HospitalInspections.org

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

Observation on 08/26/2016 at 9:50 AM located at the laundry room storage revealed the door to the storage room was not equipped with a self closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

Ref:
2000 NFPA 101, Section 19.3.2.1

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Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times. The findings were:

1. Observation on 08/26/16 at 9:40 AM of the delayed-egress cross-corridor doors located at the OB revealed that they were not provided with the required readily visible sign located adjacent to the door to indicate delayed-egress operation. Interview with the Facility Maintenance Staff at the time of observation acknowledged the doors were not provided with the required signage.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.1.6.1 (d)

2. Observation on 08/26/2016 from 9:27 AM to 11:45 AM revealed doors located at the OB Director, ICU Med Surge, Doctor Sleep Room, Cardio Pulmonary, HR Office and throughout the facility that required more than one releasing operation to make the doors operable. Interview with the Facility Maintenance Staff at the time of the observation acknowledged the door locks required more than one releasing operation.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

3. Observation on 08/26/2016 at 11:30 AM located at the OR surgery doors revealed a keyed deadbolt lock that could be locked from the corridor side and not unlocked from the OR side. Interview with the Facility Maintenance Staff at the time of observation indicated that only maintenance had the key for the lock.

Ref: 19.2.2.2.4

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Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed and continuously maintained per the requirements of NFPA 13. The finding were:

1. Observation on 08/26/16 from 10:30 AM to 11:38 AM located at HR Office, Radiology bathroom, and colonoscopy room revealed missing escutcheon rings with a resulting gap around the sprinkler head. Interview with the Facility Maintenance Staff at the time of the observations acknowledged the missing escutcheon rings.

Ref:
2000 NFPA 101, Sections 19.3.5.1, 9.7.1.1, and 9.7.5
1999 NFPA 13, Section 3-2.7.2

2. Observation on 08/26/2016 at 10:27 AM located in the HR Confidential Storage Room revealed boxes within 10 inches of the ceiling that obstructed the sprinkler head. Interview with the Facility Maintenance Staff at the time of the observation acknowledged that there were several boxes obstructing the one sprinkler head.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

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Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:

1. Observation on 08/27/2016 from 8:00 AM to 1:00 PM located in the main lobby, in the Med Surge Corridor, in the Maintenance corridor, and throughout the facility revealed fire extinguishers that were mounted approximately 68 inches from the top of the extinguisher to the floor. Interview with the Facility Maintenance Staff at the time of observation acknowledge the height of the extinguishers and was unaware of the mounting requirement.

2. Observation on 08/26/2017 at 12:50 PM located in Building C in the basement revealed a mounted fire extinguisher that was above 60 inches from the top of the extinguisher to the floor. Interview with the Facility Maintenance Staff at the time of observation acknowledge the height of the extinguishers and was unaware of the mounting requirement.

Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10

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Based on observation and staff interview, the facility failed to provide an annunciator panel in accordance to NFPA 99. The findings were:

1. Observation on 08/26/2016 at 12:36 PM located at the generator annunciator panel revealed the annunciator panel missing the required alarm for a battery charger malfunction. Interview with the Facility Maintenance Staff at the time of the observation were a unaware of the requirement.

Ref:
1999 NFPA 99, Sections 3-4.1.1.15

2. Observation on 08/26/2016 at 10:00 AM in the generator room revealed no remote manual stop station for the generator. Further observation could not establish if there was a remote manual stop located elsewhere in the facility. Interview with Facility Maintenance Staff at the time of observation acknowledged they were unaware if there was a remote manual stop.

Ref:
1999 NFPA 110, Section 3-5.5.6

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Based on Observation and Staff interview, the facility failed to meet electrical wiring in accordance with NFPA 70. The findings were:

1. Observation on 08/26/2016 at 11:05 AM in the Clean East Utility Med Surge (1 receptacle), and in the Cardiac Reading Room (2 receptacles) revealed receptacles within 72" of the handwashing sinks and was not equipped with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing ground-fault circuit-interrupter.

2. Observation on 08/26/2016 at 12:45 PM located in auxiliary buildings "A" and "C" revealed receptacles within 72 inches of a handwashing sink that was not equipped with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of observation acknowledge the missing ground-fault circuit-interrupter.

Ref:
1999 NFPA 70, Article 210.8

3. Observation on 08/26/2016 at 11:38 AM located in a colonoscopy wet room revealed a power strip on the floor adjacent to the procedure table. Further observation revealed that the power strip was plugged into the wall. Interview with the Facility Environmental Manager at the time of observation was unaware of the requirements.

Ref:
S&C Letter 14-46

4. Observation on 08/26/2016 at 10:20 AM in the Hydro Therapy Storage room revealed a circuit breaker had been removed from the panel board and not covered for protection. Interview with the Facility Maintenance Staff at the time of observation acknowledged the missing breaker.

Ref:
1993 NFPA 70, Section 240.41

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

Observation on 08/26/2016 at 9:50 AM located at the laundry room storage revealed the door to the storage room was not equipped with a self closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

Ref:
2000 NFPA 101, Section 19.3.2.1

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Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times. The findings were:

1. Observation on 08/26/16 at 9:40 AM of the delayed-egress cross-corridor doors located at the OB revealed that they were not provided with the required readily visible sign located adjacent to the door to indicate delayed-egress operation. Interview with the Facility Maintenance Staff at the time of observation acknowledged the doors were not provided with the required signage.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.1.6.1 (d)

2. Observation on 08/26/2016 from 9:27 AM to 11:45 AM revealed doors located at the OB Director, ICU Med Surge, Doctor Sleep Room, Cardio Pulmonary, HR Office and throughout the facility that required more than one releasing operation to make the doors operable. Interview with the Facility Maintenance Staff at the time of the observation acknowledged the door locks required more than one releasing operation.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

3. Observation on 08/26/2016 at 11:30 AM located at the OR surgery doors revealed a keyed deadbolt lock that could be locked from the corridor side and not unlocked from the OR side. Interview with the Facility Maintenance Staff at the time of observation indicated that only maintenance had the key for the lock.

Ref: 19.2.2.2.4

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Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed and continuously maintained per the requirements of NFPA 13. The finding were:

1. Observation on 08/26/16 from 10:30 AM to 11:38 AM located at HR Office, Radiology bathroom, and colonoscopy room revealed missing escutcheon rings with a resulting gap around the sprinkler head. Interview with the Facility Maintenance Staff at the time of the observations acknowledged the missing escutcheon rings.

Ref:
2000 NFPA 101, Sections 19.3.5.1, 9.7.1.1, and 9.7.5
1999 NFPA 13, Section 3-2.7.2

2. Observation on 08/26/2016 at 10:27 AM located in the HR Confidential Storage Room revealed boxes within 10 inches of the ceiling that obstructed the sprinkler head. Interview with the Facility Maintenance Staff at the time of the observation acknowledged that there were several boxes obstructing the one sprinkler head.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

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Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:

1. Observation on 08/27/2016 from 8:00 AM to 1:00 PM located in the main lobby, in the Med Surge Corridor, in the Maintenance corridor, and throughout the facility revealed fire extinguishers that were mounted approximately 68 inches from the top of the extinguisher to the floor. Interview with the Facility Maintenance Staff at the time of observation acknowledge the height of the extinguishers and was unaware of the mounting requirement.

2. Observation on 08/26/2017 at 12:50 PM located in Building C in the basement revealed a mounted fire extinguisher that was above 60 inches from the top of the extinguisher to the floor. Interview with the Facility Maintenance Staff at the time of observation acknowledge the height of the extinguishers and was unaware of the mounting requirement.

Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10

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Based on observation and staff interview, the facility failed to provide an annunciator panel in accordance to NFPA 99. The findings were:

1. Observation on 08/26/2016 at 12:36 PM located at the generator annunciator panel revealed the annunciator panel missing the required alarm for a battery charger malfunction. Interview with the Facility Maintenance Staff at the time of the observation were a unaware of the requirement.

Ref:
1999 NFPA 99, Sections 3-4.1.1.15

2. Observation on 08/26/2016 at 10:00 AM in the generator room revealed no remote manual stop station for the generator. Further observation could not establish if there was a remote manual stop located elsewhere in the facility. Interview with Facility Maintenance Staff at the time of observation acknowledged they were unaware if there was a remote manual stop.

Ref:
1999 NFPA 110, Section 3-5.5.6

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Based on Observation and Staff interview, the facility failed to meet electrical wiring in accordance with NFPA 70. The findings were:

1. Observation on 08/26/2016 at 11:05 AM in the Clean East Utility Med Surge (1 receptacle), and in the Cardiac Reading Room (2 receptacles) revealed receptacles within 72" of the handwashing sinks and was not equipped with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing ground-fault circuit-interrupter.

2. Observation on 08/26/2016 at 12:45 PM located in auxiliary buildings "A" and "C" revealed receptacles within 72 inches of a handwashing sink that was not equipped with a ground-fault circuit-interrupter. Interview with the Facility Maintenance Manager at the time of observation acknowledge the missing ground-fault circuit-interrupter.

Ref:
1999 NFPA 70, Article 210.8

3. Observation on 08/26/2016 at 11:38 AM located in a colonoscopy wet room revealed a power strip on the floor adjacent to the procedure table. Further observation revealed that the power strip was plugged into the wall. Interview with the Facility Environmental Manager at the time of observation was unaware of the requirements.

Ref:
S&C Letter 14-46

4. Observation on 08/26/2016 at 10:20 AM in the Hydro Therapy Storage room revealed a circuit breaker had been removed from the panel board and not covered for protection. Interview with the Facility Maintenance Staff at the time of observation acknowledged the missing breaker.

Ref:
1993 NFPA 70, Section 240.41