HospitalInspections.org

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain the ability of doors to close and be kept closed upon release of their automatic door hold-open devices. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

On 3/7/18 between approximately 0830 and 1630 hours:

-The Endoscopy Recovery double-leaf suite separation doors did not latch when released from their hold-open devices.

-The cross-corridor smoke barrier doors (#10121355) by the main floor Trauma Services room did not fully close and latch when released from their hold open devices.

-There was an inoperative door-closing coordinator on the Bronch Suite /Acute observation suite doors into the exit corridor.



The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the door closing devices to be inoperative.

Based upon observations and staff interviews on 3/7/18 during the physical tour of the facility between approximately 0830 and 1630 hours the facility has failed to ensure the means of egress are clearly identified with signage and that exit signs are maintained constantly illuminated. This could result in a delay of evacuation in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

-The was no visible exit sign within the Main Boiler Plant with no obvious exits in clear line of sight.

The above was discussed and acknowledged by the Facilities Director who said the missing exit signs have not been previously identified.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain doors to hazardous areas as self or automatic closing and able to resist the passage of smoke and fire. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

On 3/6/18 between approximately 0930 and 1530 hours:

-The door to the corridor from the Clean Linen room over 50 square feet across from room #493 is did not have enough self-closer force to fully close and latch.

On 3/7/18 between approximately 0830 and 1630 hours:

-The Acute observation Suite-OR1 is being used for storage over 50 square feet and is without a self-closing device on the door into the corridor.

-The Sterile Storage room (#c50621) over 50 square feet had an excessive gap between the meeting edge of its double wooden doors leading into the corridor.

On 3/7/18 between approximately 1630 and 1815 hours:

-The Surgery Suite's Orange storage room over 50 square feet had an excessive gap between the meeting edge of its double wooden doors leading into the corridor.

-The Surgery Suite's-Red storage room over 50 square feet had an excessive gap between the meeting edges of the metal double doors into the corridor.



The above was discussed and acknowledged by the Facilities Director who said they were unaware of the inoperative self-closers, the excessive gaps, or that the Acute Observation room needed a self-closer on the door.

Based upon observations and staff interviews on 3/6/18 thruogh 3/8/18 during the physical tour of thecampus, the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


On 3/7/18 between approximately 0830 and 1630 hours:

-There was an ABHR-dispenser installed over an electrical light switch in the basement Social Workers' Conference room.


-There was an ABHR-dispenser installed over an electrical light switch in the Outpatient Blood Draw Lab's room #2.


The above was discussed and acknowledged by the Facilities Director who said the dispensers had not been previously observed to be above the outlets/switches.

Based upon observation and staff interviews on 3/6/18 through 3/8/18 during the physical inspection of the campus, the facility has failed to maintain and install the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:

On 3/6/18 between approximately 0930 and 1630 hours:

-The 4th and 5th floor waiting rooms across from the main elevators have private restrooms with no sprinkler coverage provided (each bathroom is approx 6' by 5').

On 3/7/18 between approximately 0830 and 1630 hours:

-The approximately 30' by 6' overhang for the exterior Hazmat/combustible storage area is not equipped with sprinkler coverage. Per 2010 NFPA 25: 8.15.7.5: Sprinklers shall be installed under roofs, canopies,porte-cocheres, balconies, decks, or similar projections greater than 2 ft (0.6 m) wide over areas where combustibles are stored.

-There is no sprinkler coverage in the Projection room storage closet (approx 2' by 5') in the HEC wing.

On 3/7/18 between approximately 1630 and 1815 hours:

-There is no sprinkler coverage in the OR suite's sterile core near the hand wash sink by OR 6/7.


On 3/8/18 between approximately 0830 and 1200 hours:

-There is no sprinkler coverage in the control room for Special Procedures room #2 (room #1437).




The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the missing sprinkler coverage in the bathrooms and the control room and closet. The Facilities Director said they were unaware the hazmat storage area needed a sprinkler as it is a non-combustible overhang. Facility maintenance staff #1 said he believes the missing sprinkler coverage in the sterile core is due to a recently installed closet for sterilization equipment.

Based upon observation and staff interviews on 3/6/18 through 3/8/18 during the physical inspection of the campus, the facility has failed to maintain the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:


-On 3/6/18 between approximately 0930 and 1530 hours:

-The Industrial Communications Array rack in the rooftop mechanical penthouse was using sprinkler piping as a ground / bond. Per 2010 NFPA 13-9.1.1.7: Sprinkler piping or hangers shall not be used to support non-system components.

-There was a painted over sprinkler head in the public restroom by room #521.

-The ICU suite (1 of 10 suites on the 1st floor) was equipped with 1989 Quick-Response sprinkler heads, which required testing / replacement in 2009. The facility was unable to provide documentation of any lab-testing on the heads. Per 2011 NFPA 25-5.3.1.1.1.3: Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.

-On 3/7/18 between approximately 0830 and 1630 hours:

-There was a sprinkler head with its spray pattern obstructed from covering approximately 1/3 of the room by an overhead light fixture in the Food Services office.


The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the painted over head or the light obstructing the sprinkler head. The Facilities Director said they had not previously observed the improper use of the sprinkler piping in the penthouse, and that the communications rack was installed by an outside vendor. In addition, they said the outdated 1989 QR heads had been identified on a 2016 SFMO inspection and that they had contracted with a Sprinkler Technician company to identify all expired heads in the hospital and replace them. He is unsure why the heads in the ICU were not replaced by their contractor.



Based upon record review and staff interviews on 3/7/18 during the document review portion of the inspection between approximately 0830 and 1230 hours, the facility has failed to maintain the fire sprinkler system as required by NFPA 13 and NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:


-Records indicate there was no 4th quarter 2017 Quarterly Sprinkler inspection.


The above was discussed and acknowledged by the Facilities Director who said their sprinkler contractor incorrectly showed up to do two quarterly inspections in the 3rd quarter of 2017 (July and August) instead of the 4th quarter.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain walls protecting corridors as capable of resisting smoke. This could result in toxic products of combustion traveling from a use area/room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

On 3/7/18 between approximately 0830 and 1630 hours:

There was an unsealed through penetration under a permanently installed desk in the intervening wall between the corridor and the Clinac storage room.


The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the penetration in the corridor wall.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain the ability of smoke barriers as being able to resist the passage of smoke. This could result in the products of combustion traveling from one compartment into another compartment, thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

On 3/7/18 between approximately 0830 and 1630 hours:

-There was an unsealed through penetration in the fire/smoke barrier above the drop ceiling at the basement cross-corridor doors # 10121153.

-On 3/8/18 between approximately 0830 and 1200 hours:

-There was an unsealed through penetration (improperly sealed) in the smoke barrier above the drop ceiling at the cross corridor doors # 10121111 in the basement.


The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the unsealed / improperly sealed penetrations in the barriers, but that they were not noticed on their most recent routine barrier audit.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain the ability of smoke barrier doors as being able to resist the passage of smoke. This could result in the products of combustion traveling from one compartment into another compartment, thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

On 3/7/18 between approximately 0830 and 1630 hours:

-There was a greater than 1/4" gap between the meeting edges of the wooden double door leaves at smoke barrier # 10121290 (near data closet MN1424).



The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the the excessive gap.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to prohibit the use of suspended heaters in the means of egress. This could result in a fire hazard that would render the means of egress unusable, which would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:

On 3/6/18 between approximately 0930 and 1530 hours:

-There was a suspended electric heater in use in the West-exit enclosed stairwell from the 3rd floor.

The above was discussed and acknowledged by the Facilities Director who said they were unaware suspended heaters are not permitted in the means of egress.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to prohibit the use of all space heaters in resident areas, staff-sleeping areas and non-approved heaters in non-sleeping staff areas. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:
On 3/6/18 between approximately 0930 and 1530 hours:
-There was a portable heater in use in the Maternity Physicians' sleep room (#244). In addition, the in-use portable heater was sitting on a cardboard box.

The above was discussed and acknowledged by the Facilities Director who said the facility policy does not allow portable heaters in the building.

Based upon observations and staff interviews on 3/7/18 during the physical tour of the campus between approximately 0830 and 1630 hours, the facility has failed to properly maintain the Type 1 EES in the facility. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


The facility's Type I electrical system's Automatic Transfer Switch-OCS C feeds both Endoscopy Critical panels CR-1 and Cr-2 as well as supplying power -Life Safety Branch panel LS-1. As the facility electrical demand exceeds 150 kva (based on the 2000 LSC citation for K-145), each branch must be fed from separate transfer switches and distribution panels.

The above was discussed and acknowledged by the Facilities Director who said the hospital is currently upgrading their Type 1 electrical system following the 2016 Life Safety survey. The facility was issued a waiver for K-145 (now K-915) that expired on 12/31/17. The Facilities Director said he was unaware that the waiver was expired at this time.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to maintain the room housing their emergency generator in accordance with NFPA 110. This could result in a fire event effecting the generator, causing failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

On 3/7/18 between approximately 0830 and 1630 hours:

There was a flammable roofing-sealant/ primer can and other non-generator/EPS equipment storage located in the room housing Generators #1 and 2.

Per NFPA 110-7.11.1: The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

The above was discussed and acknowledged by the Facilities Director who said the improper storage had not been previously identified.

Based upon observations and staff interviews on 3/6/18 through 3/8/18 during the physical tour of the campus, the facility has failed to ensure all electrical wiring is in accordance with NFPA 99, NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

On 3/6/18 between approximately 0930 and 1530 hours:

-There was an extension cord used in place of permanent wiring with a television in the 5th floor report room.

On 3/7/18 between approximately 0830 and 1630 hours:

-There was an extension cord used in place of permanent wiring with a phone in the the Outpatient Blood Draw Lab room #1.

-There was an extension cord used in place of permanent wiring with a video monitor in the Bronch Room.

On 3/7/18 between approximately 1630 and 1815 hours;

-All of the Operating Rooms (1-10) contained un-fused multi-plug adapters that are used with patient care related equipment and do not comply with UL-1363A requirements.


The above was discussed and acknowledged by the Facilities Director who said they had not previously observed the extension cords in use and that they would be immediately removed. In addition he said they were unaware the non-approved multiplugs were being used in the ORs.