HospitalInspections.org

Based on observation and interview, the facility failed to maintain the corridor walls which form a barrier to limit the transfer of smoke in accordance with NFPA 101, Section(s) 18.3.6.1, 18.3.6.2 and 18.3.6.5. This deficient practice could effect all patients in the Emergency Department.

Findings include:

On facility tour between 12/16/2013 and 12/19/2013, observation revealed that the corridor smoke wall separating the Emergency Department from the waiting room located behind the triage room terminates at the suspended ceiling grid and does not extend to the roof deck.

This deficient practice was verified by the Facilities Manager at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the operating room patients.

Findings include:

During facility tour between 12/16/2013 and 12/19/2013, observation revealed that the Pre-Op Phase II room doors that open into the corridor have inactive door leaves with manual flush bolts that do not automatically latch. It was also observed that several of the active door leaves in Pre-Op Phase II do not latch closed.

This deficient practice was verified by the Director of Facilities at the time of the inspection.

Based on observation, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 18.3.6.2. This deficient practice could affect staff patients and visitors within the smoke compartment.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 12/16/2013, it was observed that the corridor door to the lower level Hazardous Waste Storage Room was a 20 minute fire rated door and not the 45 minute fire rated door and assembly required.

This deficiency was verified by the facility maintenance director.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 12/16/2013 and 12/19/2013, observation revealed that the equipment room, Room 106, is also being utilized as a soiled linen room and is not properly separated from the egress corridor.

This deficient practice was verified by the facility staff at the time of the inspection.

Based on review of reports and records, it was determined that the facility failed to conduct fire drills in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire.

Findings include:

On facility tour between 09:00 AM and 04:00 PM on 12/16/2013, based on review of available documentation it was revealed that fire drills are conducted at least one per shift per quarter, however are not conducted at unexpected times throughout the shift during the evening shift and night shift as noted:
- During the evening shift 8 drills were conducted and all drills were held between 3:55 PM and 4:10 PM.
- During the night shift 8 drills were conducted. 7 of 8 drills were held between 5:00 AM and 6:00 AM.

This deficiency was verified by the facility maintenance director.

Based on observation and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice could affect some patients.

Findings include:

During facility tour between 12/16/2013 and 12/19/2013, observation revealed that Room(s) 1624-1, 9E01, 8E03, 8E02, 7E01, 7E04, 6E01, 5E01, 5E03 and the basement electrical distribution room were not protected by fire sprinkler heads.

This deficient practice was verified by the Director of Facilities at the time of the inspection.

Based on observation and interview, the facility failed to maintain the medical gas storage in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 12/16/2013 and 12/19/2013, observation revealed that the portable oxygen and portable medical air cylinders serving the medgas blenders stored in Rooms 8131 and 4112 are being stored in the same racking system with no separation of the cylinders. It could be determined where the empty medical gas bottles are being stored.

This deficient practice was verified by the Director of Facilities at the time of the inspection.

Based on observation and interview, the facility failed to properly install and maintain the piped medical gas system in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 12/16/2013 and 12/19/2013, observation revealed that the facility is using the Medical Air gas system to clean equipment in Room 2746.

This deficient practice was verified by the Facilities Manager at the time of the inspection.