HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the two- hour wall separation in one instance on one of two floors.

Findings Include:

1. Observation on August 26, 2014, at 8:29 a.m., revealed the 3rd floor firewall leading to Registration had numerous penetrations on the Registration side of the wall.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the two hour wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain the two- hour wall separation in two instances on two of three floors.

Findings Include:

1. Observation on August 25, 2014, at 10:11 a.m., revealed the 1st floor firewall separating the Pharmacy and Kitchen had a 4-inch penetration around wires above the dish washing area.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the two hour wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke wall separations in one of two smoke zones.

Findings Include:

1. Observation on August 25, 2014, at 11:03 a.m., revealed the 5th floor smoke wall above the corridor smoke wall doors near Room 7 was not sealed to the deck.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke wall penetration.

Based on observation and interview, it was determined the facility failed to maintain smoke wall separations in two instances impacting four of 12 smoke zones.
Findings Include:
1. Observation on August 25 and 26, 2014, revealed the following smoke wall penetrations:
a) On August 25, 2014, at 1:37 p.m., the 1st floor smoke wall above the corridor doors leading to Critical Care has several penetrations.
b) On August 25, 2014, at 1:51 p.m., the 1st floor smoke wall across from surgery and Room 1133 has several unsealed 4-inch conduits.
c) On August 26, 2014, at 8:59 a.m., the 2nd floor smoke wall leading to OB had a penetration around a large black wire.
d) On August 26, 2014, at 9:59 a.m., the 2nd floor smoke wall above the corridor doors between ASU and Wing 3 had a penetration around a large black wire.
Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke wall penetrations.

Based on observation and interview, it was determined the facility failed to ensure that door openings in smoke barriers would properly close and resist the passage of smoke affecting two of 12 smoke zones.

Findings include:

1. Observation on August 25, 2014, at 10:25 a.m., revealed the 1st floor cross corridor smoke wall doors leading to Wing One were not smoke tight. Additionally, one door had a locking mechanism on top.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke barrier door issue.

Based on observation and interview the facility failed to meet the required exists as required by regulations on two of two floors.

Findings include:

1. Observation on August 26, 2014, revealed the second means of egress on Levels 1 and 2 of Wing 1 and 2 building is through a non-compliant building, creating a dead-end corridor in excess of 30 feet. Meets with FSES dated August 26, 2014.

Interview with the facility representative on August 26, 2014, at 1:30 p.m., confirmed the exit egress issues stated above.

Based on observation and interview, the facility failed to ensure that exit access was maintained readily accessible to a public way at two of four exits.

Findings include:

1. Observation on August 25, 2014, at 10:49 a.m., revealed the two exit doors in the Windber Place conference room were blocked by chairs and two tables.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the exit access issue.

Based on documentation review and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one of one generator rooms within the facility.

Findings include:

1. Review of documentation on August 25, 2014, revealed there was no documentation reflecting that the battery operated emergency lights in the Generator Room were tested annually for 90 minutes.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the generator battery back-up lighting issue.

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Documentation review on August 26, 2014, revealed the facility had no documentation reflecting that a semi-annual visual inspection had been conducted on the fire alarm system six months before or six months after their annual fire alarm system inspection on March 25, 2014.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the fire alarm issue.

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Review of documentation on August 26, 2014, revealed the facility had no documentation reflecting that a semi-annual visual inspection had been conducted on the fire alarm system six months before or six months after their annual fire alarm system inspection on March 25, 2014.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the fire alarm issue.

Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Observation on August 26, 2014, revealed the facilities most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.

Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Review of documentation on August 26, 2014, revealed the facility's most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one room within the entire facility.

Findings include:

1. Observation on August 25, 2014, at 11:25 a.m., revealed the 4th floor Staff Lounge had an orange extension cord providing power to a microwave.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the electrical issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in six instances on two of three floors.

Findings include:

1. Observation on August 25 and August 26, 2014, revealed the following electrical issues:

a) On August 25, 2014, at 1:09 a.m., there was a coffee pot and toaster plugged into a surge protector, which was plugged into another surge protector (piggy-backed) with a microwave in the 1st floor Housekeeping Lounge.

b) On August 25, 2014, at 1:27 p.m., there was a microwave and a refrigerator plugged into a surge protector in the 1st floor CCU Waiting Room Lounge across from the Outpatient Clinic, Room #5.

c) On August 25, 2014, at 2:41 p.m., there was a microwave plugged into a surge protector in the 1st floor Transcription Room.

d) On August 25, 2014, at 2:53 p.m., there was a microwave, coffee pot and an orange extension cord plugged into a surge protector in the 1st floor X-Ray Lounge.

e) On August 26, 2014, at 9:23 a.m., there was a microwave plugged into an extension cord in the 2nd floor Patient Lounge across from Room 309.

f) On August 26, 2014, at 10:05 a.m., there was a coffee pot plugged into a surge protector in the 2nd floor ASU Lounge.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the electrical issues.

Based on observation and interview, it was determined the facility failed to maintain the two- hour wall separation in one instance on one of two floors.

Findings Include:

1. Observation on August 26, 2014, at 8:29 a.m., revealed the 3rd floor firewall leading to Registration had numerous penetrations on the Registration side of the wall.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the two hour wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain the two- hour wall separation in two instances on two of three floors.

Findings Include:

1. Observation on August 25, 2014, at 10:11 a.m., revealed the 1st floor firewall separating the Pharmacy and Kitchen had a 4-inch penetration around wires above the dish washing area.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the two hour wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke wall separations in one of two smoke zones.

Findings Include:

1. Observation on August 25, 2014, at 11:03 a.m., revealed the 5th floor smoke wall above the corridor smoke wall doors near Room 7 was not sealed to the deck.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke wall penetration.

Based on observation and interview, it was determined the facility failed to maintain smoke wall separations in two instances impacting four of 12 smoke zones.
Findings Include:
1. Observation on August 25 and 26, 2014, revealed the following smoke wall penetrations:
a) On August 25, 2014, at 1:37 p.m., the 1st floor smoke wall above the corridor doors leading to Critical Care has several penetrations.
b) On August 25, 2014, at 1:51 p.m., the 1st floor smoke wall across from surgery and Room 1133 has several unsealed 4-inch conduits.
c) On August 26, 2014, at 8:59 a.m., the 2nd floor smoke wall leading to OB had a penetration around a large black wire.
d) On August 26, 2014, at 9:59 a.m., the 2nd floor smoke wall above the corridor doors between ASU and Wing 3 had a penetration around a large black wire.
Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke wall penetrations.

Based on observation and interview, it was determined the facility failed to ensure that door openings in smoke barriers would properly close and resist the passage of smoke affecting two of 12 smoke zones.

Findings include:

1. Observation on August 25, 2014, at 10:25 a.m., revealed the 1st floor cross corridor smoke wall doors leading to Wing One were not smoke tight. Additionally, one door had a locking mechanism on top.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the smoke barrier door issue.

Based on observation and interview the facility failed to meet the required exists as required by regulations on two of two floors.

Findings include:

1. Observation on August 26, 2014, revealed the second means of egress on Levels 1 and 2 of Wing 1 and 2 building is through a non-compliant building, creating a dead-end corridor in excess of 30 feet. Meets with FSES dated August 26, 2014.

Interview with the facility representative on August 26, 2014, at 1:30 p.m., confirmed the exit egress issues stated above.

Based on observation and interview, the facility failed to ensure that exit access was maintained readily accessible to a public way at two of four exits.

Findings include:

1. Observation on August 25, 2014, at 10:49 a.m., revealed the two exit doors in the Windber Place conference room were blocked by chairs and two tables.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the exit access issue.

Based on documentation review and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one of one generator rooms within the facility.

Findings include:

1. Review of documentation on August 25, 2014, revealed there was no documentation reflecting that the battery operated emergency lights in the Generator Room were tested annually for 90 minutes.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the generator battery back-up lighting issue.

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Documentation review on August 26, 2014, revealed the facility had no documentation reflecting that a semi-annual visual inspection had been conducted on the fire alarm system six months before or six months after their annual fire alarm system inspection on March 25, 2014.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the fire alarm issue.

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Review of documentation on August 26, 2014, revealed the facility had no documentation reflecting that a semi-annual visual inspection had been conducted on the fire alarm system six months before or six months after their annual fire alarm system inspection on March 25, 2014.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the fire alarm issue.

Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Observation on August 26, 2014, revealed the facilities most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.

Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Review of documentation on August 26, 2014, revealed the facility's most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator that provides emergency power for the entire facility.

Findings Include:

1. Review of documentation on August 26, 2014, revealed that the facility lacked documentation verifying that a load bank inspection was conducted on the generator.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the generator issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one room within the entire facility.

Findings include:

1. Observation on August 25, 2014, at 11:25 a.m., revealed the 4th floor Staff Lounge had an orange extension cord providing power to a microwave.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the electrical issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in six instances on two of three floors.

Findings include:

1. Observation on August 25 and August 26, 2014, revealed the following electrical issues:

a) On August 25, 2014, at 1:09 a.m., there was a coffee pot and toaster plugged into a surge protector, which was plugged into another surge protector (piggy-backed) with a microwave in the 1st floor Housekeeping Lounge.

b) On August 25, 2014, at 1:27 p.m., there was a microwave and a refrigerator plugged into a surge protector in the 1st floor CCU Waiting Room Lounge across from the Outpatient Clinic, Room #5.

c) On August 25, 2014, at 2:41 p.m., there was a microwave plugged into a surge protector in the 1st floor Transcription Room.

d) On August 25, 2014, at 2:53 p.m., there was a microwave, coffee pot and an orange extension cord plugged into a surge protector in the 1st floor X-Ray Lounge.

e) On August 26, 2014, at 9:23 a.m., there was a microwave plugged into an extension cord in the 2nd floor Patient Lounge across from Room 309.

f) On August 26, 2014, at 10:05 a.m., there was a coffee pot plugged into a surge protector in the 2nd floor ASU Lounge.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the electrical issues.