HospitalInspections.org

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish for corridors. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following area:
a. Door (81212)

This finding was confirmed by Maintenance Supervisor A at 12:50 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish of rooms and spaces. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Networking Office
This finding was confirmed by Maintenance Supervisor A at 12:25 PM on 3/13/12.

(2000, NFPA 101:18/19.3.3)

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Environmental Services
This finding was confirmed by Maintenance Supervisor A at 2:11 PM on 3/13/12.

b. Ultra Sound 3 (including restroom)
This finding was confirmed by Maintenance Supervisor A at 2:19 PM on 3/13/12.

c. CT Room
This finding was confirmed by Maintenance Supervisor A at 2:40 PM on 3/13/12.

d. Break Room
This finding was confirmed by Maintenance Supervisor A at 2:42 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish of rooms and spaces. Findings include:

During a tour of the hospital on 3/12, 3/13 and 3/14/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Patient room 2009/2010 bathroom
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/12/12.

b. 2nd floor Dialysis Wash room
This finding was confirmed by Maintenance Supervisor A at 11:55 AM on 3/12/12.

c. CT Machine Room
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/12/12.

d. Training Room Closet
This finding was confirmed by Maintenance Supervisor A at 3:34 PM on 3/12/12.

e. Clinical and Nursing Room
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

f. Kitchen and Diet office
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

g. Facilities work area
This finding was confirmed by Maintenance Supervisor A at 10:35 AM on 3/13/12.

2. Unprotected and non-sealed penetrations above the ceiling need sealing with rated materials in the following areas:

a. 2nd floor Environmental Services closet
This finding was confirmed by Maintenance Supervisor A at 11:00 AM on 3/12/12.

b. Administration IT closet
This finding was confirmed by Maintenance Supervisor A at 3:10 PM on 3/12/12.

c. Basement IT room D
This finding was confirmed by Maintenance Supervisor A at 3:45 PM on 3/12/12.

d. IT Server room
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

e. Facilities' Office
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

f. Room 3025 bathroom
This finding was confirmed by Maintenance Supervisor A at 1:36 PM on 3/14/12.

g. 3rd floor Physician's Dictation room
This finding was confirmed by Maintenance Supervisor A at 1:58 PM on 3/14/12.

Based on observation and staff interview, it was determined that the facility has not maintained the corridor walls involving penetrations through corridor walls. Findings include:

During a tour of the hospital on 3/12 and 3/14/12, the following was observed:

1. Unprotected and non-sealed penetrations above the ceiling need sealing with rated materials in the following areas:

a. 2nd floor Smoke Doors by room 2020
This finding was confirmed by Maintenance Supervisor A at 11:25 AM on 3/12/12.

b. Fire door (81658)
This finding was confirmed by Maintenance Supervisor A at 11:21 AM on 3/14/12.

c. 4th floor elevator lobby
This finding was confirmed by Maintenance Supervisor A at 12:12 PM on 3/14/12.

d. 3rd floor Staff Lounge
This finding was confirmed by Maintenance Supervisor A at 1:42 PM on 3/14/12.

e. Fire door (81731)
This finding was confirmed by Maintenance Supervisor A at 1:50 PM on 3/14/12.

Based on observation and staff interview, it was determined that the facility has not maintained corridor doors to resist the passage of smoke. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. 3rd floor Ante room
This finding was confirmed by Maintenance Mechanic A at 10:55 AM on 3/12/12.

2. Patient sleeping room doors 3021 & 3022
This finding was confirmed by Maintenance Mechanic A at 10:58 AM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained doors to hazardous areas. Findings include:

During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Door to future MRI Room does not latch properly.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained smoke compartmentation doors. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Fire door (81777) in elevator lobby to patient floor not latching properly.
This finding was confirmed by Maintenance Supervisor A at 10:35 AM on 3/12/12.

2. Fire door next to Human Resources not latching properly.
This finding was confirmed by Maintenance Mechanic A at 11:47 AM on 3/12/12.

3. Fire door between 2nd floor elevator lobby and ICU access door not latching properly.
This finding was confirmed by Maintenance Supervisor A at 12:10 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained hazardous areas. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Exit door from lower utility room difficult to open.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

2. 2nd floor office converted to storage must have proper separation and a rated door with a self-closing device.
This finding was confirmed by Maintenance Supervisor A at 12:55 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing and penetrations need to be sealed in the following areas:

a. Mechanical Room
This finding was confirmed by Maintenance Supervisor A at 2:25 PM on 3/13/12.

b. IT Room
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

C. During a tour of Nanticoke Occupational Health on 3/13/12, the following was observed:

1. Door to Soiled Utility Room needs to be rated.
This finding was confirmed by Maintenance Supervisor A at 3:25 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained hazardous areas. Findings include:

During a tour of the hospital on 3/12 and 3/13/12, the following was observed:

1. Unprotected and non-sealed penetrations in the rated walls need sealing with rated materials in the following areas:

a. Basement Elevator Equipment room
This finding was confirmed by Maintenance Supervisor A at 3:00 PM on 3/12/12.

b. Mechanical Room D
This finding was confirmed by Maintenance Supervisor A at 3:00 PM on 3/12/12.

c. Mechanical Room C
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

2. Door to dry storage in Kitchen is not latching properly.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained minimum exit access width. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Exit access must be maintained in storage room by Mechanical Room D.
This finding was confirmed by Maintenance Supervisor A at 3:25 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained exit and directional signs. Findings include:

During a tour of the hospital on 3/13/12, the following was observed:

1. Exit Sign/Emergency Light over south exit door was obstructed.
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the fire alarm signaling system in accordance with NFPA 70 and NFPA 72. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Open junction boxes for Fire Alarm Wiring in Preaction FSS Room need covers.
This finding was confirmed by Maintenance Supervisor A at 11:50 AM on 3/13/12.

2. Smoke detector in 2nd floor storage room too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 12:42 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Cover needed for Fire Alarm transformer box in IT Room.
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

2. Install proper receptacle for Fire Alarm transformer box in IT Room.
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

3. Install proper detector in Future MRI Room.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

4. Smoke detector in Lab Waiting area too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 2:50 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the fire alarm signaling system in accordance with NFPA 70 and NFPA 72. Findings include:

During a tour of the hospital on 3/12 and 3/13/12, the following was observed:

1. No smoke detectors coverage in 4th floor On Call sleeping rooms.
This finding was confirmed by Maintenance Supervisor A at 10:46 AM on 3/12/12.

2. Smoke detector in Communication Room 23 too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 12:45 PM on 3/12/12.

3. Smoke detector (1D57) in basement not secured to back box.
This finding was confirmed by Maintenance Supervisor A at 2:55 PM on 3/12/12.

4. Smoke detector in Kitchen Prep Area needs to be cleaned.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

5. Smoke detector in Kitchen Prep Area not properly labeled.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the automatic sprinkler system in accordance to NFPA 13 and NFPA 25. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Preaction FSS Room.

a. Verify with licensed fire suppression company that the pre-action sprinkler system has a "release" function for water to enter the piping system, a tag on the system noted nothing was found to do the release function.

b. Install ceiling tiles or change heads to uprights.

c. Replace corroded pipe nipple and reducer.
These findings were confirmed by Maintenance Supervisor A at 11:50 AM on 3/13/12.

2. Wires tied to sprinkler pipes in Electrical Room.
This finding was confirmed by Maintenance Supervisor A at 12:05 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Loaded sprinkler heads through the entire facility.
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/13/12.

C. During a tour of Nanticoke Rehabilitation on 3/13/12, the following was observed:

1. Loaded sprinkler heads through the entire facility.
This finding was confirmed by Maintenance Mechanic A at 2:12 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the automatic sprinkler system in accordance to NFPA 13 and NFPA 25. Findings include:

During a tour of the hospital on 3/8, 3/12 and 3/14/12, the following was observed:

1. Loaded sprinkler head(s) in the following locations (2002, NFPA 25:5.2.1.1.1):

a. Room 5002
This finding was confirmed by Quality Manager A at 10:58 AM on 3/8/12.

b. 5th floor staff lounge
This finding was confirmed by Maintenance Supervisor A at 11:24 AM on 3/8/12.

c. Day Surgery
This finding was confirmed by Maintenance Mechanic A at 11:50 AM on 3/12/12.

d. Supply Closet by Dialysis
This finding was confirmed by Maintenance Supervisor A at 11:58 AM on 3/12/12.

e. Room 2905
This finding was confirmed by Maintenance Supervisor A at 12:15 PM on 3/12/12.

f. X-Ray File Room
This finding was confirmed by Maintenance Supervisor A at 1:30 PM on 3/12/12.

g. Kitchen
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

2. Sprinkler escutcheons missing, displaced, or not covering cutout in the following locations (2007, NFPA 13:6.2.7):

a. 1st floor Communication closet
This finding was confirmed by Maintenance Mechanic A at 11:18 AM on 3/12/12.

b. 1st floor Men's Restroom behind the elevators
This finding was confirmed by Maintenance Supervisor A at 1:10 PM on 3/12/12.

c. Command Center Conference Room and closet
This finding was confirmed by Maintenance Supervisor A at 2:55 PM on 3/12/12.

d. Clinical & Nursing Room
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

3. Side wall sprinkler head in 2nd floor waiting room needs to be adjusted (too deep in the wall).
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/12/12.

4. Sprinkler head in 2nd floor linen storage closet needs to be adjusted (head is flush to the ceiling).
This finding was confirmed by Maintenance Supervisor A at 10:52 AM on 3/12/12.

5. Sprinkler escutcheon plate in 2nd floor Environmental Services closet needs to be adjusted to fit tightly to the ceiling.
This finding was confirmed by Maintenance Supervisor A at 11:00 AM on 3/12/12.

6. Sprinkler head in 2nd floor Med Room needs to be adjusted.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not properly maintained the storage of oxygen cylinders. Findings include:

During a tour of the hospital on 3/8/12, the following was observed:

1. Unsecured oxygen cylinder in 4th floor equipment storage room.
This finding was confirmed by Quality Manager A at 12:04 PM on 3/8/12.

Based on observation and staff interview, it was determined that the facility has not maintained electrical wiring and equipment in accordance with NFPA 70. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Install covers in the following areas:

a. Open electrical junction box in Electrical Room.
This finding was confirmed by Maintenance Supervisor A at 12:05 PM on 3/13/12.

b. Low voltage outlet box in Networking office.
This finding was confirmed by Maintenance Supervisor A at 12:25 PM on 3/13/12.

2. Follow installation instructions as per the requirements of NFPA 70 in the following areas:

a. Data lines in Electrical Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 12:14 PM on 3/13/12.

b. Data lines in Main Server Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

3. Discontinue the use of multi-tap outlets in the following area:

a. Main Server Room
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Remove construction type lighting and wires in the future MRI room and install lighting in accordance to NFPA 70.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

C. During a tour of Nanticoke Occupational Health on 3/13/12, the following was observed:

1. Open splices in wiring above door to conference room need to be in back boxes.
This finding was confirmed by Maintenance Supervisor A at 4:05 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained electrical wiring and equipment in accordance with NFPA 70. Findings include:

During a tour of the hospital on 3/12, 3/13 and 3/14/12, the following was observed:

1. Loose electrical outlet in corridor between patient rooms 2001/2002 and 2003/2004.
This finding was confirmed by Maintenance Supervisor A at 10:37 AM on 3/12/12.

2. Install covers in the following areas:

a. Junction box above door in 2nd floor North West stair tower.
This finding was confirmed by Maintenance Supervisor A at 10:45 AM on 3/12/12.

b. Low voltage wiring exposed behind seating in the 2nd floor waiting room.
This finding was confirmed by Maintenance Supervisor A at 10:45 AM on 3/12/12.

c. Junction box above ceiling in 2nd floor Smoke Doors by room 2020.
This finding was confirmed by Maintenance Supervisor A at 11:25 AM on 3/12/12.

d. Electrical boxes in CT Control Room.
This finding was confirmed by Maintenance Supervisor A at 2:00 PM on 3/12/12.

e. Electrical box in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

f. Electrical box in IT Server Room.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

g. 5th floor door control box above ceiling.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/14/12.

h. Open junction box above ceiling 5th floor A&S office.
This finding was confirmed by Maintenance Supervisor A at 11:36 AM on 3/14/12.

i. 4th floor fire door (81692) door control box above ceiling.
This finding was confirmed by Maintenance Supervisor A at 12:10 PM on 3/14/12.

3. Follow installation instructions as per the requirements of NFPA 70 in the following areas:

a. Data lines in 2nd floor Med Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/12/12.

b. Data lines in 2nd floor Charting Area pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 11:15 AM on 3/12/12.

c. Exposed wire splices above ceiling at the 2nd floor West Stair tower door not in a junction box.
This finding was confirmed by Maintenance Supervisor A at 11:40 AM on 3/12/12.

d. Exposed spliced conductors above electrical panel N1B-A Section 2 in electrical room #7.
This finding was confirmed by Maintenance Supervisor A at 1:00 PM on 3/12/12.

e. Low voltage cable in X-ray Work Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 1:40 PM on 3/12/12.

f. Low voltage cable in CT Reading Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 1:50 PM on 3/12/12.

g. Low voltage cable in CT Control Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 2:00 PM on 3/12/12.

h. Low voltage cable in Medical Records Reading Room pinched between wall and cover plate.
This finding was confirmed by Maintenance Supervisor A at 2:20 PM on 3/12/12.

i. Low voltage wiring running through ceiling tile into wall in Compliance & Control room shall be installed properly.
This finding was confirmed by Maintenance Supervisor A at 3:50 PM on 3/12/12.

j. Secure low voltage wiring at the bottom of the wire mold in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

k. Secure low voltage wiring with open conductors in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

l. Wiring running through ceiling tile in IT Server Room shall be installed properly.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

m. Open conductors in Telephone Room not in back box above electrical panel.
This finding was confirmed by Maintenance Supervisor A at 9:30 AM on 3/13/12.

n. Open wiring in Mechanical Room C needs to be terminated in back boxes.
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

o. Data lines in Kitchen office pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 9:40 AM on 3/13/12.

p. Data lines in Kitchen pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 9:40 AM on 3/13/12.

q. Power supply wiring for refrigerator (RF55) pulled out of ceiling mounted back box.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

r. Power cord for refrigerator (80605) retained to ceiling grill with steel wires.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

s. Data Lines in Kitchen running through ceiling shall be secured and sealed accordingly.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM
on 3/13/12.

t. Low voltage wiring in Facilities Director's office not secured.
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/13/12.

u. Exposed wiring and wiring running under baseboard trim in the Facilities Director's office.
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/13/12.

v. Exposed low voltage wiring and wiring pulled out of the wall in the Facilities Office.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

w. Data lines in Facilities' office pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

x. Cable box not secured to wall in 3rd floor Staff Lounge.
This finding was confirmed by Maintenance Supervisor A at 1:55 PM on 3/14/12.

4. Discontinue the use of extension cords used in place of fixed wiring in the flowing locations:

a. Camera transformer in Charting Area.
This finding was confirmed by Maintenance Supervisor A at 11:15 AM on 3/12/12.

b. IT Server Room.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

c. Refrigerator (80605) in Kitchen.
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

d. Kitchen work area ceiling.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

5. Discontinue the use of multi-tap outlets in the following areas:

a. Account Director's office.
This finding was confirmed by Maintenance Supervisor A at 2:35 PM on 3/12/12.

b. Compliance Risk Management's office.
This finding was confirmed by Maintenance Supervisor A at 2:50 PM on 3/12/12.

c. Facilities office.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

6. Machine electrical disconnect in CT Machine Room blocked by carts.
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/12/12.

7. Electrical room in basement IT Room blocked by a refrigerator and microwave.
This finding was confirmed by Maintenance Supervisor A at 3:45 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish for corridors. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following area:
a. Door (81212)

This finding was confirmed by Maintenance Supervisor A at 12:50 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish of rooms and spaces. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Networking Office
This finding was confirmed by Maintenance Supervisor A at 12:25 PM on 3/13/12.

(2000, NFPA 101:18/19.3.3)

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Environmental Services
This finding was confirmed by Maintenance Supervisor A at 2:11 PM on 3/13/12.

b. Ultra Sound 3 (including restroom)
This finding was confirmed by Maintenance Supervisor A at 2:19 PM on 3/13/12.

c. CT Room
This finding was confirmed by Maintenance Supervisor A at 2:40 PM on 3/13/12.

d. Break Room
This finding was confirmed by Maintenance Supervisor A at 2:42 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the interior finish of rooms and spaces. Findings include:

During a tour of the hospital on 3/12, 3/13 and 3/14/12, the following was observed:

1. Ceiling tiles were either damaged or missing in the following areas:

a. Patient room 2009/2010 bathroom
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/12/12.

b. 2nd floor Dialysis Wash room
This finding was confirmed by Maintenance Supervisor A at 11:55 AM on 3/12/12.

c. CT Machine Room
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/12/12.

d. Training Room Closet
This finding was confirmed by Maintenance Supervisor A at 3:34 PM on 3/12/12.

e. Clinical and Nursing Room
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

f. Kitchen and Diet office
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

g. Facilities work area
This finding was confirmed by Maintenance Supervisor A at 10:35 AM on 3/13/12.

2. Unprotected and non-sealed penetrations above the ceiling need sealing with rated materials in the following areas:

a. 2nd floor Environmental Services closet
This finding was confirmed by Maintenance Supervisor A at 11:00 AM on 3/12/12.

b. Administration IT closet
This finding was confirmed by Maintenance Supervisor A at 3:10 PM on 3/12/12.

c. Basement IT room D
This finding was confirmed by Maintenance Supervisor A at 3:45 PM on 3/12/12.

d. IT Server room
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

e. Facilities' Office
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

f. Room 3025 bathroom
This finding was confirmed by Maintenance Supervisor A at 1:36 PM on 3/14/12.

g. 3rd floor Physician's Dictation room
This finding was confirmed by Maintenance Supervisor A at 1:58 PM on 3/14/12.

Based on observation and staff interview, it was determined that the facility has not maintained the corridor walls involving penetrations through corridor walls. Findings include:

During a tour of the hospital on 3/12 and 3/14/12, the following was observed:

1. Unprotected and non-sealed penetrations above the ceiling need sealing with rated materials in the following areas:

a. 2nd floor Smoke Doors by room 2020
This finding was confirmed by Maintenance Supervisor A at 11:25 AM on 3/12/12.

b. Fire door (81658)
This finding was confirmed by Maintenance Supervisor A at 11:21 AM on 3/14/12.

c. 4th floor elevator lobby
This finding was confirmed by Maintenance Supervisor A at 12:12 PM on 3/14/12.

d. 3rd floor Staff Lounge
This finding was confirmed by Maintenance Supervisor A at 1:42 PM on 3/14/12.

e. Fire door (81731)
This finding was confirmed by Maintenance Supervisor A at 1:50 PM on 3/14/12.

Based on observation and staff interview, it was determined that the facility has not maintained corridor doors to resist the passage of smoke. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. 3rd floor Ante room
This finding was confirmed by Maintenance Mechanic A at 10:55 AM on 3/12/12.

2. Patient sleeping room doors 3021 & 3022
This finding was confirmed by Maintenance Mechanic A at 10:58 AM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained doors to hazardous areas. Findings include:

During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Door to future MRI Room does not latch properly.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained smoke compartmentation doors. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Fire door (81777) in elevator lobby to patient floor not latching properly.
This finding was confirmed by Maintenance Supervisor A at 10:35 AM on 3/12/12.

2. Fire door next to Human Resources not latching properly.
This finding was confirmed by Maintenance Mechanic A at 11:47 AM on 3/12/12.

3. Fire door between 2nd floor elevator lobby and ICU access door not latching properly.
This finding was confirmed by Maintenance Supervisor A at 12:10 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained hazardous areas. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Exit door from lower utility room difficult to open.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

2. 2nd floor office converted to storage must have proper separation and a rated door with a self-closing device.
This finding was confirmed by Maintenance Supervisor A at 12:55 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Ceiling tiles were either damaged or missing and penetrations need to be sealed in the following areas:

a. Mechanical Room
This finding was confirmed by Maintenance Supervisor A at 2:25 PM on 3/13/12.

b. IT Room
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

C. During a tour of Nanticoke Occupational Health on 3/13/12, the following was observed:

1. Door to Soiled Utility Room needs to be rated.
This finding was confirmed by Maintenance Supervisor A at 3:25 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained hazardous areas. Findings include:

During a tour of the hospital on 3/12 and 3/13/12, the following was observed:

1. Unprotected and non-sealed penetrations in the rated walls need sealing with rated materials in the following areas:

a. Basement Elevator Equipment room
This finding was confirmed by Maintenance Supervisor A at 3:00 PM on 3/12/12.

b. Mechanical Room D
This finding was confirmed by Maintenance Supervisor A at 3:00 PM on 3/12/12.

c. Mechanical Room C
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

2. Door to dry storage in Kitchen is not latching properly.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained minimum exit access width. Findings include:

During a tour of the hospital on 3/12/12, the following was observed:

1. Exit access must be maintained in storage room by Mechanical Room D.
This finding was confirmed by Maintenance Supervisor A at 3:25 PM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not maintained exit and directional signs. Findings include:

During a tour of the hospital on 3/13/12, the following was observed:

1. Exit Sign/Emergency Light over south exit door was obstructed.
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the fire alarm signaling system in accordance with NFPA 70 and NFPA 72. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Open junction boxes for Fire Alarm Wiring in Preaction FSS Room need covers.
This finding was confirmed by Maintenance Supervisor A at 11:50 AM on 3/13/12.

2. Smoke detector in 2nd floor storage room too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 12:42 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Cover needed for Fire Alarm transformer box in IT Room.
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

2. Install proper receptacle for Fire Alarm transformer box in IT Room.
This finding was confirmed by Maintenance Supervisor A at 2:30 PM on 3/13/12.

3. Install proper detector in Future MRI Room.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

4. Smoke detector in Lab Waiting area too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 2:50 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the fire alarm signaling system in accordance with NFPA 70 and NFPA 72. Findings include:

During a tour of the hospital on 3/12 and 3/13/12, the following was observed:

1. No smoke detectors coverage in 4th floor On Call sleeping rooms.
This finding was confirmed by Maintenance Supervisor A at 10:46 AM on 3/12/12.

2. Smoke detector in Communication Room 23 too close to air discharge.
This finding was confirmed by Maintenance Supervisor A at 12:45 PM on 3/12/12.

3. Smoke detector (1D57) in basement not secured to back box.
This finding was confirmed by Maintenance Supervisor A at 2:55 PM on 3/12/12.

4. Smoke detector in Kitchen Prep Area needs to be cleaned.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

5. Smoke detector in Kitchen Prep Area not properly labeled.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the automatic sprinkler system in accordance to NFPA 13 and NFPA 25. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Preaction FSS Room.

a. Verify with licensed fire suppression company that the pre-action sprinkler system has a "release" function for water to enter the piping system, a tag on the system noted nothing was found to do the release function.

b. Install ceiling tiles or change heads to uprights.

c. Replace corroded pipe nipple and reducer.
These findings were confirmed by Maintenance Supervisor A at 11:50 AM on 3/13/12.

2. Wires tied to sprinkler pipes in Electrical Room.
This finding was confirmed by Maintenance Supervisor A at 12:05 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Loaded sprinkler heads through the entire facility.
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/13/12.

C. During a tour of Nanticoke Rehabilitation on 3/13/12, the following was observed:

1. Loaded sprinkler heads through the entire facility.
This finding was confirmed by Maintenance Mechanic A at 2:12 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained the automatic sprinkler system in accordance to NFPA 13 and NFPA 25. Findings include:

During a tour of the hospital on 3/8, 3/12 and 3/14/12, the following was observed:

1. Loaded sprinkler head(s) in the following locations (2002, NFPA 25:5.2.1.1.1):

a. Room 5002
This finding was confirmed by Quality Manager A at 10:58 AM on 3/8/12.

b. 5th floor staff lounge
This finding was confirmed by Maintenance Supervisor A at 11:24 AM on 3/8/12.

c. Day Surgery
This finding was confirmed by Maintenance Mechanic A at 11:50 AM on 3/12/12.

d. Supply Closet by Dialysis
This finding was confirmed by Maintenance Supervisor A at 11:58 AM on 3/12/12.

e. Room 2905
This finding was confirmed by Maintenance Supervisor A at 12:15 PM on 3/12/12.

f. X-Ray File Room
This finding was confirmed by Maintenance Supervisor A at 1:30 PM on 3/12/12.

g. Kitchen
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

2. Sprinkler escutcheons missing, displaced, or not covering cutout in the following locations (2007, NFPA 13:6.2.7):

a. 1st floor Communication closet
This finding was confirmed by Maintenance Mechanic A at 11:18 AM on 3/12/12.

b. 1st floor Men's Restroom behind the elevators
This finding was confirmed by Maintenance Supervisor A at 1:10 PM on 3/12/12.

c. Command Center Conference Room and closet
This finding was confirmed by Maintenance Supervisor A at 2:55 PM on 3/12/12.

d. Clinical & Nursing Room
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

3. Side wall sprinkler head in 2nd floor waiting room needs to be adjusted (too deep in the wall).
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/12/12.

4. Sprinkler head in 2nd floor linen storage closet needs to be adjusted (head is flush to the ceiling).
This finding was confirmed by Maintenance Supervisor A at 10:52 AM on 3/12/12.

5. Sprinkler escutcheon plate in 2nd floor Environmental Services closet needs to be adjusted to fit tightly to the ceiling.
This finding was confirmed by Maintenance Supervisor A at 11:00 AM on 3/12/12.

6. Sprinkler head in 2nd floor Med Room needs to be adjusted.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/12/12.

Based on observation and staff interview, it was determined that the facility has not properly maintained the storage of oxygen cylinders. Findings include:

During a tour of the hospital on 3/8/12, the following was observed:

1. Unsecured oxygen cylinder in 4th floor equipment storage room.
This finding was confirmed by Quality Manager A at 12:04 PM on 3/8/12.

Based on observation and staff interview, it was determined that the facility has not maintained electrical wiring and equipment in accordance with NFPA 70. Findings include:

A. During a tour of the Cancer Care Center on 3/13/12, the following was observed:

1. Install covers in the following areas:

a. Open electrical junction box in Electrical Room.
This finding was confirmed by Maintenance Supervisor A at 12:05 PM on 3/13/12.

b. Low voltage outlet box in Networking office.
This finding was confirmed by Maintenance Supervisor A at 12:25 PM on 3/13/12.

2. Follow installation instructions as per the requirements of NFPA 70 in the following areas:

a. Data lines in Electrical Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 12:14 PM on 3/13/12.

b. Data lines in Main Server Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

3. Discontinue the use of multi-tap outlets in the following area:

a. Main Server Room
This finding was confirmed by Maintenance Supervisor A at 12:17 PM on 3/13/12.

B. During a tour of Nanticoke Diagnostic Imaging on 3/13/12, the following was observed:

1. Remove construction type lighting and wires in the future MRI room and install lighting in accordance to NFPA 70.
This finding was confirmed by Maintenance Supervisor A at 2:36 PM on 3/13/12.

C. During a tour of Nanticoke Occupational Health on 3/13/12, the following was observed:

1. Open splices in wiring above door to conference room need to be in back boxes.
This finding was confirmed by Maintenance Supervisor A at 4:05 PM on 3/13/12.

Based on observation and staff interview, it was determined that the facility has not maintained electrical wiring and equipment in accordance with NFPA 70. Findings include:

During a tour of the hospital on 3/12, 3/13 and 3/14/12, the following was observed:

1. Loose electrical outlet in corridor between patient rooms 2001/2002 and 2003/2004.
This finding was confirmed by Maintenance Supervisor A at 10:37 AM on 3/12/12.

2. Install covers in the following areas:

a. Junction box above door in 2nd floor North West stair tower.
This finding was confirmed by Maintenance Supervisor A at 10:45 AM on 3/12/12.

b. Low voltage wiring exposed behind seating in the 2nd floor waiting room.
This finding was confirmed by Maintenance Supervisor A at 10:45 AM on 3/12/12.

c. Junction box above ceiling in 2nd floor Smoke Doors by room 2020.
This finding was confirmed by Maintenance Supervisor A at 11:25 AM on 3/12/12.

d. Electrical boxes in CT Control Room.
This finding was confirmed by Maintenance Supervisor A at 2:00 PM on 3/12/12.

e. Electrical box in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

f. Electrical box in IT Server Room.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

g. 5th floor door control box above ceiling.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/14/12.

h. Open junction box above ceiling 5th floor A&S office.
This finding was confirmed by Maintenance Supervisor A at 11:36 AM on 3/14/12.

i. 4th floor fire door (81692) door control box above ceiling.
This finding was confirmed by Maintenance Supervisor A at 12:10 PM on 3/14/12.

3. Follow installation instructions as per the requirements of NFPA 70 in the following areas:

a. Data lines in 2nd floor Med Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 11:05 AM on 3/12/12.

b. Data lines in 2nd floor Charting Area pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 11:15 AM on 3/12/12.

c. Exposed wire splices above ceiling at the 2nd floor West Stair tower door not in a junction box.
This finding was confirmed by Maintenance Supervisor A at 11:40 AM on 3/12/12.

d. Exposed spliced conductors above electrical panel N1B-A Section 2 in electrical room #7.
This finding was confirmed by Maintenance Supervisor A at 1:00 PM on 3/12/12.

e. Low voltage cable in X-ray Work Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 1:40 PM on 3/12/12.

f. Low voltage cable in CT Reading Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 1:50 PM on 3/12/12.

g. Low voltage cable in CT Control Room pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 2:00 PM on 3/12/12.

h. Low voltage cable in Medical Records Reading Room pinched between wall and cover plate.
This finding was confirmed by Maintenance Supervisor A at 2:20 PM on 3/12/12.

i. Low voltage wiring running through ceiling tile into wall in Compliance & Control room shall be installed properly.
This finding was confirmed by Maintenance Supervisor A at 3:50 PM on 3/12/12.

j. Secure low voltage wiring at the bottom of the wire mold in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

k. Secure low voltage wiring with open conductors in Clinical & Nursing Room.
This finding was confirmed by Maintenance Supervisor A at 3:55 PM on 3/12/12.

l. Wiring running through ceiling tile in IT Server Room shall be installed properly.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

m. Open conductors in Telephone Room not in back box above electrical panel.
This finding was confirmed by Maintenance Supervisor A at 9:30 AM on 3/13/12.

n. Open wiring in Mechanical Room C needs to be terminated in back boxes.
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

o. Data lines in Kitchen office pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 9:40 AM on 3/13/12.

p. Data lines in Kitchen pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 9:40 AM on 3/13/12.

q. Power supply wiring for refrigerator (RF55) pulled out of ceiling mounted back box.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

r. Power cord for refrigerator (80605) retained to ceiling grill with steel wires.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

s. Data Lines in Kitchen running through ceiling shall be secured and sealed accordingly.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM
on 3/13/12.

t. Low voltage wiring in Facilities Director's office not secured.
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/13/12.

u. Exposed wiring and wiring running under baseboard trim in the Facilities Director's office.
This finding was confirmed by Maintenance Supervisor A at 10:40 AM on 3/13/12.

v. Exposed low voltage wiring and wiring pulled out of the wall in the Facilities Office.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

w. Data lines in Facilities' office pinched between ceiling tile and grid.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

x. Cable box not secured to wall in 3rd floor Staff Lounge.
This finding was confirmed by Maintenance Supervisor A at 1:55 PM on 3/14/12.

4. Discontinue the use of extension cords used in place of fixed wiring in the flowing locations:

a. Camera transformer in Charting Area.
This finding was confirmed by Maintenance Supervisor A at 11:15 AM on 3/12/12.

b. IT Server Room.
This finding was confirmed by Maintenance Supervisor A at 4:00 PM on 3/12/12.

c. Refrigerator (80605) in Kitchen.
This finding was confirmed by Maintenance Supervisor A at 9:35 AM on 3/13/12.

d. Kitchen work area ceiling.
This finding was confirmed by Maintenance Supervisor A at 9:45 AM on 3/13/12.

5. Discontinue the use of multi-tap outlets in the following areas:

a. Account Director's office.
This finding was confirmed by Maintenance Supervisor A at 2:35 PM on 3/12/12.

b. Compliance Risk Management's office.
This finding was confirmed by Maintenance Supervisor A at 2:50 PM on 3/12/12.

c. Facilities office.
This finding was confirmed by Maintenance Supervisor A at 10:50 AM on 3/13/12.

6. Machine electrical disconnect in CT Machine Room blocked by carts.
This finding was confirmed by Maintenance Supervisor A at 2:10 PM on 3/12/12.

7. Electrical room in basement IT Room blocked by a refrigerator and microwave.
This finding was confirmed by Maintenance Supervisor A at 3:45 PM on 3/12/12.