HospitalInspections.org

Based on observation and interview, the hospital does not ensure that exits are readily accessible at all times, as evidenced by:

1) The means of egress is not maintained free of all obstructions or impediments.
2) The hospital did not provide "exit signage" per Life Safety Code in the construction zone adjacent to the security office.

Findings include:

Findings #1:
- During facility tour on 8/19/14, it was observed that "Stair E", the exit door to the outside in the stairwell, had a hornets' nest in the corner of the jamb and the head, on the latch side of the door. Eight hornets were observed to be in the nest.

This finding was verified with Director of Facility Engineering Staff #5 on 8/19/14.

- During facility tour on 8/19/14, it was observed that there was a flex hose, two inches in diameter, lying across the outside stair at the kitchen exit. This stair is the route of travel from the kitchen exit door to grade level.
- Staff #5 verified this finding, and stated that the hose was used to pump out runoff water during heavy rain.

- During facility tour on 8/19/14, it was observed that the wooden deck directly outside the exit from the Cancer Center had a warped board that presented a tripping hazard. The board projected upward approximately 1.5 inches.

This finding was verified with Staff #5 on 8/19/14.

Findings #2:
- Observation during facility tour on 8/21/14 at 3:00 PM revealed exit signs near the security office that directed egress into an external construction area where a crane was stationed. Alternative egress was available in this location, but was not properly labeled.

This finding was verified with Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not maintain all components of the fire alarm system.

Findings include:

- Observation during tour of the kitchen on 8/19/14 revealed that a smoke head located in the nourishment area had an orange dust cover on it. This cover would prevent the device from functioning as intended.

This finding was verified with System Director for Facilities Engineering Staff #6 on 8/19/14.

- Observation during tour of the sterile processing department on 8/21/14 at 11:45 AM revealed one smoke head above the door to the prep and pack area covered with blue masking tape.

This finding was verified with Director of Facility Engineering Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not provide clear means of egress and exit access related to storage of pallets in the exit corridor.

Findings include:

Observation during facility tour on 8/21/14 at 10:45AM revealed storage of 6 pallets of patient care solutions and copy paper in the corridor of the physicians' entrance to the hospital. These items consisted of 3 pallets of sodium chloride solution, 1 pallet of Optiflux materials, 1 pallet of hemodialysis solution and 1 pallet of Staples copy paper. This corridor is a main exit corridor to the rear of the facility.

This finding was verified with Director of Facility Engineering Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not provide proper storage of medical gases in the loading dock storage room.

Findings include:

Observation during facility tour on 8/21/14 at 12:30 PM revealed the light switch and electric receptacle in the Medical Gas Storage room were not 60 inches above the floor as required by this regulation. In addition, the medical gas tanks were not properly individually secured. Chains were wrapped around the valves and stems of the tanks. There was no door closer on the door to insure the one hour fire separation was maintained.

These findings were confirmed with Director of Facility Engineering Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not ensure that exits are readily accessible at all times, as evidenced by:

1) The means of egress is not maintained free of all obstructions or impediments.
2) The hospital did not provide "exit signage" per Life Safety Code in the construction zone adjacent to the security office.

Findings include:

Findings #1:
- During facility tour on 8/19/14, it was observed that "Stair E", the exit door to the outside in the stairwell, had a hornets' nest in the corner of the jamb and the head, on the latch side of the door. Eight hornets were observed to be in the nest.

This finding was verified with Director of Facility Engineering Staff #5 on 8/19/14.

- During facility tour on 8/19/14, it was observed that there was a flex hose, two inches in diameter, lying across the outside stair at the kitchen exit. This stair is the route of travel from the kitchen exit door to grade level.
- Staff #5 verified this finding, and stated that the hose was used to pump out runoff water during heavy rain.

- During facility tour on 8/19/14, it was observed that the wooden deck directly outside the exit from the Cancer Center had a warped board that presented a tripping hazard. The board projected upward approximately 1.5 inches.

This finding was verified with Staff #5 on 8/19/14.

Findings #2:
- Observation during facility tour on 8/21/14 at 3:00 PM revealed exit signs near the security office that directed egress into an external construction area where a crane was stationed. Alternative egress was available in this location, but was not properly labeled.

This finding was verified with Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not maintain all components of the fire alarm system.

Findings include:

- Observation during tour of the kitchen on 8/19/14 revealed that a smoke head located in the nourishment area had an orange dust cover on it. This cover would prevent the device from functioning as intended.

This finding was verified with System Director for Facilities Engineering Staff #6 on 8/19/14.

- Observation during tour of the sterile processing department on 8/21/14 at 11:45 AM revealed one smoke head above the door to the prep and pack area covered with blue masking tape.

This finding was verified with Director of Facility Engineering Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not provide clear means of egress and exit access related to storage of pallets in the exit corridor.

Findings include:

Observation during facility tour on 8/21/14 at 10:45AM revealed storage of 6 pallets of patient care solutions and copy paper in the corridor of the physicians' entrance to the hospital. These items consisted of 3 pallets of sodium chloride solution, 1 pallet of Optiflux materials, 1 pallet of hemodialysis solution and 1 pallet of Staples copy paper. This corridor is a main exit corridor to the rear of the facility.

This finding was verified with Director of Facility Engineering Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not provide proper storage of medical gases in the loading dock storage room.

Findings include:

Observation during facility tour on 8/21/14 at 12:30 PM revealed the light switch and electric receptacle in the Medical Gas Storage room were not 60 inches above the floor as required by this regulation. In addition, the medical gas tanks were not properly individually secured. Chains were wrapped around the valves and stems of the tanks. There was no door closer on the door to insure the one hour fire separation was maintained.

These findings were confirmed with Director of Facility Engineering Staff #5 on 8/21/14.