HospitalInspections.org

Based upon observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in care of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect ALL occupants in this smoke compartment in the event of a fire.

Findings Include:

1. On 12/09/2020, at approximately 9:30 AM, the following observation was made and confirmed by safety officer, of supplies being stored in the first floor CVI -O.R. rear corridor.

2. On 12/09/2020, at approximately 11:41 AM, the following observation was made and confirmed by safety officer, of storage in Peri Operative Services corridor 1G153, from north to south.

Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8.

This deficient practice could potentially affect all occupants of the smoke compartments on the listed floors in the event of a fire emergency that is not confined as designed as a result of unclosed doors.

Findings Include:

1. On 12/09/2020, at approximately 9:40 AM, the following observation was made and confirmed by safety officer that door BMP-14981 did not fully close and latch when tested.

2. On 12/09/2020, at approximately 9:33 AM, the following observation was made and confirmed by safety officer that door BMP-13520 did not fully close and latch when tested.

3. On 12/09/2020, at approximately 10:13 AM, the following observation was made and confirmed by safety officer that door BMP-4611 did not fully close and latch when tested.

4. On 12/09/2020, at approximately 1:12 PM, the following observation was made and confirmed by safety officer that door BMP-4833 Data Management did not fully close and latch when tested.

5. On 12/09/2020, at approximately 11:56 AM, the following observation was made and confirmed by safety officer that door BMP-123799 did not fully close and latch when tested.

6. On 12/09/2020, at approximately 1:30 PM, the following observation was made and confirmed by safety officer that door to CVI Specialty Area was blocked open with a rubber wedge.

7. On 12/09/2020, at approximately 12:14 PM, the following observation was made and confirmed by safety officer that door to CVI Housekeeping 21081 did not fully close and latch when tested. (Note: Staff stuffed fabric into latch plate).

8. On 12/09/2020, at approximately 3:09 PM, the following observation was made and confirmed by safety officer that door to CVI Stairwell 110X5 did not fully close and latch when tested.

9. On 12/09/2020, at approximately 2:44 PM, the following observation was made and confirmed by safety officer that door to 6th floor Webber office 8358 did not fully close and latch when tested.


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Findings Include:

10. On 12/09/2020, at approximately 11:44 AM, the following observation was made and confirmed by safety officer that door to 5th floor Webber South fire doors to ICU BMP-13475 did not fully close and latch when tested.

11. On 12/09/2020, at approximately 2:37 PM, the following observation was made and confirmed by safety officer that handle on door to Stairwell HUH-27, 5th floor Webber, was damaged and did not open.

12. On 12/09/2020, at approximately 1:14 PM, the following observation was made and confirmed by safety officer that fire doors to 5th floor Webber, by room 5426, did not fully close and latch when tested.

13. On 12/09/2020, at approximately 9:31 AM, the following observation was made and confirmed by safety officer that 4th floor Webber fire doors, at room 4425, the west leaf did not fully close and latch when tested.

14. On 12/09/2020, at approximately 10:33 AM, the following observation was made and confirmed by safety officer that 1st floor Webber fire doors, by stairwell HUH-27 did not fully close and latch when tested.

15. On 12/09/2020, at approximately 2:05 PM, the following observation was made and confirmed by safety officer that ground floor Peri Operative Services fire doors, have a gap exceeding 1/8".

Based upon observation and interview, the facility failed to ensure that a fire alarm system is installed in accordance with NFPA 70 and NFPA 72 as required by 19.3.4.1, 9.6, and 9.6.1.8. This deficient practice could affect 10 occupants in the event of fire.

Findings Include:

On 12/09/2020, at approximately 2:55 PM, the following observation was made and confirmed by safety officer that Staff Lounge 10520 requires a fire alarm notification appliance.

Based upon observation and interview, the facility failed to ensure that corridors are separated from use areas by walls of at least 1/2-hour fire resistance rating or meet the requirements of smoke partitions in smoke compartments protected throughout by a supervised, automatic sprinkler system as required by 19.3.6.2 and 19.3.6.2.7. This deficient practice could affect ALL occupants in the this smoke zone in the event of a fire.

Findings Include:

On 12/09/2020, at approximately 10:57 AM, the following observation was made and confirmed by safety officer, of multiple unsealed wall penetrations in 6th floor CVI shell space.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect ALL occupants in the event of fire.

Findings Include:

On 12/09/2020, at approximately 2:58 PM, the following observation was made and confirmed by safety officer that a power strip is plugged into another power strip, 8-Webber North, office 8358.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect ALL occupants in this smoke zone in the event of a fire.

Findings Include:

On 12/09/2020, at approximately 3:05 PM, the following observation was made and confirmed by safety officer that an unapproved electrical adapter/ multiplier is being used in corridor at room 9509.

Based upon observation and interview, the facility failed to ensure that storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect ALL occupants in smoke compartment the event of fire.

Findings Include:

On 12/09/2020, at approximately 9:53 AM, the following observation was made and confirmed by safety officer that combustibles are being stored within five feet of oxygen cylinders, in clean utility room 6521.