HospitalInspections.org

Based on observation, on July 18, 2012 at approximately 5:30am onward, there is fireproofing missing from structural column in electrical room beside room #145 - first floor cardiopulmonary area.

Based on observation, on July 17, 2012 at approximately 11:00am onward, doors and hardware are incomplete in the following areas:

1. room 318 dutch type door - upper an lower door leaf cannot be closed with a single motion of the hand.

2. room 314 - positive latching hardware is broken and will not latch properly.

3. office impact room located on the third floor south near the ICU - room is equipped with a key-activated deadbolt lock from both sides of the door. There is no positive latching hardware provided for the referenced room.

4. Doctor's dictation room located on second floor North wing - wedge observed under door to room.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the smoke damper did not close during activation of the facility fire alarm system - located at smoke barrier near room 212 on the second floor north wing.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the clean supply room is greater than one hundred square feet without one hour fire resistive enclosure. The room is located within the operating room suite - above ceiling partitions are not equipped with fire code gysumboard on both sides of studs.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the storage room adjacent to the rehabilitation room is not equipped with sprinklers and a one hour fire resistive enclosure. The room is greater than one hundred square feet in area.

A. Based on observation, on July 17, 2012 at approximately 11:00am onward, the required exits are impeded in the following areas due to incomplete electromagnetic locking arrangements:

1. room 316 - access controlled egress locking arrangement is not equipped with a switch less than five feet from the exit access door containing the magnetic lock.

2. ICU exit access doors are not equipped with release switches located less than five feet from the door containing the electromagnetic lock.

3. lack of master release switch in ER Suite , and on/off release switch beside exit access door from ER suite.

4. exit discharge door at materials management area near the kitchen - the access controlled egress lock is not equipped with a release switch less than five feet from the door in accordance with NFPA 101; Section 7-2.1.6.

5. lack of release switch less than five feet from the exit access controlled egress door in the second floor C-Section anesthesia room.

B. Based on observation, on July 18, 2012 at approximately 5:30am onward, the electromagnetic locking arrangements did not release with activation of the facility fire alarm system by detection device in the following area:

1. Labor and Delivery unit - the locks did release with activation of on/off release switches within the unit.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the exit discharge does not terminate at the publicway by way of a solid, slip-resistant surface other than grass or soil.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there is a key-activated deadbolt latch greater than forty-eight inches above finished floor in the outpatient surgery room #132.

Based on observation, on July 17, 2012 at approximately 11:00am onward, emergency lighting is incomplete due to the following:

1. lack of emergency lighting for medication preparation room #326.

2. lack of emergency lighting connected to the Life Safety Branch of the essential electrical system in the materials management area near the exit discharge.

3. exit access doors and hardware from walk-in coolers and freezers cannot be seen in all lighting levels - located in kitchen area on the first floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there are no emergency lights at the exit discharges serving the Rehabilitation Services Building.

Based on observation, on July 17, 2012 at approximately 11:00am onward, exit sign directional symbols are improperly located for direction to required exit - located on third floor of north wing beyond nurse's station.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the fire alarm system is incomplete due to the following:

1. There is no single line wiring diagram posted at the main facility fire alarm panel - the diagram must illustrate the electromagnetic locking system arrangement and the interface with the fire alarm control system.(located in maintenance and engineering room on first floor)

2. There is no smoke detector located in the vicinity of the main fire alarm control panel - panel is located in the maintenance and engineering room on the first floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the sprinkler system is incomplete due to the following:

1. lack of sprinkler coverage for the lower landing of stairwell #5.

2. lack of sprinkler in NICU closet - located on second floor.

3. lack of sprinkler in ER electrical room - the room does not meet all exceptions for exclusion of sprinkler; most specifically, the two hour fire resistive enclosure.

4. lack of sprinkler in closet of operating room #4.

Based on observation, on July 17, 2012 at approximately 11:00am onward, main control valves in outdoor valve pit are not electrically supervised. The valve pit cover could not be opened for observation during the survey. Erosion appeared to occur at the perimeter of valve pit; and pit is not equipped with sump pump connected to emergency power system.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the mechanical systems are incomplete due to the following:

1. Lack of an emergency shutdown switch for the air handling units serving the third floor north, east and west wing.

2. Lack of an emergency shutdown switch for the air handling unit serving the ICU located on the south wing of the third floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the mechanical system components are incomplete due to the following:

1. air handling unit shut-down switch did not shut-off air handing unit #11 during activation - located in first floor GI Lab.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there are is no emergency shut-down switch(es) for air handling units serving the Rehabilitation Services Building.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the kitchen mechanical system is incomplete due to the following:

1. deep fryer within sixteen inches of range cooking surface - no baffle is provided between fryer and cooking surface.

2. doors to kitchen are left in the open position with airflow pulled from corridor areas of laundry and front entrance lobby through the dining room to the kitchen area. Exhaust air is not replaced primarily through the filtered makeup air unit.

Based on observation, on July 17, 2012 at approximately 11:00am onward, there are impediments in the means of egress that are not in immediate and continuous use. The following areas were observed with carts and other impediments:

1. first floor - corridor leading to exit discharge near the laundry and maintenance area.

2.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the medical gas piping system is incomplete due to the following:

1. medical gas piping is not identified by labels on both sides of partitions penetrated by piping system - corridor area near birthing center.

2. medical gas cylinders are not protected from extremes of weather in the outdoor oxygen bank area. The cylinders are gang secure, and supported directly on the concrete pad with rust accumulation on cylinders.

1. Based on observation, on July 17, 2012 at approximately 11:00am onward, the generator annunciator panel is not located in a continuously supervised area. The maintenance room, and engineering office is not staffed for twenty-four hours, seven days a week. Audible alarm signals from panel cannot be heard in corridor areas due to ambient sound levels from mechanical equipment room.

2. Based on observation, on July 18, 2012 at approximately 5:30am onward, there is no low fuel level alarm signal for a three hour operating capacity in the main fuel tank serving the emergency generators.

Based on observation, on July 18, 2012 at approximately 5:30am onward, operating room #2 medical gas sensor did not respond to a loss of pressure by closing the zone valve; and opening valve at ancillary equipment outlet.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the facility is noncompliant with the National Electrical Code due to the following:

1. there is a multioutlet power tap used in room 319 of the Dialysis Unit. Receptacles in patient care areas shall be wired in metal raceways with redundant ground path as required by NFPA 99; and Section 517 of the National Electrical Code.

2. lack of minimum number #10 green insulated bonding jumper between normal and emergency panels serving the same patient vicinity - located in electrical room on second floor south wing.

3. receptacle under sink is not equipped with ground-fault interrupter protection - located in kitchen

4. lack of damp-proof rated emergency light fixture at loading dock exit discharge - lense of existing fixture has a hole in lense and covered with wire mesh.

5. lack of label on fire alarm control panel identifying the utility power supply from the Life Safety Branch panel circuit breaker serving the main fire alarm control panel - panel is located in the first maintenance room near the engineering office.

6. temporary wiring in hospital conex units containing hospital supplies - exposed bulb fixtures are located directly above combustible supplies; and romex wiring is exposed and installed improperly without junction boxes and proper fasteners.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there is fireproofing missing from structural column in electrical room beside room #145 - first floor cardiopulmonary area.

Based on observation, on July 17, 2012 at approximately 11:00am onward, doors and hardware are incomplete in the following areas:

1. room 318 dutch type door - upper an lower door leaf cannot be closed with a single motion of the hand.

2. room 314 - positive latching hardware is broken and will not latch properly.

3. office impact room located on the third floor south near the ICU - room is equipped with a key-activated deadbolt lock from both sides of the door. There is no positive latching hardware provided for the referenced room.

4. Doctor's dictation room located on second floor North wing - wedge observed under door to room.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the smoke damper did not close during activation of the facility fire alarm system - located at smoke barrier near room 212 on the second floor north wing.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the clean supply room is greater than one hundred square feet without one hour fire resistive enclosure. The room is located within the operating room suite - above ceiling partitions are not equipped with fire code gysumboard on both sides of studs.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the storage room adjacent to the rehabilitation room is not equipped with sprinklers and a one hour fire resistive enclosure. The room is greater than one hundred square feet in area.

A. Based on observation, on July 17, 2012 at approximately 11:00am onward, the required exits are impeded in the following areas due to incomplete electromagnetic locking arrangements:

1. room 316 - access controlled egress locking arrangement is not equipped with a switch less than five feet from the exit access door containing the magnetic lock.

2. ICU exit access doors are not equipped with release switches located less than five feet from the door containing the electromagnetic lock.

3. lack of master release switch in ER Suite , and on/off release switch beside exit access door from ER suite.

4. exit discharge door at materials management area near the kitchen - the access controlled egress lock is not equipped with a release switch less than five feet from the door in accordance with NFPA 101; Section 7-2.1.6.

5. lack of release switch less than five feet from the exit access controlled egress door in the second floor C-Section anesthesia room.

B. Based on observation, on July 18, 2012 at approximately 5:30am onward, the electromagnetic locking arrangements did not release with activation of the facility fire alarm system by detection device in the following area:

1. Labor and Delivery unit - the locks did release with activation of on/off release switches within the unit.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the exit discharge does not terminate at the publicway by way of a solid, slip-resistant surface other than grass or soil.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there is a key-activated deadbolt latch greater than forty-eight inches above finished floor in the outpatient surgery room #132.

Based on observation, on July 17, 2012 at approximately 11:00am onward, emergency lighting is incomplete due to the following:

1. lack of emergency lighting for medication preparation room #326.

2. lack of emergency lighting connected to the Life Safety Branch of the essential electrical system in the materials management area near the exit discharge.

3. exit access doors and hardware from walk-in coolers and freezers cannot be seen in all lighting levels - located in kitchen area on the first floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there are no emergency lights at the exit discharges serving the Rehabilitation Services Building.

Based on observation, on July 17, 2012 at approximately 11:00am onward, exit sign directional symbols are improperly located for direction to required exit - located on third floor of north wing beyond nurse's station.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the fire alarm system is incomplete due to the following:

1. There is no single line wiring diagram posted at the main facility fire alarm panel - the diagram must illustrate the electromagnetic locking system arrangement and the interface with the fire alarm control system.(located in maintenance and engineering room on first floor)

2. There is no smoke detector located in the vicinity of the main fire alarm control panel - panel is located in the maintenance and engineering room on the first floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the sprinkler system is incomplete due to the following:

1. lack of sprinkler coverage for the lower landing of stairwell #5.

2. lack of sprinkler in NICU closet - located on second floor.

3. lack of sprinkler in ER electrical room - the room does not meet all exceptions for exclusion of sprinkler; most specifically, the two hour fire resistive enclosure.

4. lack of sprinkler in closet of operating room #4.

Based on observation, on July 17, 2012 at approximately 11:00am onward, main control valves in outdoor valve pit are not electrically supervised. The valve pit cover could not be opened for observation during the survey. Erosion appeared to occur at the perimeter of valve pit; and pit is not equipped with sump pump connected to emergency power system.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the mechanical systems are incomplete due to the following:

1. Lack of an emergency shutdown switch for the air handling units serving the third floor north, east and west wing.

2. Lack of an emergency shutdown switch for the air handling unit serving the ICU located on the south wing of the third floor.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the mechanical system components are incomplete due to the following:

1. air handling unit shut-down switch did not shut-off air handing unit #11 during activation - located in first floor GI Lab.

Based on observation, on July 18, 2012 at approximately 5:30am onward, there are is no emergency shut-down switch(es) for air handling units serving the Rehabilitation Services Building.

Based on observation, on July 18, 2012 at approximately 5:30am onward, the kitchen mechanical system is incomplete due to the following:

1. deep fryer within sixteen inches of range cooking surface - no baffle is provided between fryer and cooking surface.

2. doors to kitchen are left in the open position with airflow pulled from corridor areas of laundry and front entrance lobby through the dining room to the kitchen area. Exhaust air is not replaced primarily through the filtered makeup air unit.

Based on observation, on July 17, 2012 at approximately 11:00am onward, there are impediments in the means of egress that are not in immediate and continuous use. The following areas were observed with carts and other impediments:

1. first floor - corridor leading to exit discharge near the laundry and maintenance area.

2.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the medical gas piping system is incomplete due to the following:

1. medical gas piping is not identified by labels on both sides of partitions penetrated by piping system - corridor area near birthing center.

2. medical gas cylinders are not protected from extremes of weather in the outdoor oxygen bank area. The cylinders are gang secure, and supported directly on the concrete pad with rust accumulation on cylinders.

1. Based on observation, on July 17, 2012 at approximately 11:00am onward, the generator annunciator panel is not located in a continuously supervised area. The maintenance room, and engineering office is not staffed for twenty-four hours, seven days a week. Audible alarm signals from panel cannot be heard in corridor areas due to ambient sound levels from mechanical equipment room.

2. Based on observation, on July 18, 2012 at approximately 5:30am onward, there is no low fuel level alarm signal for a three hour operating capacity in the main fuel tank serving the emergency generators.

Based on observation, on July 18, 2012 at approximately 5:30am onward, operating room #2 medical gas sensor did not respond to a loss of pressure by closing the zone valve; and opening valve at ancillary equipment outlet.

Based on observation, on July 17, 2012 at approximately 11:00am onward, the facility is noncompliant with the National Electrical Code due to the following:

1. there is a multioutlet power tap used in room 319 of the Dialysis Unit. Receptacles in patient care areas shall be wired in metal raceways with redundant ground path as required by NFPA 99; and Section 517 of the National Electrical Code.

2. lack of minimum number #10 green insulated bonding jumper between normal and emergency panels serving the same patient vicinity - located in electrical room on second floor south wing.

3. receptacle under sink is not equipped with ground-fault interrupter protection - located in kitchen

4. lack of damp-proof rated emergency light fixture at loading dock exit discharge - lense of existing fixture has a hole in lense and covered with wire mesh.

5. lack of label on fire alarm control panel identifying the utility power supply from the Life Safety Branch panel circuit breaker serving the main fire alarm control panel - panel is located in the first maintenance room near the engineering office.

6. temporary wiring in hospital conex units containing hospital supplies - exposed bulb fixtures are located directly above combustible supplies; and romex wiring is exposed and installed improperly without junction boxes and proper fasteners.