HospitalInspections.org

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) The two hour wall separating old from newer construction on first floor with 3 hour rated doors has penetrations above the ceiling through 2 hour wall the wall and the doors do not self close and positive latch.

2) The two hour wall separating old from newer construction at ramp doorway has penetrations above the ceiling through the 2 hour wall and doors to not latch upon closing.

3) Fire rated doors going to OT gym could not be verified due to fire rating tags on door being painted and no legible.

The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Dutch door in pharmacy that is open to corridor does not have a self closing and positive latching devices for both top and bottom of Dutch door.

2) Kitchen door open to corridor does not close.

The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16 the following areas have penetrations in ceiling to floor assembly that will not resist the passage of smoke for non-hazardous areas

1) Bathroom near medical staff office has pipe going to 2nd floor that has data cables and other cables penetrating with holes that do not resist the passage of smoke

2) Old basement hallway has register in ceiling that will not resist the passage of smoke

The maintainence worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Exit sign at OT gym is no operating in lighted mode
2) Exit sign at main entrance is not operating in lighted mode

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Smoke barrier doors at ER going to X-ray have more than 1/8 inch gap where doors meet in center.

The maintainence worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Data Closet on second floor has open chaseway that will not resist the passage of smoke

2) Storage room second floor across from data closet with combustible storage does not have a self closing and positive latching device.

3) Bio hazard room door in ER does not latch upon closing

4) ASU electric room has penetrations in wall and ceiling and will not resist the passage of smoke

5) House keeping door on med surg does not self close and positive latch

6) Mechanical room on med surge has penetrations in ceiling and will not resist the passage of smoke

7) Soiled utility room on med surg has open chaseway in ceiling and will not resist the passage of smoke

8) Storage room door near patient room door 20 does not self close and positive latch

9) The maintenance shop door does not latch

10) Basement corridor has storage area of tents, tables and boards with no door to protect corridor

11) Universal Waste room door has hold open device on door open to corridor.

12) Mail handling room door has hold open device on door open to corridor

13) PBS room has penetrations above ceiling and plastic pipe above ceiling that will not resist the passage of smoke.

14) PBS room has pipes penetrating the wall with unlisted spray foam to resist the passage of smoke.

15) Electrical room has penetrations in ceiling that will not resist the passage of smoke

16) The mechanical room across from cafeteria has penetrations and will not resist the passage of smoke.

17) Laundry room door leading to exit of old section does not latch

18) Mechanical room near x-ray has penetrations that will not resist the passage of smoke

19) The MRI storage room has fireproofing material missing from steel beams and no fireproofing material around sprinkler clamps on steel beam.

20) Med gas/mechanical room has fire proofing missing from ceiling



The maintenance worker was present during the observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Stair tower door at PT/OT does not positive latch
2) Stair tower door going down to PT/OT does not positive latch
3) North stairwell has combustible cardboard storage
4) North stairwell has not maintained its two hour rating. There is new orange fiber optic cable in stairwell, holes in walls, and spray foam being used for firestopping which is not properly rated material.
5) Stair tower exit door near oncology has sign on door that says use another exit when the exit is required for egress

The maintenance worker was present during these observations

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Exit door 2nd floor near administrative assistant would not open do to lack of use of the door. The door was pushed on several times and finally open with great force.

2) Exit stairs that terminate on ground near quality manager office has tree growth at bottom of stairs that obstructs exiting

3) North stairwell has sign to exit into maintenance shop. Sign shall be removed as cannot exit into a higher hazard.

4) Extension cord plugged into multi outlet device at Ecolab equipment in laundry room.

5) Non hospital rated relocated power tap being used in OR 2 room.

6) Portable X-ray machine being stored in employee entrance hallway waiting to be picked up for repair. Machine was there at beginning of survey and still being stored at end of survey

7) ASU exterior door has sign on door construction area do not use. When the door is opened there is no walkway and a person will fall into a dug pit.

8) Exit sliding doors at emergency room exit would not breakaway properly if the power was lost due to binding up.

9) Exit sliding doors at main entrance would not breakaway properly if power is lost due to obstruction of garbage can and canopy column.






The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

There is no written plan for the protection of all patients and for their evacuation in the event of an emergency at the ER desk. The only plan is on computer and there shall be a written book for backup.

The maintainence director was present during this observation

Based on observation, records and interview of surveyors 16732 and 35163 on 06/20/16

The midnight fire drill is being done as a talk drill. There is no simulating of the drill being conducted.

Based on observation of surveyors 16732 and 35163 on 06/20/16

There is a standpipe system and no documentation as to the operation or testing of them

The maintenance worker was present during this observation.

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) The following areas do not have proper sprinkler coverage.
a) Storage room on second floor across from data closet
b) Ambulance bay area is aprox 30 feet wide and 20 feet long with 2 sidewall sprinkler heads that do not provide coverage for the total area
c) Data room at Emergency Department has no sprinkler coverage
d) Four and one half foot combustible entry way for employees has no sprinkler coverage
e) Operating rooms have no sprinkler coverage (identified back in 2005)
f) Operating room corridors and exit ways from operating rooms have no sprinkler coverage
g) Stair tower to courtyard and basement does not have sprinkler coverage
h) There is no sprinkler protection for walk in coolers in kitchen
I) Four foot alcove storing paper shredder has no sprinkle coverage

2) Sprinkler piping in mechanical room on Med surg has wires attached to sprinkler piping.
3) Third floor skills lab area has sprinkler heads that have been painted.
4) Sprinkler head obstruction storage room 2nd floor with storage within 18 inches of sprinkler head.
5) Sprinkler head obstruction accounts payable closed with storage within 18 inches of sprinkler head.
6) Storage room near housekeeping 2nd floor has storage within 18 inches of sprinkler head

Based on observation of surveyors 16732 and 35163 on 06/20/16



1) Oxygen shut off valve labeled OR recovery 1,2,3,4,6,7,9,10,11,13 with no documentation of testing. Maintenance worker believes no longer in use.
2) Medical gas 2nd floor panel not properly labeled. Maintenance worker believes no linger in use and no documentation of testing
3) Med gas panel labeled trauma and treatment room in ER not properly labeled
4) Oxygen emergency shut off valve in health information not labeled
5) Flammable acetylene gas tank being stored with medical oxygen gas



The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

Dryer mop heads are being dried in the dryer. There is a warning label on dryer that mop heads are not to be dried in the dryer.


The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Generator Room 1 has emergency light that is not working.
2) Generator Room 2 does not have an emergency light.


The maintenance worker was present during this presentation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Bare electrical wires above 3 hour doors in ceiling at 2 hour wall
2) Open electrical box in data closet second floor.
3) Water cooler plugged into extension cord in PT/OT area
4) Open electrical box in laundry not properly attached

The maintainence worker was present during these observations

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) The two hour wall separating old from newer construction on first floor with 3 hour rated doors has penetrations above the ceiling through 2 hour wall the wall and the doors do not self close and positive latch.

2) The two hour wall separating old from newer construction at ramp doorway has penetrations above the ceiling through the 2 hour wall and doors to not latch upon closing.

3) Fire rated doors going to OT gym could not be verified due to fire rating tags on door being painted and no legible.

The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Dutch door in pharmacy that is open to corridor does not have a self closing and positive latching devices for both top and bottom of Dutch door.

2) Kitchen door open to corridor does not close.

The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16 the following areas have penetrations in ceiling to floor assembly that will not resist the passage of smoke for non-hazardous areas

1) Bathroom near medical staff office has pipe going to 2nd floor that has data cables and other cables penetrating with holes that do not resist the passage of smoke

2) Old basement hallway has register in ceiling that will not resist the passage of smoke

The maintainence worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Exit sign at OT gym is no operating in lighted mode
2) Exit sign at main entrance is not operating in lighted mode

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Smoke barrier doors at ER going to X-ray have more than 1/8 inch gap where doors meet in center.

The maintainence worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Data Closet on second floor has open chaseway that will not resist the passage of smoke

2) Storage room second floor across from data closet with combustible storage does not have a self closing and positive latching device.

3) Bio hazard room door in ER does not latch upon closing

4) ASU electric room has penetrations in wall and ceiling and will not resist the passage of smoke

5) House keeping door on med surg does not self close and positive latch

6) Mechanical room on med surge has penetrations in ceiling and will not resist the passage of smoke

7) Soiled utility room on med surg has open chaseway in ceiling and will not resist the passage of smoke

8) Storage room door near patient room door 20 does not self close and positive latch

9) The maintenance shop door does not latch

10) Basement corridor has storage area of tents, tables and boards with no door to protect corridor

11) Universal Waste room door has hold open device on door open to corridor.

12) Mail handling room door has hold open device on door open to corridor

13) PBS room has penetrations above ceiling and plastic pipe above ceiling that will not resist the passage of smoke.

14) PBS room has pipes penetrating the wall with unlisted spray foam to resist the passage of smoke.

15) Electrical room has penetrations in ceiling that will not resist the passage of smoke

16) The mechanical room across from cafeteria has penetrations and will not resist the passage of smoke.

17) Laundry room door leading to exit of old section does not latch

18) Mechanical room near x-ray has penetrations that will not resist the passage of smoke

19) The MRI storage room has fireproofing material missing from steel beams and no fireproofing material around sprinkler clamps on steel beam.

20) Med gas/mechanical room has fire proofing missing from ceiling



The maintenance worker was present during the observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Stair tower door at PT/OT does not positive latch
2) Stair tower door going down to PT/OT does not positive latch
3) North stairwell has combustible cardboard storage
4) North stairwell has not maintained its two hour rating. There is new orange fiber optic cable in stairwell, holes in walls, and spray foam being used for firestopping which is not properly rated material.
5) Stair tower exit door near oncology has sign on door that says use another exit when the exit is required for egress

The maintenance worker was present during these observations

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Exit door 2nd floor near administrative assistant would not open do to lack of use of the door. The door was pushed on several times and finally open with great force.

2) Exit stairs that terminate on ground near quality manager office has tree growth at bottom of stairs that obstructs exiting

3) North stairwell has sign to exit into maintenance shop. Sign shall be removed as cannot exit into a higher hazard.

4) Extension cord plugged into multi outlet device at Ecolab equipment in laundry room.

5) Non hospital rated relocated power tap being used in OR 2 room.

6) Portable X-ray machine being stored in employee entrance hallway waiting to be picked up for repair. Machine was there at beginning of survey and still being stored at end of survey

7) ASU exterior door has sign on door construction area do not use. When the door is opened there is no walkway and a person will fall into a dug pit.

8) Exit sliding doors at emergency room exit would not breakaway properly if the power was lost due to binding up.

9) Exit sliding doors at main entrance would not breakaway properly if power is lost due to obstruction of garbage can and canopy column.






The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

There is no written plan for the protection of all patients and for their evacuation in the event of an emergency at the ER desk. The only plan is on computer and there shall be a written book for backup.

The maintainence director was present during this observation

Based on observation, records and interview of surveyors 16732 and 35163 on 06/20/16

The midnight fire drill is being done as a talk drill. There is no simulating of the drill being conducted.

Based on observation of surveyors 16732 and 35163 on 06/20/16

There is a standpipe system and no documentation as to the operation or testing of them

The maintenance worker was present during this observation.

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) The following areas do not have proper sprinkler coverage.
a) Storage room on second floor across from data closet
b) Ambulance bay area is aprox 30 feet wide and 20 feet long with 2 sidewall sprinkler heads that do not provide coverage for the total area
c) Data room at Emergency Department has no sprinkler coverage
d) Four and one half foot combustible entry way for employees has no sprinkler coverage
e) Operating rooms have no sprinkler coverage (identified back in 2005)
f) Operating room corridors and exit ways from operating rooms have no sprinkler coverage
g) Stair tower to courtyard and basement does not have sprinkler coverage
h) There is no sprinkler protection for walk in coolers in kitchen
I) Four foot alcove storing paper shredder has no sprinkle coverage

2) Sprinkler piping in mechanical room on Med surg has wires attached to sprinkler piping.
3) Third floor skills lab area has sprinkler heads that have been painted.
4) Sprinkler head obstruction storage room 2nd floor with storage within 18 inches of sprinkler head.
5) Sprinkler head obstruction accounts payable closed with storage within 18 inches of sprinkler head.
6) Storage room near housekeeping 2nd floor has storage within 18 inches of sprinkler head

Based on observation of surveyors 16732 and 35163 on 06/20/16



1) Oxygen shut off valve labeled OR recovery 1,2,3,4,6,7,9,10,11,13 with no documentation of testing. Maintenance worker believes no longer in use.
2) Medical gas 2nd floor panel not properly labeled. Maintenance worker believes no linger in use and no documentation of testing
3) Med gas panel labeled trauma and treatment room in ER not properly labeled
4) Oxygen emergency shut off valve in health information not labeled
5) Flammable acetylene gas tank being stored with medical oxygen gas



The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

Dryer mop heads are being dried in the dryer. There is a warning label on dryer that mop heads are not to be dried in the dryer.


The maintenance worker was present during this observation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Generator Room 1 has emergency light that is not working.
2) Generator Room 2 does not have an emergency light.


The maintenance worker was present during this presentation

Based on observation of surveyors 16732 and 35163 on 06/20/16

1) Bare electrical wires above 3 hour doors in ceiling at 2 hour wall
2) Open electrical box in data closet second floor.
3) Water cooler plugged into extension cord in PT/OT area
4) Open electrical box in laundry not properly attached

The maintainence worker was present during these observations