HospitalInspections.org

Based on observation and interview, this building does not meet the requirements for construction type and height. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that there is a plywood ceiling with wood joists in the 8th floor-IVAC pump controller room.

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

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

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:

1. Storage Room 620 opens to the corridor and does not positively latch,
2. The basement office suite door near the atrium stair opens to the corridor and does not positively latch,
3. The basement locker rooms, LL20 and LL20B, opens to the corridor and does not positively latch,
4. The basement trash collection room, LL119, opens to the corridor and has an unsealed transfer grill.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. In the 8th floor - IVAC Pump Controller Room, there is a Nopen conduit in the floor that is not properly firestopped,
2. In Room 753, there is an open penetration in the floor that is not properly firestopped,
3. By the west basement elevator shaft, there are conduits penetrating the shaft that are not properly firestopped,
4. In the Conference Room hallway, there are conduits in the ceiling that are not properly firestopped.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain the smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3. The deficient practice could affect the patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The smoke barrier near Room 701 has penetrations above the ceiling that are not properly firestopped,
2. The smoke barrier walls on the First Floor near the Eye Center and Same Day Surgery, above the smoke barrier doors, terminate at the suspended ceiling grid and do not resist the passage of smoke.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

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:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The following storage rooms are over 50 sq.ft. with door window glazing in excess of 100 sq.in.: Rooms 818, 706, 539A, 520, 516, 506 and the storage room between 619 and 620,
2. The following rooms do not have a self-closing device on the door: Rooms 841D-1, 645A and the 7th floor Environmental Services Room
3. The door to trash room 645B does not positively latch,
4. Storage room 828A has an unsealed transfer grill.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to properly protect the laboratory in accordance with NFPA 99, Chapter 10. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The 1-hour fire rated walls in the Pathology Lab terminate at the suspended ceiling grid and do not extend to the roof deck as they are required,
2. The door leading into the 1-hour fire rated room in the Pathology Lab is not 45-minute fire rated and does not self-closing device.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the stairway enclosure of this facility does not meet the required two (2) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the 8th Floor of Stairwell D and 6th Floor of Stairwell B have open penetrations through the wall around the fire sprinkler piping that are not properly firestopped.

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

Based on observation and interview, the facility failed to maintain the stairwells in accordance with LSC (2000) Chapter 7.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the signs located in the stairwells do not indicate that there is no re-entry into the floors.

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

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that when activated, the fire alarm system sounds throughout the entire building, however, the fire alarm system does not deactivate all magnetic door locks on the 7th floor, 4th floor, 2nd floor and the Secured Unit within the Emergency Department.

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

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. There is no smoke detector in Room 815 or the 3 secured holding rooms located in the Emergency Department,
2. The 8th Floor Printer Room does not have a smoke detector within 18" of the room door,
3. There is no smoke detector within 21 feet of the wall in Room 753,
4. Smoke detectors are located within 3 feet of HVAC supply/return vents in the Emergency Department Ambulance entrance, the Operating Room Suite, the Main Dining Room and on the 4th floor(detector N3L4D42).

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. There are no gauges at the top of the fire sprinkler risers in stairwells B, C, D,
2. The ceilings are not smooth and continuous in Room 828A, the 6th Floor Family Lounge, Room 529A, Room LL3K, the basement 2-hour rolling fire door and the corridor serving as linen storage,
3. There are no fire sprinkler heads in the Compactor Room, Room LL26 E-1, the Powerhouse high voltage electrical vault and the 8th floor-IVAC Pump cCntroller Room,
4. The fire sprinkler heads are obstructed by conduits and storage bins in the basement Medical Air Compressor Room near the tube system terminal.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of staff in an emergency situation.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that storage in the service corridors serving Maintenance, Sterile Processing and the Laundry Area, is located on both sides of the corridors and restricts the clear with to less than the required 44".

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

Based on observations and interview, the facility has medical gas storage not in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. Portable oxygen cylinders located in Respiratory Therapy, rooms 876 and 706B, have combustible materials stored within 5 feet of the cylinders,
2. Oxygen storage signage on rooms 876, 706B, 601B and 446A do not comply with NFPA 99 requirements,
3. In the Compressed Gas Manifold Room, different gas-type cylinders are intermixed together and are not segregated between empty and full and are not properly secured against tipping.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:

1. The vacuum gauge in the zone valve box serving the Biomedical Laboratory shows a vacuum greater than 32 InHg,
2. The ceiling mounted station outlets in Sterile Processing used to clean equipment are labeled "Med Air". These station outlets have a gauge pressure of 72 psig, which is the same pressure as the "Lab Air" mainline pressure,
3. The station outlets in the Endoscopy Dirty Equipment Cleaning Area are labeled "Med Air". These station outlets have a gauge pressure of 52 psig, which is the same pressure as the "Med Air" and "Oxygen" mainline pressures,
4. The medical air gas system zone boxes are improperly labeled throughout the facility,
5. The "Lab Air" station outlets which serve as the facility instrument air system are not uniformly labeled.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to properly store, dispense and use flammable and combustible liquids in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals and NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that in the Pathology Lab:

1. The 1-gallon containers and 4-gallon cases of alcohols, Xylene and Formalin are not stored in a flammable storage cabinet,
2. Alcohols, Xylene and Formalin are being dispensed and used from 1-gallon plastic storage containers without self-closing lids or spark arrestors,
3. A paraffin wax melting machine is located within the 1-hour fire rated enclosure but was on an unstable thin gauge metal table next to the room door,
4. A high-temperature sterilizing device is located next to the 1-hour fire rated enclosure,
5. The exhaust vent serving the 1-hour fire rated enclosure was found to be not operational.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the facility's emergency generators do not comply with NFPA 99 Health Care Facilities (1999 edition) nor NFPA 110 Standard for Standby Power Systems (1998 edition). This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the three emergency generators do not have a remote alarm annunciating panel that provides individual operational displays in a constantly attended location. The only panel found was in the Maintenance Office.

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

Based on observation and interview, the facility failed to maintain the existing dumbwaiters in accordance with the requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the dumbwaiter doors on the fourth through eighth floors were open without the car present and could not be closed and locked. These dumbwaiters are located in rooms with either 20-minute fire doors or non-rated doors.

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

Based on observation and interview, this building does not meet the requirements for construction type and height. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that there is a plywood ceiling with wood joists in the 8th floor-IVAC pump controller room.

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

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

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:

1. Storage Room 620 opens to the corridor and does not positively latch,
2. The basement office suite door near the atrium stair opens to the corridor and does not positively latch,
3. The basement locker rooms, LL20 and LL20B, opens to the corridor and does not positively latch,
4. The basement trash collection room, LL119, opens to the corridor and has an unsealed transfer grill.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC(00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. In the 8th floor - IVAC Pump Controller Room, there is a Nopen conduit in the floor that is not properly firestopped,
2. In Room 753, there is an open penetration in the floor that is not properly firestopped,
3. By the west basement elevator shaft, there are conduits penetrating the shaft that are not properly firestopped,
4. In the Conference Room hallway, there are conduits in the ceiling that are not properly firestopped.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain the smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3. The deficient practice could affect the patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The smoke barrier near Room 701 has penetrations above the ceiling that are not properly firestopped,
2. The smoke barrier walls on the First Floor near the Eye Center and Same Day Surgery, above the smoke barrier doors, terminate at the suspended ceiling grid and do not resist the passage of smoke.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

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:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The following storage rooms are over 50 sq.ft. with door window glazing in excess of 100 sq.in.: Rooms 818, 706, 539A, 520, 516, 506 and the storage room between 619 and 620,
2. The following rooms do not have a self-closing device on the door: Rooms 841D-1, 645A and the 7th floor Environmental Services Room
3. The door to trash room 645B does not positively latch,
4. Storage room 828A has an unsealed transfer grill.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to properly protect the laboratory in accordance with NFPA 99, Chapter 10. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. The 1-hour fire rated walls in the Pathology Lab terminate at the suspended ceiling grid and do not extend to the roof deck as they are required,
2. The door leading into the 1-hour fire rated room in the Pathology Lab is not 45-minute fire rated and does not self-closing device.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the stairway enclosure of this facility does not meet the required two (2) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the 8th Floor of Stairwell D and 6th Floor of Stairwell B have open penetrations through the wall around the fire sprinkler piping that are not properly firestopped.

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

Based on observation and interview, the facility failed to maintain the stairwells in accordance with LSC (2000) Chapter 7.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the signs located in the stairwells do not indicate that there is no re-entry into the floors.

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

Based on observation and interview, the facility has failed to maintain the door locks in accordance with Life Safety Code Section 18.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that when activated, the fire alarm system sounds throughout the entire building, however, the fire alarm system does not deactivate all magnetic door locks on the 7th floor, 4th floor, 2nd floor and the Secured Unit within the Emergency Department.

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

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. There is no smoke detector in Room 815 or the 3 secured holding rooms located in the Emergency Department,
2. The 8th Floor Printer Room does not have a smoke detector within 18" of the room door,
3. There is no smoke detector within 21 feet of the wall in Room 753,
4. Smoke detectors are located within 3 feet of HVAC supply/return vents in the Emergency Department Ambulance entrance, the Operating Room Suite, the Main Dining Room and on the 4th floor(detector N3L4D42).

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. There are no gauges at the top of the fire sprinkler risers in stairwells B, C, D,
2. The ceilings are not smooth and continuous in Room 828A, the 6th Floor Family Lounge, Room 529A, Room LL3K, the basement 2-hour rolling fire door and the corridor serving as linen storage,
3. There are no fire sprinkler heads in the Compactor Room, Room LL26 E-1, the Powerhouse high voltage electrical vault and the 8th floor-IVAC Pump cCntroller Room,
4. The fire sprinkler heads are obstructed by conduits and storage bins in the basement Medical Air Compressor Room near the tube system terminal.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of staff in an emergency situation.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that storage in the service corridors serving Maintenance, Sterile Processing and the Laundry Area, is located on both sides of the corridors and restricts the clear with to less than the required 44".

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

Based on observations and interview, the facility has medical gas storage not in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:
1. Portable oxygen cylinders located in Respiratory Therapy, rooms 876 and 706B, have combustible materials stored within 5 feet of the cylinders,
2. Oxygen storage signage on rooms 876, 706B, 601B and 446A do not comply with NFPA 99 requirements,
3. In the Compressed Gas Manifold Room, different gas-type cylinders are intermixed together and are not segregated between empty and full and are not properly secured against tipping.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that:

1. The vacuum gauge in the zone valve box serving the Biomedical Laboratory shows a vacuum greater than 32 InHg,
2. The ceiling mounted station outlets in Sterile Processing used to clean equipment are labeled "Med Air". These station outlets have a gauge pressure of 72 psig, which is the same pressure as the "Lab Air" mainline pressure,
3. The station outlets in the Endoscopy Dirty Equipment Cleaning Area are labeled "Med Air". These station outlets have a gauge pressure of 52 psig, which is the same pressure as the "Med Air" and "Oxygen" mainline pressures,
4. The medical air gas system zone boxes are improperly labeled throughout the facility,
5. The "Lab Air" station outlets which serve as the facility instrument air system are not uniformly labeled.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to properly store, dispense and use flammable and combustible liquids in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals and NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that in the Pathology Lab:

1. The 1-gallon containers and 4-gallon cases of alcohols, Xylene and Formalin are not stored in a flammable storage cabinet,
2. Alcohols, Xylene and Formalin are being dispensed and used from 1-gallon plastic storage containers without self-closing lids or spark arrestors,
3. A paraffin wax melting machine is located within the 1-hour fire rated enclosure but was on an unstable thin gauge metal table next to the room door,
4. A high-temperature sterilizing device is located next to the 1-hour fire rated enclosure,
5. The exhaust vent serving the 1-hour fire rated enclosure was found to be not operational.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the facility's emergency generators do not comply with NFPA 99 Health Care Facilities (1999 edition) nor NFPA 110 Standard for Standby Power Systems (1998 edition). This deficient practice could affect all patients.

Findings include:

On facility tour between 04/02/2012 and 04/05/2012, observation revealed that the three emergency generators do not have a remote alarm annunciating panel that provides individual operational displays in a constantly attended location. The only panel found was in the Maintenance Office.

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