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Tag No.: K0022
Based on facility tour and staff verification it was determined this facility failed to ensure all paths of egress in which the exit access was not obvious, was equipped with exit and directional signs displayed in accordance with the National Fire Protection Association 101, Chapter 19 and Chapter 7. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 319.
Findings include:
On 12/03/12 through 12/06/12, main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the fifth floor same day medical/EEG area of the facility and being near the elevators, this writer observed the following: While facing west observation was made of no exit signage directing flow of egress to the angled corridor leading toward the north stair exit access. The north stair exit access was one of two exit accesses located within this smoke compartment.
During tour of the second floor north wing and at the access to the physician ' s office building, observation was made of an area that had been newly renovated which had two sets of stairs, one which provided access to the upper floors and another which provided exit access to the exit discharge on the lower floor. Also noted were two exit signs, one directing occupant flow to the stairwell leading up and the other directing occupant flow to the stairs leading to the lower level. Staff A1 stated the sign directing occupant flow up should have been removed.
Within the medical records office near room GS0018 observation was made of conflicting exit signs. One exit sign was directing occupant flow to the right while about 20 feet further another exit sign was directing flow to the left. Staff did note that a door was found within room G30017 located between the two exit signs which opened to the corridor but was unsure if this was a designated exit.
During tour of the ground floor kitchen area, observation was made of no exit signs throughout the kitchen directing occupant flow to exit accesses or placed above the exit doors, primarily those which were not obvious exit accesses.
This finding was verified by all staff members present during tour of this area.
Tag No.: K0025
Based on review of architectural building schematics, observation during facility tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed with the required fire resistance rating determined and documented on the building schematics by the facility's architect. This affected a one hour fire rated wall on the fifth floor. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 319.
Findings include:
A building facility tour took place with staff members B2, H8, and I9 on 12/03/12 at 3:20 PM. During tour of the smoke/fire barriers penetrations one area on the fifth floor was observed without the one hour fire rated barrier intact. This portion of the barrier was located on the fifth floor in the Womens bathroom door 5L0012, which opened into the corridor. The corridor door lacked latching hardware and was observed with a louvered vent without a damper. The smoke barrier above the ceiling tile was incomplete and did not extend to the floor above. These
These findings were verified by Staff I9 during tour of this area.
Tag No.: K0025
Based on review of architectural building schematics, observation during facility tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed with the required fire resistance rating determined and documented on the building schematics by the facility's architect. This affected one half, one and two hour fire rated walls. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the smoke/fire barriers penetrations were observed above the ceiling tiles at the following areas:
Fifth floor:
*At the west end of the smoke barrier by room 5W00SA and above the double doors, looking from the 1964 existing side, observation was made of an approximate two foot by two foot section of drywall missing in the top right corner of that portion of the smoke barrier.
* At the west end of the smoke barrier by room 5W0042 and above the double doors, looking from the 1964 existing side, observation was made of an approximate eight foot by two foot section of drywall missing from the mid portion of that section of the drywall.
* At the north end of the smoke barrier by room 5N0005 and above the double doors, looking from the 1964 existing side, observation was made of an approximate four foot by six foot section of drywall missing from about mid way up to the roof decking.
Third floor:
*Positioned facing the 3 west smoke barrier at the double doors located by room 3W0056, observation was made of an approximate four inch by eight inch open area located at the bottom left of a round insulated duct.
Ground floor:
*At the south end of the main building at the two hour smoke/fire barrier separating the main building from the college building, observation was made of penetrations around conduits and insulated lines.
*Between elevators P8 and P9, observation was made of a two and a half inch water line that was not sealed around the annular space.
*Above the double smoke doors GL0001, observation was made of one open end conduit and an approximate one inch square piece of drywall that had been cut out and replaced but not sealed.
*Within room GL0004 observation was made of an approximate two foot by eighteen inch opening in the block wall at the northeast corner.
*Within conference room GN0039 and at the west section of the smoke barrier, observation was made of one open end conduit.
*At the front of the cafeteria and adjacent to the elevators, being the south end of the kitchenette and conference room GN0336, observation was made of an approximate 22 foot by 5 foot section of drywall missing from the smoke barrier.
*Above door GN0151, observation was made of an approximate ten inch by three inch opening in the block wall.
These findings were verified by staff E5 during tour of these areas.
Tag No.: K0027
Based on observations, architectural building schematics, and staff interviews, the facility failed to ensure three sets of doors in smoke barriers were self closing, and failed to ensure two additional sets of smoke barrier doors had leaf door gaps between the doors that did not exceed 1/8 inch. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 319.
Findings include:
Tour was conducted on the first floor on 12/06/12 with Staff A1,C3, D4, and I9. During this tour, the following sets of smoke barrier doors failed to latch when released from the magnetic hold open device:
* The set of fire doors 1N0334 in the Operating room suite by room #16.
* Near the radiology hallway, doors 1S0371, and
* The doors 1S0195 near room 1S0174A in the first floor corridor.
In addition, two sets of glass doors located in the smoke barrier between the Pre Admission Testing (PAT) area on the first floor and the main lobby were observed with gaps between the doors leafs which exceeded greater that 1/8 inch. One set of doors was observed with a 2/8 inch gap between the leafs. The other set of doors was observed with a 3/8 inch gap between the leafs. These gaps were measured and verified by staff who accompanied the surveyor on tour.
Tag No.: K0029
A tour was conducted on 12/04/12 at 2:35 PM with staff members B2, H8, and I9. The soiled utility room 2E0039 door in the 2 East Wing was observed equipped with an automatic closing device. When opened and tested, the door failed to latch into the frame as the door was observed out of alignment, and bumped into the doorframe at the top of the door.
This was verified with the aforementioned staff during tour.
21957
Based on facility tour and staff verification it was determined this facility failed to ensure all hazardous areas, specifically soiled utility rooms, were constructed with at least a one hour fire resistance rating, and failed to ensure a soiled utility room had a self-closing door. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the second floor north wing which had recently been renovated and upgraded, observation was made within the soiled utility room 2N0039 and above the ceiling tiles, of a small section of a duct not sealed, unsealed grey wires and an unsealed curved conduit around the annular space. This finding was verified by staff E5 during tour of this area.
Tag No.: K0038
Based on observation during facility tour and staff verification it was determined this facility failed to ensure the special locking arrangements of doors within the labor and delivery unit did include more than one within the path of egress. These doors were also equipped with a sign stating push until alarm sounds 30 seconds. This exceeds the 15 second delay as required by the code. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Building facility tour took place with staff members B2, H8, the city fire marshall, and an electrical contractor employee E5 on 12/07/12. During tour of the fourth floor East wing, doors were observed equipped with a magnetic locking device which delayed egress. These doors were located as follows:
*Stairwell door 4E00SA. The door was equipped with a sign stating push until alarm sounds 30 seconds.
*Inner hallway door between nurses stations and stairwell door 4E00SA, which lacked a sign indicating push until alarm sounds.
On 12/07/12 at 8:55 AM, these three doors were tested with the fire alarm system activation. Prior to activation of the fire alarm, observations of the doors revealed they release with a keypad code, with 30 second pushing pressure, and upon activation of the fire alarm system.
These doors released immediately upon fire alarm pull station activation; however, the stairwell door 4E00SA was observed relocking for 30 seconds with an infant security device in hand. Interview with Staff B2 verified the reason this stairwell door relocks with the security device is to prevent a person pulling a fire alarm, and leaving the unit with an infant via the stairwell. Staff B2 verified this floor of the facility is equipped with two delayed egress locks in two different locations. The city fire marshall verified the inner hallway door 4E00SA should have a sign indicating push until alarm sounds.
These findings were verified by all staff present during tour.
Tag No.: K0038
Based on observation during facility tour and staff verification it was determined this facility failed to ensure the special locking arrangements of doors within the labor and delivery unit did include more than one within the path of egress. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the fourth floor labor and delivery unit observation was made of the far west doors located by the elevators equipped with a delayed locking mechanism. Just beyond this door heading east into the labor and delivery unit another delayed exit access door was observed at stairwell 4NW00SA. This finding concluded that the adjacent department, medical education, had to access both of these doors as a means of a second exit access from their department. This finding was verified by all staff present during tour and again a review was made by additional staff members B2 and H8 the morning of 12/07/12 along with the fire marshal and security staff members.
Tag No.: K0045
Based on observations and staff interviews, the facility failed to ensure one exit discharge was illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness in accordance with the code at 7.8.1.4.
Findings include:
Based on observations, on 12/04/12 at 4:23 PM, with Staff B2, H8, and I9, the first floor ground level exit discharge on the south end of the building lacked an electrical fixture and lighting outside the exit discharge. This exit discharge door was observed with a label of 1E0123.
The lack of exit discharge lighting was verified during tour with Staff B2, H8, and I9.
Tag No.: K0045
Based on observations and staff interviews, the facility failed to ensure three exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness in accordance with the code at 7.8.1.4. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Tour was conducted on the first floor on 12/06/12 with Staff A1,C3, D4, and I9. During this tour, three designated exit discharges were observed with either one light or none at the exit discharge.
These exits are as follows:
* The exit discharge by Business Development, near the emergency department, lacked lighting outside the exit.
* The exit discharge near the morgue dock lacked exit discharge lighting, and
*The back of the building by the surgical Womens locker room door 1N0220B lacked lighting outside the discharge. Three steps were located outside the exit to the paved parking area.
The lack of exit discharge lighting was verified during tour with Staff A1,C3, D4, and I9.
Tag No.: K0064
Based on facility tour and staff verification it was determined this facility failed to ensure all 'K' fire extinguishers had the required placard with instructions regarding the use of the fire extinguisher located in an conspicuous location near the fire extinguisher. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the ground floor kitchen, observation was made of a 'K' fire extinguisher mounted near doors GN0005. The area in which this fire extinguisher was located lacked the required placard with necessary instructions for its use. This finding was verified by all staff present during tour of the kitchen.
Tag No.: K0069
Based on observation and staff interview it was determined this facility failed to ensure all suppression systems in the kitchen area were updated to UL-300 compliance at the six year maintenance or when hydrostatic testing was due. This had the potential to affect all those utilizing this area of the facility. The total patient census was 319 at the beginning of the survey.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the kitchen area observation was made of two CO2 hood suppression systems which were fed from the same manifold system. This writer asked when the last hydrostatic testing and/or the last six year maintenance were performed and the staff present did not know.
During interview with staff G7 on 12/07/12 at 10:20 AM the same question was asked. Staff G7 stated just this month they did the five year maintenance and prior to that was in 2007. Documentation review on 12/07/12 verified the maintenance performed in 2007. This writer questioned the five year maintenance as opposed to a six year maintenance and staff G7 stated they do it every five years. This writer then stated the hood suppression systems should have been updated at the time of the regular maintenance.
Tag No.: K0071
Based on observation and staff verification it was determined this facility failed to ensure the laundry chute access was free of obstructions and all doors to the chutes located in the discharge rooms would close properly when activated. This had the potential to affect all occupants within each smoke compartment of all floor levels in which the chute access was available. The total patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the fourth floor west wing, observation was made within the laundry chute located in room 4S0081 of bags of laundry stuck within the chute access. This writer and all staff present relocated to the second floor laundry chute room where it was confirmed there were bags of laundry stuck within the chute. Again, this writer and all staff present relocated to laundry discharge room GS0079 on the ground floor where observation was made of a large mobile laundry cart positioned in a manner in which the access door to the laundry chute, if activated, would have been obstructed by this cart, rendering it inoperable.
This finding was verified by all staff present during tour of the fourth and second floor laundry chute room and the ground floor laundry chute discharge room.
Tag No.: K0075
Based on observation during tour and staff interview, it was determined this facility failed to ensure all soiled linen or trash collection receptacles exceeding 32 gallons were located in a room protected as a hazardous area when not attended. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of east entrance area off of the parking garage and within room GN0039A located adjacent to the conference room, observation was made of two large mobile trash bins. Tour of this area took approximately one hour and prior to leaving this area this writer and staff revisited room GN0039A and noted the mobile trash bins were still in the same location. All staff present verified this finding.
Additionally, just prior to the exit conference, this writer observed two trash bins, one filled to the top with combustible materials located in the same area. This finding was shared with all staff present during the exit conference on 12/07/12 at approximately 3:00 PM.
Tag No.: K0076
Tour was conducted on the first floor on 12/06/12 with Staff A1,C3, D4, and I9. During this tour, a medical gas storage room 1N0222A was observed in the egress corridor near the surgical suite locker rooms. This room was observed with greater than 300 cubit feet of oxygen, carbon dioxide, and nitrogen cylinders. The electrical light switch inside this room was observed and measured at 46 inches above the floor. This was verified by the aforementioned staff who accompanied the surveyor on tour.
21957
Based on observation during tour and staff verification it was determined this facility failed to ensure all medical gas cylinders were secured in accordance with the National Fire Protection Association 99. The facility also failed to ensure one medical gas storage room had and electrical fixture located at least 5 feet above the floor. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
Main building facility tour took place with staff members A1, C3, D4 and E5 on 12/03/12 through 12/06/12. During tour of the third floor intensive and critical care units, specifically by room 3NW0041, observation was made of two unsecured E cylinders of oxygen located on the floor beside additional E cylinders of oxygen located in a storage rack. This finding was verified by all staff present during tour of the intensive and critical care units.
Tag No.: K0078
Based on review of relative humidity logs and staff interview, the facility failed to maintain relative humidity in anesthetizing locations equal to or greater than 35%. This affected all operating rooms, cardiac catheter procedure rooms, endoscopy rooms, and infant delivery rooms. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
On 12/07/12, a review of relative humidity logs for 11/01/11 through 03/01/12 for Operating room s 1, 2, 3,13, 14, 15, 16, and 21. These logs revealed the relative humidity levels were less than 35% on 12/01/11, 12/02/11, 12/23/11, 12/24/11, 01/17/12, 01/18/12, 02/02/12, 02/09/12, 02/10/12, and 02/19/12. The logs also revealed when the relative humidity levels dropped less than 30%, an alarm was initiated to alert staff to the lower levels.
On 12/07/12 at 12:00 P.M., an interview with Staff A1 (Manager of Facilities) revealed the facility policy for acceptable relative humidity levels was 30-60%. Staff A1 stated facility maintenance staff monitor the relative humidity levels via a computerized system. This employee stated when the levels dropped below 30% an alarm is initiated to alert facility staff to the lower levels, at which time a work order is initiated to adjust the relative humidity levels. Staff A1 verified the facility has piped-in oxygen and uses general anesthesia during surgery and procedures in which the patient is not conscious.
Tag No.: K0130
Based on documentation review and staff verification it was determined this facility failed to ensure the sprinkler system was tested quarterly as required by the National Fire Protection Association (NFPA), Chapter 25 2-1.
Based on interview with facility staff, it was determined this facility failed to ensure generator test reports were available for review in order to verify the weekly visual inspections and monthly load tests according to NFPA 99 and 110.
This had the potential to affect all those utilizing this facility. The patient census the day of the survey was 15.
Findings include:
Documentation review of the sprinkler system testing took place on 12/06/12 with staff members B2 and H8. During review observation was made of only the fourth quarter test reports. A request was made for the first three quarters of 2012 but according to staff B2 they would not be available until Monday of next week because they were locked in an office and the manager would not be back until next week.
During documentation review this writer requested the weekly visual test reports and monthly load test reports for the generator. Facility staff stated the generator reports were not available and would they have to check to see if they could be obtained. Interview with staff B2 on 12/07/12 at 11:45 AM reveals they have performed the weekly and monthly tests but no documentation was available in order to verify this.
Tag No.: K0130
Based on documentation review and staff verification it was determined this facility failed to ensure the sprinkler system was tested quarterly as required by the National Fire Protection Association (NFPA), Chapter 25 2-1.
Based on interview with facility staff, it was determined this facility failed to ensure generator test reports were available for review in order to verify the weekly visual inspections and monthly load tests according to NFPA 99 and 110.
This had the potential to affect all those utilizing this facility. The patient census the day of the survey was 19.
Findings include:
Documentation review of the sprinkler system testing took place on 12/06/12 with staff members B2 and H8. During review observation was made of only the fourth quarter test reports. A request was made for the first three quarters of 2012 but according to staff B2 they would not be available until Monday of next week because they were locked in an office and the manager would not be back until next week.
During documentation review this writer requested the weekly visual test reports and monthly load test reports for the generator. Facility staff stated the generator reports were not available and would they have to check to see if they could be obtained. Interview with staff B2 on 12/07/12 at 11:45 AM reveals they have performed the weekly and monthly tests but no documentation was available in order to verify this.
Tag No.: K0130
Based on documentation review and staff verification it was determined this facility failed to ensure the sprinkler system was tested quarterly as required by the National Fire Protection Association (NFPA), Chapter 25 2-1.
Based on interview with facility staff, it was determined this facility failed to ensure generator test reports were available for review in order to verify the weekly visual inspections and monthly load tests according to NFPA 99 and 110.
This had the potential to affect all those utilizing this facility. The patient census the day of the survey was 22.
Findings include:
Documentation review of the sprinkler system testing took place on 12/06/12 with staff members B2 and H8. During review observation was made of only the fourth quarter test reports. A request was made for the first three quarters of 2012 but according to staff B2 they would not be available until Monday of next week because they were locked in an office and the manager would not be back until next week.
During documentation review this writer requested the weekly visual test reports and monthly load test reports for the generator. Facility staff stated the generator reports were not available and would they have to check to see if they could be obtained. Interview with staff B2 on 12/07/12 at 11:45 AM reveals they have performed the weekly and monthly tests but no documentation was available in order to verify this.
Tag No.: K0130
Based on documentation review and staff verification it was determined this facility failed to ensure the sprinkler system was tested quarterly as required by the National Fire Protection Association (NFPA), Chapter 25 2-1. This had the potential to affect all those utilizing this facility. The patient census the day of the survey was 87.
Findings include:
Documentation review of the sprinkler system testing took place on 12/06/12 with staff members B2 and H8. During review observation was made of only the fourth quarter test reports. A request was made for the first three quarters of 2012 but according to staff B2 they would not be available until Monday of next week because they were locked in an office and the manager would not be back until next week.
Tag No.: K0130
Based on facility tour and staff verification it was determined this facility failed to ensure all doors in the fire rated occupancy separation closed and latched properly. This had the potential to affect all those utilizing this area of the facility. The patient census at the time of the survey was zero.
Findings include:
During facility tour two fire rated doors located in the fire barrier separating the hyperbaric room from the offices and waiting area were tested and failed to close and latch properly. The doors were identified as 1GGC3 and 1GG18. This finding was verified by all staff members present.
Tag No.: K0147
Based on observation during facility tour and staff verification it was determined this facility failed to ensure the electrical wiring and equipment is in accordance with the National Fire Protection Association (NFPA) 70. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
On 12/03/12 through 12/06/12, main building facility tour took place with staff members A1, C3, D4 and E5. During tour of the second floor west wing, specifically at the nurse's station, observation was made of two electrical cover panels located under the work desk, which were not attached to the panel box leaving multiple wires exposed. Staff A1 stated this was dangerous and someone should have placed a work order for this to be repaired.