HospitalInspections.org

Based on observation, it was determined that the facility failed to ensure that corridor walls resist the passage of smoke.

Findings include:

On 5/11/15 at 12:20 PM, in the presence of Staff #8, the corridor wall behind Treatment Station's #1 and #2 within the Dialysis Suite, was not secured to the floor.

A. Based on observation, it was determined that the facility failed to ensure that hazardous areas are separated from other spaces by doors that are self-closing.

Findings include:

1. On 5/11/15 at 2:45 PM, in the presence of Staff #8, the following doors separating the Laboratory from the corridor were not self-closing:

a. The door near Phlebotomy

b. The main entrance to the Laboratory

Based on observation, it was determined that the facility failed to ensure that hazardous areas are protected.

Findings include:

1. On 5/12/15 at 11:00 AM in the presence of Staff #8, the use of eight (8) patient rooms on the Second Floor North Wing were changed into storage rooms greater then fifty (50) square feet and did not have the required one-hour fire resistance rating based on the following:

a. The doors were not marked as fire rated doors by an approved testing laboratory.

b. Facility Plans did not provide evidence that the floor, ceiling, or wall assemblies of these rooms are designed to meet the one-hour fire resistance rating.

c. The doors to these rooms were not self-closing or automatic-closing.

2. On 5/12/15 at 11:45 AM, in the presence of Staff #8, the Soiled Utility Room door in Radiology did not close fully and latch.

3. On 5/12/15 at 2:30 PM, in the presence of Staff #8, the door to the Fire Pump Room was held open by a wooden wedge.

4. On 5/12/15 at 2:35 PM, in the presence of Staff #8, fire door #AB01 in the basement, was held open by storage.

5. On 5/12/15 at 2:40 PM, in the presence of Staff #8, the door to the Elevator Machine Room was held open by a wooden wedge.

6. On 5/12/15 at 2:45 PM, in the presence of Staff #8, two (2) fire doors were held open with wire outside of the Elevator Machine Room.

Base on a tour of the facility and interview with staff, it was determined that the facility failed to ensure that exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1.19.2.1.

Findings include:

On 5/12/15 at 11:50 AM in the MRI Suite, two (2) wheel chairs were stored side by side in the exit access corridor blocking one hundred percent (100%) of the exit.

a. A curtain was also drawn across one hundred percent (100%) of the exit access corridor.

b. Staff #8 confirmed these findings.

Based on observation, it was determined that the facility failed to ensure that the exit access is arranged to be readily available at all times.

Findings include:

On 5/14/15 at 11:10 AM, in the presence of Staff #8, an accordion style gate with a padlock was secured to the wall within the means of egress from the East Pavilion 6th Floor Physical Therapy Treatment area.

Based on observation and document review, it was determined that the facility failed to ensure that patient sleeping rooms greater then one thousand (1,000) square feet have at least two (2) exit access doors remote from each other.

Findings include:

Reference: East Orange General Hospital Architectural Plan NK Project Number 1782.013 dated 10/17/13.

1. On 5/11/15 at 11:05 AM, in the presence of Staff #8, the Intensive Care Unit on the 5th floor contained a room at the end of the unit with eight (8) inpatient sleep bays and a Nurse's Station.

a. A review of the facility document referenced above indicates that the unit is one thousand five hundred and ninety five (1,595) square feet in area.

(i) The Intensive Care Unit has a single exit.

b. Staff #8 confirmed this finding.

Based on observation, it was determined that the facility failed to ensure that the fire alarm system is maintained in accordance with the National Fire Protections Association's National Fire Alarm Code.

Findings include:

On 5/14/15 at 1:00 PM, in the presence of Staff #8, a manual pull station for the fire alarm system, located in the Corridor outside the Cafe, was blocked by a wooden cabinet.

Based on observation, it was determined that the facility failed to ensure that required smoke detectors are maintained.

Findings include:

On 5/14/15 at 11:20 AM, in the presence of Staff #8, in the East Pavilion, two (2) smoke detectors located over the Physical Therapy Gym Floor, were missing their outer covers.

Based on document review, it was determined that the facility failed to ensure that fire sprinkler systems are maintained in reliable operating condition.

Findings include:

Reference: Fire Sprinkler and Standpipe Test Report dated 4/23/15

1. On 5/14/15, a review of the facility Fire Sprinkler and Standpipe Inspection Reports, dated 4/23/15, provided evidence that the following hose station devices failed testing on 8/29/13 and 10/30/14, and were still not repaired:

a. Basement Device #13, located in Stair #3.

b. Ground Floor Device #19, located in Stair #3.

Based on observation, it was determined that the facility failed to ensure that medical gas cylinders are stored in accordance with NFPA 99, Standard for Health Care Facilities.

Findings include:

On 5/11/15 at 10:45 AM, in the presence of Staff #8, an "E" size compressed gas cylinder containing oxygen was located in an alcove next to the crash cart outside of Room #569.

Based on document review and staff interview, it was determined that the facility failed to ensure that anesthetizing locations are protected in accordance with National Fire Protection Association's 99, Standard for Health Care Facilities, 1999 edition.

Findings include:

Reference: Cardinal Medical Gas Services Inc. 2014 Medical Gas Service Report dated 12/28/14.

1. On 5/14/15, a review of the facility's medical gas service report, provided evidence that shutoff valves serving the Surgical Suite Post Anesthesia Care Unit (PACU), are located within the PACU.

2. On 5/14/15, a review of the facilities medical gas service report provided evidence that shutoff valves serving the Holding Area are located within the Holding Area and not outside the unit.

A. Based on observation, it was determined that the facility failed to ensure that doors within the required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Findings include:

Reference: 2000 edition of National Fire Protection Association's Life Safely Code, 101:19.2.2.2.4, Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

1. On 5/14/15 at 11:20 AM, in the presence of Staff #8, in the stairwell of the East Pavilion, the exit door from the stair tower exposure to the outside, was electronically locked with magnets and required the activation of the buildings fire alarm system or a special key to release the door.

2. On 5/14/15 at 11:50 AM, in the presence of Staff #8, the Lobby exit door facing the street was electronically locked with magnets and required the activation of the buildings fire alarm system or a special key to release the door.

Based on observation, staff interview and document review, it was determined that the facility failed to ensure that doors in the means of egress that are permitted to be locked under other provisions of this chapter, shall have adequate provisions made to rapid removal of occupants.

Findings include:

Reference: 2000 edition of National Fire Protection Association's Life Safely Code, 101:19.2.2.2.5, Doors located in the means of means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made to rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all time, or other such reliable means available to the staff at all time. Only one such locking device shall be permitted on each door.

1. On 5/12/15 in the presence of Staff #8, in the Crisis Management Unit, the emergency exit door complete with a lighted exit sign leading directly to the outside, was electronically locked by a magnet hold device with no other means of releasing the door.

a. During interview, Staff #8 confirmed that the door would release upon loss of power or by operating the manual pull stations for the building's fire alarm system.

b. Staff #8 confirmed that no other means are available to unlock this door.

Based on observation and staff interview, it was determined that fume hoods are not operated in accordance with the National Fire Protection Association's Standard for Health Care Facilities 1999 edition.

Findings include:

On 5/11/15 at 2:20 PM, in the presence of Staff #8, the DRS-601 Sakura Diversified Lide Strainer machine in the Laboratory, located under the XPert Balance Fume Hood, prevented the protective door from closing.

Based on observation, it was determined that the facility failed to ensure that an emergency shower is available for immediate emergency use.

Findings include:

1. On 5/11/15 at 2:30 PM, in the presence of Staff #8, the emergency shower in the Histology Laboratory was blocked by a cart, a chair, and work counters.

a. The door handle to the room is capable of being locked and would require a key to access.

Based on observation, it was determined that the facility failed to ensure that flammable liquid cabinets are maintained in accordance with the National Fire Protection Association 30, Flammable and Combustible Liquid Code.

Findings include:

On 5/11/15 at 2:35 PM in the presence of Staff #8, the Flammable Liquid Cabinet in the Histology Laboratory did not self-close and latch.

Based on observation, it was determined that the facility failed to ensure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.

Findings include:

On 5/14/15 at 10:35 AM, in the presence of Staff #8, electrical extension cords were used to power computers in CAPS Room 106 in the East Pavilion.

Based on observation, it was determined that the facility failed to ensure that corridor walls resist the passage of smoke.

Findings include:

On 5/11/15 at 12:20 PM, in the presence of Staff #8, the corridor wall behind Treatment Station's #1 and #2 within the Dialysis Suite, was not secured to the floor.

A. Based on observation, it was determined that the facility failed to ensure that hazardous areas are separated from other spaces by doors that are self-closing.

Findings include:

1. On 5/11/15 at 2:45 PM, in the presence of Staff #8, the following doors separating the Laboratory from the corridor were not self-closing:

a. The door near Phlebotomy

b. The main entrance to the Laboratory

Based on observation, it was determined that the facility failed to ensure that hazardous areas are protected.

Findings include:

1. On 5/12/15 at 11:00 AM in the presence of Staff #8, the use of eight (8) patient rooms on the Second Floor North Wing were changed into storage rooms greater then fifty (50) square feet and did not have the required one-hour fire resistance rating based on the following:

a. The doors were not marked as fire rated doors by an approved testing laboratory.

b. Facility Plans did not provide evidence that the floor, ceiling, or wall assemblies of these rooms are designed to meet the one-hour fire resistance rating.

c. The doors to these rooms were not self-closing or automatic-closing.

2. On 5/12/15 at 11:45 AM, in the presence of Staff #8, the Soiled Utility Room door in Radiology did not close fully and latch.

3. On 5/12/15 at 2:30 PM, in the presence of Staff #8, the door to the Fire Pump Room was held open by a wooden wedge.

4. On 5/12/15 at 2:35 PM, in the presence of Staff #8, fire door #AB01 in the basement, was held open by storage.

5. On 5/12/15 at 2:40 PM, in the presence of Staff #8, the door to the Elevator Machine Room was held open by a wooden wedge.

6. On 5/12/15 at 2:45 PM, in the presence of Staff #8, two (2) fire doors were held open with wire outside of the Elevator Machine Room.

Base on a tour of the facility and interview with staff, it was determined that the facility failed to ensure that exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1.19.2.1.

Findings include:

On 5/12/15 at 11:50 AM in the MRI Suite, two (2) wheel chairs were stored side by side in the exit access corridor blocking one hundred percent (100%) of the exit.

a. A curtain was also drawn across one hundred percent (100%) of the exit access corridor.

b. Staff #8 confirmed these findings.

Based on observation, it was determined that the facility failed to ensure that the exit access is arranged to be readily available at all times.

Findings include:

On 5/14/15 at 11:10 AM, in the presence of Staff #8, an accordion style gate with a padlock was secured to the wall within the means of egress from the East Pavilion 6th Floor Physical Therapy Treatment area.

Based on observation and document review, it was determined that the facility failed to ensure that patient sleeping rooms greater then one thousand (1,000) square feet have at least two (2) exit access doors remote from each other.

Findings include:

Reference: East Orange General Hospital Architectural Plan NK Project Number 1782.013 dated 10/17/13.

1. On 5/11/15 at 11:05 AM, in the presence of Staff #8, the Intensive Care Unit on the 5th floor contained a room at the end of the unit with eight (8) inpatient sleep bays and a Nurse's Station.

a. A review of the facility document referenced above indicates that the unit is one thousand five hundred and ninety five (1,595) square feet in area.

(i) The Intensive Care Unit has a single exit.

b. Staff #8 confirmed this finding.

Based on observation, it was determined that the facility failed to ensure that the fire alarm system is maintained in accordance with the National Fire Protections Association's National Fire Alarm Code.

Findings include:

On 5/14/15 at 1:00 PM, in the presence of Staff #8, a manual pull station for the fire alarm system, located in the Corridor outside the Cafe, was blocked by a wooden cabinet.

Based on observation, it was determined that the facility failed to ensure that required smoke detectors are maintained.

Findings include:

On 5/14/15 at 11:20 AM, in the presence of Staff #8, in the East Pavilion, two (2) smoke detectors located over the Physical Therapy Gym Floor, were missing their outer covers.

Based on document review, it was determined that the facility failed to ensure that fire sprinkler systems are maintained in reliable operating condition.

Findings include:

Reference: Fire Sprinkler and Standpipe Test Report dated 4/23/15

1. On 5/14/15, a review of the facility Fire Sprinkler and Standpipe Inspection Reports, dated 4/23/15, provided evidence that the following hose station devices failed testing on 8/29/13 and 10/30/14, and were still not repaired:

a. Basement Device #13, located in Stair #3.

b. Ground Floor Device #19, located in Stair #3.

Based on observation, it was determined that the facility failed to ensure that medical gas cylinders are stored in accordance with NFPA 99, Standard for Health Care Facilities.

Findings include:

On 5/11/15 at 10:45 AM, in the presence of Staff #8, an "E" size compressed gas cylinder containing oxygen was located in an alcove next to the crash cart outside of Room #569.

Based on document review and staff interview, it was determined that the facility failed to ensure that anesthetizing locations are protected in accordance with National Fire Protection Association's 99, Standard for Health Care Facilities, 1999 edition.

Findings include:

Reference: Cardinal Medical Gas Services Inc. 2014 Medical Gas Service Report dated 12/28/14.

1. On 5/14/15, a review of the facility's medical gas service report, provided evidence that shutoff valves serving the Surgical Suite Post Anesthesia Care Unit (PACU), are located within the PACU.

2. On 5/14/15, a review of the facilities medical gas service report provided evidence that shutoff valves serving the Holding Area are located within the Holding Area and not outside the unit.

A. Based on observation, it was determined that the facility failed to ensure that doors within the required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Findings include:

Reference: 2000 edition of National Fire Protection Association's Life Safely Code, 101:19.2.2.2.4, Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

1. On 5/14/15 at 11:20 AM, in the presence of Staff #8, in the stairwell of the East Pavilion, the exit door from the stair tower exposure to the outside, was electronically locked with magnets and required the activation of the buildings fire alarm system or a special key to release the door.

2. On 5/14/15 at 11:50 AM, in the presence of Staff #8, the Lobby exit door facing the street was electronically locked with magnets and required the activation of the buildings fire alarm system or a special key to release the door.

Based on observation, staff interview and document review, it was determined that the facility failed to ensure that doors in the means of egress that are permitted to be locked under other provisions of this chapter, shall have adequate provisions made to rapid removal of occupants.

Findings include:

Reference: 2000 edition of National Fire Protection Association's Life Safely Code, 101:19.2.2.2.5, Doors located in the means of means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made to rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all time, or other such reliable means available to the staff at all time. Only one such locking device shall be permitted on each door.

1. On 5/12/15 in the presence of Staff #8, in the Crisis Management Unit, the emergency exit door complete with a lighted exit sign leading directly to the outside, was electronically locked by a magnet hold device with no other means of releasing the door.

a. During interview, Staff #8 confirmed that the door would release upon loss of power or by operating the manual pull stations for the building's fire alarm system.

b. Staff #8 confirmed that no other means are available to unlock this door.

Based on observation, it was determined that the facility failed to ensure that an emergency shower is available for immediate emergency use.

Findings include:

1. On 5/11/15 at 2:30 PM, in the presence of Staff #8, the emergency shower in the Histology Laboratory was blocked by a cart, a chair, and work counters.

a. The door handle to the room is capable of being locked and would require a key to access.

Based on observation, it was determined that the facility failed to ensure that flammable liquid cabinets are maintained in accordance with the National Fire Protection Association 30, Flammable and Combustible Liquid Code.

Findings include:

On 5/11/15 at 2:35 PM in the presence of Staff #8, the Flammable Liquid Cabinet in the Histology Laboratory did not self-close and latch.

Based on observation, it was determined that the facility failed to ensure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.

Findings include:

On 5/14/15 at 10:35 AM, in the presence of Staff #8, electrical extension cords were used to power computers in CAPS Room 106 in the East Pavilion.