth floor smoke barrier door by patient room 5123 did not close completely which would not prevent the passage of smoke.

Interview with the Maintenance Supervisor on December 6, 2016 at 9:00 AM confirmed the smoke barrier door did not close completely.

Based on observation and interview it was determined that the facility failed to maintain electrical outlets on one of six levels.

Findings include:

Observation on December 6, 2016 at 8:50 AM revealed the Sixth Floor Waiting Room had a broken electrical outlet (plastic below the ground inlet), located below an abandoned fire extinguisher cabinet.

Interview with the DF on December 6, 2016 at 8:50 AM confirmed the broken electrical outlet existed.

Based on document review and interview it was determined that the facility failed to document weekly generator inspections on all generator sets.

Findings include:

Document review on December 5, 2016, at 9:40 AM revealed the facility lacked documentation that the generator battery electrolyte/specific gravity was performed weekly for the previous twelve months.

Interview with the DF on December 5, 2016 at 9:40 AM confirmed the lack of documentation for the weekly generator battery tests.

Based on observation and interview it was determined that the facility failed to maintain the proper use of power strips and extension cords on one of seven levels.

Findings include:

Observation on December 6, 2016 at 11:00 AM revealed the Second Floor, Main Lobby had artificial tree lights plugged into extension cords.

Interview with the DF on December 6, 2016 at 11:00 AM confirmed the tree lights were plugged into extension cords.

Based on observation and interview it was determined that the facility failed to maintain the proper use of power strips and extension cords on three of six levels.

Findings include:

1. Observation on December 5, 2016, between 11:45 AM and 2:05 PM revealed surge protectors were suspended by their power supply cords in the following locations:
A. Fourth Floor, Nurse Station, right work station. (11:45 AM)
B. Fourth Floor, X Wing, Video Monitoring Office, below the desk. (1:17 PM)
C. Second Floor, URGI Care, Security Cubicle, below the desk. (2:05 PM)

Interview with the DF on December 5, 2016 at 2:05 PM confirmed the surge protectors were suspended by their power cords.

2. Observation on December 6, 2016 at 8:25 AM revealed the following:
A. Basement Data Abstraction Office:
1. A surge protector was suspended by the power supply cord.
2. A surge protector was plugged into a surge protector.

Interviw with the DF on December 6, 2016 at 8:25 AM confirmed the surge protector deficiencies listed above existed.

3. Observation on December 5, 2016 at 11:25 AM revealed the Fifth Floor Materials Management office across from the stairwell had a portable electric heater plugged into a surge protector.

Interview with the Maintenance Supervisor on December 5, 2016 at 11:25 AM confirmed the portable electric heater was plugged into a surge protector.

4. Observation on December 5, 2016 at 11:40 AM revealed the Fifth Floor Drug and Alcohol Unit Nurse Station had a surge protector plugged into another surge protector.

Interview with the Maintenance Supervisor on December 5, 2016 at 11:40 AM confirmed the surge protector was plugged into another surge protector.

Based on observation and interview it was determined that the facility failed to maintain the proper use of power strips and extension cords on two of six levels.

Findings include:

1. Observation on December 6, 2016 between 8:58 AM and 9:55 AM revealed:
A. Sixth Floor, Nurse Station had three surge protectors suspended by their power cords. (8:58 AM)
B. Ground Floor, Lobby had artificial tree lights plugged into multiple extension cords. (9:55 AM)

Interview with the DF on December 6, 2016 at 9:55 AM confirmed the electrical deficiencies above existed.

2. Observation on December 6, 2016 at 11:35 AM revealed the First Floor Lab had a surge protector plugged into an extension cord, at the rear of the Lab by the acid hood.

Interview with the Maintenance Supervisor on December 6, 2016 at 11:35 AM confirmed the surge protected was plugged into an extension cord.

Based on observation and interview it was determined that the facility failed to maintain compressed gas cylinders in one of one kitchens.

Findings include:

Observation on December 6, 2016 at 9:51 AM revealed the Ground Floor Kitchen had an unsecured CO2 cylinder next to the soft drink dispenser.

Interview with the DF on December 6, 2016 at 9:51 AM confirmed the CO2 cylinder was unsecured.

Based on observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulation on one of six floors.

Findings include:

Observation on December 5, 2016 at 11:55 AM revealed the Third Floor Geriatric Behavior Health patient belonging room had an unsecured oxygen e-tank.

Interview with the Maintenance Supervisor on December 5, 2016 at 1:55 AM confirmed the oxygen e-tank was not secured.