HospitalInspections.org

Based on observations by surveyor 34673, 35163 and the facility maintenance staff on 11-5--2018, the facility failed to ensure that labeled 90 and 45 minute fire rated doors meet the requirements of NFPA 80, the findings are as follows:


90 minute labeled doors near Pharmacy missing latching hardware at the bottom of both doors.

90 minute labeled fire door near stairwell "B" missing latching hardware at the bottom of both doors.

90 minute doors (47 & 48 ) ( 73 & 74 ) do not latch.

45 minute labeled fire door located in the cancer care area near exam room 1186 has holes in the top of the door from a previous installed door closing device.

Based on observations and interviews by surveyor 34673, 35163 and the facility maintenance staff on 11-5--2018, the facility failed to ensure that egress from the lower level to the first floor met egress requirements, the findings are as follows:

Stairwell "B" & "C" are marked as exit stairs from the lower level of the building. Both stairs terminate within the interior of the building at level one.
Observations and interviews with maintenance staff confirm that the original door swing for both stairs at the first level stairs always swung back into the stairwell and have been reversed by the maintenance staff to swing towards egress. Maintenance staff also confirmed that these stairs have never discharged to the exterior of the building.
My conclusion after observations and interviews, is that both of these stairs have always been convenient stairs to access one level to another and are not compliant exit stairs.


39983

This REQUIREMENT is not met as evidenced by:

On 11/5/18, Based on observation of Surveyors 39983, 16732 and 16776 in the accompany of the Maintenance Supervisor observed:

1. Med-Surge North Unit cart (computer cart) plugged in to the wall, charging and stored in front of the nurses station desk, obstructing the corridor.

2. Food storage cart stored obstructing the corridor next to room 22 in the Med-Surge Unit.

3. Supply cart stored near med-prep room 54 in corridor obstructing the corridor to 6'4".

4. Supply cart stored in the Med-Surge Unit corridor next to room 53 obstructing the corridor. ( Blue cart with sheet covering it)

5. Food carts and milk crates stored outside of main kitchen obstructing the corridor.

6. Flat screen TV (2) affixed to the wall in Med-Surge North and South protruding 7" from wall, 60 5/8" from floor obstructing corridor.

On 11-5-2018, Based on Observation, Surveyor 16776 and 16732 and 39983 with the Maintenance Supervisor observed: The following was not met.


1. In the Basement Exit door's; Signs on the doors marked with 30 seconds door release, when testing the doors all released after 15 seconds.










































35163

Based on observations and interviews surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. Delayed egress door located across from room # 1179 were signed to release in 30 seconds, door actually released within 15 seconds upon testing.

2. Single delayed egress door located in OB/GYN has a coded pin pad and staff did not have the required code to release the door. The staff advised only nurse manager has the code and she was not available and was off site.

3. Double egress doors located in OB/GYN have a functioning delayed egress locking arrangement on the door, but was not signed to indicate how to release the door or timeframe in which it would release.

4. Bifold exit doors located at main entrance/reception area not labeled "push to open in emergency".

5. The sliding exit doors located in the emergency department do not have the proper sized labels that indicate push to exit in an emergency

6. Hoyer lift rail attached to ceiling, handles located at the exit doors in the emergency department are located within the exit path and extend below 6'-8" and could cause an obstruction to egress.






39983

This REQUIREMENT is not met as evidenced by:

On 11/5/18, Based on observation of Surveyors 39983, 16732 and 16776 in the accompany of the Maintenance Supervisor observed:

1. Delayed egress door across from room 14 in Med-Surge South has sign on door stating door will release after 30 seconds, when tested the door released after 15 seconds.

2. Delayed egress door across from room 45 in Med-Surge North has sign on door stating door will release after 30 seconds, when tested the door released after 15 seconds.

On 11-5-2018, Based on Observation, Surveyor 16776 and 16732 and 39983 with the maintenance Supervisor observed: The following was not met.


1. First Floor Stockroom, Dutch Door type has a pass out shelf / counter, extend out to 6" in to the hall-way. ( greater than > 4.5".).

Based on observations by surveyor 34673, 35163 and the facility maintenance staff on 11-5--2018, the facility failed to ensure that 45 minute fire rated corridors remained in place, the findings are as follows:


During the survey of the anticoagulation and infussion unit a set of 45 minute fire rated doors located across from the Cancer Care area were missing.
A set of double doors were shown and assumed required According to a set architectural plans dated 2013.

On 11-5-2018, Based on Observation, Surveyor 16776 and 16732 and 39983 with the Maintenance Supervisor observed: The following was not met.


1. Basement North side Janitor Closet P.A.R.C. Unit, Observed hole penetrations in the ceiling and walls.





































39983

This REQUIREMENT is not met as evidenced by:

On 11/5/18, Based on observation of Surveyors 39983, 16732 and 16776 in the accompany of the Maintenance Supervisor observed:

Electric room door next to room 100 in Med-Surge does not self-close.

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. Housekeeping closet # 1424 has urethane spray foam and no documentation could be provided to indicate it meets requirements for interior finish.

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. The audio visual aids located in the gift shop were blocked by merchandise on the shelves and not visible.

Based on observations surveyors 35163 and 34673 on 11/05/18, in the presence of maintenance staff the following was not met;

1. The glassed display cabinet located in hall near special care unit does not have sprinkler protection.

2. Storage room #1 (1173) does not have sprinkler protection.

3. Construction area (new pharmacy) has area of no sprinkler coverage.

4. Construction area (new pharmacy) existing sprinkler heads are the wrong orientation (not upright) to cover construction area. NFPA 13-2010, section 8.5.4.1.1 says the distance between the sprinkler deflector and the ceiling above must be based on the type of sprinkler and the type of construction. Section 8.6.4.1.1.1 of the same standard says for standard pendant and upright type sprinklers, the minimum distance is 1 inch and the maximum distance is 12 inches between the sprinkler deflector and the ceiling. The suspended grid and acoustical tile ceiling has been removed for construction, the deck above now becomes the ceiling. If you have 6 feet of interstitial space above the suspended ceiling, that is more than 12 inches so the piping needs to extend upwards so the sprinkler deflector are within 12 inches of the deck.

5. The ceiling in the area between the building and the MRI trailer does not have adequate sprinkler protection.









37695


Based on observation of surveyors 16732, 37695, 35163 and 39983 11/05/18

The main corridor of the hospital has a void space above the current dropped in ceiling. The void space is approximately 25 feet in height. There is no sprinkler protection in the area. There is exposed insulation, wood and unprotected steel beams.

The maintenance supervisor was present during this observation.

Based on record review of surveyor 16732 on 11/05/18


Sprinkler report dated 05/18/18 advises wet sprinkler heads are over 20 years old and require UL testing. The heads have not been tested and this was confirmed with interview of facility director



35163

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. Prep closet # 1153 had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

2. Telecom room # 1422 had a missing sprinkler escutcheon plate.

Based on observation of surveyor 37695 and 39983, in the presence of the maintenance department, the two hour wall located near endoscopy has a large penetration through it to allow negative air to be taken out of the construction area. Fire wall needs to remain intact and keep its two hour rating.

Based on observation of surveyor 37695 and 39983, in the presence of the maintenance department, the two hour fire wall located near the surgical center has penetrations around piping that is not sealed. Penetration must be sealed.

Based on observation of surveyor 37695 and 39983, in the presence of the maintenance department, the two hour fire wall located in the main corridor does not extend to the roof deck.

Based on observation of surveyor 16732 on 11/05/18

1) Patient room door 53 would not close as IV pump was blocking door. The Charge nurse, director or quality and maintenance supervisor were present during this observation.

2) Double 90 minute rated corridor fire doors near med surg room 32 do not close and latch. The maintenance supervisor was present during this observation







16776

On 11-5-2018, Based on Observation, Surveyor 16776 and 16732 and 39983 with the maintenance Supervisor observed: the following was not met.


1. In the Basement Electrical Closet double Door's observed gap space greater than 1/2/", Failed to resist the passage of smoke.



































34673

Based on observations by surveyor 34673, 35163 and the facility maintenance staff on 11-5--2018, the facility failed to ensure that patient doors would close and latch, the findings are as follows:

Patient room doors on the OBGYN Wing had Computers On Wheels (COWS) being charged in the door open of patient rooms 1122 & 1120. COWS were placed in the patient room doorway and the charging cord was pulled into the corridor and plugged into the electrical outlet so that the unit could be charged.


35163

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. Soiled linen door located in BB/GYN would not properly latch. It appears the latching mechanism is not fully reaching the strike plate.

2. Housekeeping closet # 1143 would not properly latch. The left door leaf has a flush bolt that would not engage when door was closed.

3. Double smoke doors located in the emergency department had a chair and wheeled gurney stored in front of doors and would not allow for proper closure if the doors magnetic hold open devices released the doors.

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. The medical gas zone valve panel located in OB/GYN that serves cardiology is not visible (behind door) when the door is held open with the magnetic hold open device.

This REQUIREMENT is not met as evidenced by:

On 11/5/18, Based on observation of Surveyors 39983, 16732 and 16776 in the accompany of the Maintenance Supervisor observed:

Wires exposed in junction box on upper left wall in med storage room 23 on Med-Surge South, required to be covered, per NFPA 70 National Electric Code.

Based on record review of surveyor 16732 on 11/05/18:

The weekly generator inspection was not conducted the 2nd week of October of 2018

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. There are exposed electrical wires located outside of the main door/canopy.

Based on observations surveyors 35163 and 34673 on 011/05/18, in the presence of maintenance staff the following was not met;

1. Cardiology room #1105 had a power strip in patient area powering non-patient care equipment. Power strips in the patient care vicinity may not be used for non-PCREE

2. Infusion/Anticoagulation office located behind the nursing station had a portable space heater plugged into a power strip.






39983

This REQUIREMENT is not met as evidenced by:

On 11/5/18, Based on observation of Surveyors 39983, 16732 and 16776 in the accompany of the Maintenance Supervisor observed:

1. Power strip used to plug in refrigerator in Room 65 (Office in Case Management), Psychiatric wing.

2. Power strip used to plug in refrigerator, microwave and keurig coffee maker in Supply Stockroom.