HospitalInspections.org

Based on observation and staff interview the facility failed to ensure that building construction type and sprinklered stories were sprinklered throughout in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 3:00 p.m. revealed Elevator Penthouse 3 and 4 lacking the required sprinkler protection.

2) An observation on 10/30/18 at approximately 3:13 p.m. revealed Elevator Penthouse 1 and 2 lacking the required sprinkler protection.

3) An observation on 10/30/18 at approximately 3:54 p.m. revealed the Data Closet 2417 in Endoscopy 2 lacking the required sprinkler protection.

4) Interview on 10/30/18 at approximately 3:56 p.m. with the Director of Facilities Management verified this finding. The finding was also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 9:23 a.m. revealed two (2) penetrations in the left Elevator Control Room across from the Elevators on the 6th floor.

2) An observation on 10/30/18 at approximately 9:45 a.m. revealed an Information Technology Storage Room on the 1st floor lacking an automatic closer.

3) An observation on 10/30/18 at approximately 4:20 p.m. revealed the Emergency Department (ED) Storage Room 2301 on the 2nd floor was lacking an automatic door closer.

4) An observation on 10/30/18 at approximately 4:23 p.m. revealed a penetration around a high pressure steam line in the left rear corner of the Radiology Air Handler 10 Room.

5) An observation on 10/30/18 at approximately 4:26 p.m. revealed the Gift Shop Storage Room 2230 in Radiology was missing a door closure.

6) Interview on 10/30/18 at approximately 4:28 p.m. with the Environmental Safety Coordinator verified this finding. The finding was also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with National Fire Protection Association (NFPA) 25. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 9:38 a.m. revealed communication wiring tied to the sprinkler system in the interstitial space above the 6th floor corridor near Rooms 662 and 664.

2) An observation on 10/30/18 at approximately 10:01 a.m. revealed wires in the interstitial space above the 1st floor being supported by the sprinkler piping near the Room 1169 smoke doors.

3) An observation on 10/30/18 at approximately 10:02 a.m. revealed fire alarm wiring wrapped around the sprinkler system in the interstitial space above the 6th floor corridor near Room 6093.

4) An observation on 10/30/18 at approximately 10:20 a.m. revealed communication wires laying on the sprinkler system in the interstitial space above the 5th floor corridor near the 5 Northwest Nurse's Station.

5) An observation on 10/30/18 at approximately 10:22 a.m. revealed wires in the interstitial space above the 1st floor being supported by the sprinkler piping near the Room 1001B.

6) An observation on 10/30/18 at approximately 10:48 a.m. revealed communication wires tied to the sprinkler system in the interstitial space above the 5th floor corridor near Room 563.

7) An observation on 10/30/18 at approximately 1:36 p.m. revealed a drain line in the interstitial space above the 3rd floor taped to the sprinkler piping near the North Operating Room Staff Lounge.

8) An observation on 10/30/18 at approximately 1:59 p.m. revealed communication wires laying on the sprinkler system in the interstitial space above the 4th floor corridor near the 4 South Team 3 Nurse's Station.

9) An observation on 10/30/18 at approximately 2:09 p.m. revealed communication wires laying on the sprinkler system in the interstitial space above the 4th floor corridor near Room 432.

10) An observation on 10/30/18 at approximately 3:42 p.m. revealed communication wires and flex conduit laying on the sprinkler system in the interstitial space above the Stress Lab corridor near Room 2418.

11) An observation on 10/30/18 at approximately 3:57 p.m. revealed ductwork being supported by the sprinkler piping in the 2nd floor Endoscopy Mechanical Room

12) An observation on 10/30/18 at approximately 4:07 p.m. revealed communication wires and flex conduit laying on the sprinkler system in the interstitial space above the Radiology corridor near Room 2174.

13) Interview on 10/30/18 at approximately 4:09 p.m. with the Environmental Safety Coordinator verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview the facility failed to ensure that smoke and fire barriers were constructed and maintained to the appropriate fire resistance rating in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 9:52 a.m. revealed three (3) penetrations around conduit piping in the interstitial space above the the doors of the two (2) hour horizontal evacuation wall near Room 6068.

2) An observation on 10/30/18 at approximately 2:52 p.m. revealed an approximately two (2) inch piece of conduit which was not sealed in the interstitial space above the doors of the two (2) hour horizontal evacuation wall near Room 4139.

3) An observation on 10/30/18 at approximately 4:09 p.m. revealed an approximately two (2) inch penetration in the interstitial space above the two (2) hour fire doors in Radiology near Room 2239.

4) Interview on 10/30/18 at approximately 12:30 p.m. with the Director of Facilities Management verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview the facility failed to maintain smoke and fire barrier doors in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 11:01 a.m. revealed a set of ninety minute corridor doors not latching near Room 1167 on the 1st floor.

2) An observation on 10/30/18 at approximately 11:04 a.m. revealed the ninety (90) minute rated Horizontal Evacuation barrier doors near the Lactation Office Room 5007 exceeded the 1/8 inch requirement at the meeting edges of the doors.

3) An observation on 10/30/18 at approximately 11:08 a.m. revealed a set of ninety (90) minute corridor doors with an astragal lacking a coordinator near the Laboratory on the 1st floor.

4) An observation on 10/30/18 at approximately 11:27 a.m. revealed the smoke barrier doors near Room 516 exceeded the 1/8 inch requirement at the meeting edges near the top of the doors.

5) An observation on 10/30/18 at approximately 12:43 p.m. revealed a set of ninety (90) minute corridor doors lacking an astragal and a coordinator near Stairwell 3 and the Timeclock on the 1st floor.

6) An observation on 10/30/18 at approximately 2:23 p.m. revealed the smoke barrier doors near Room 415 would not close and exceeded the 1/8 inch requirement at the meeting edges of the doors.

7) An observation on 10/30/18 at approximately 2:30 p.m. revealed two sets of double smoke doors lacking coordinators near the Surgicare Corridor on the 1st floor.

8) An observation on 10/30/18 at approximately 2:52 p.m. revealed the ninety (90) minute rated horizontal evacuation doors near Room 4139 would not close and latch.

9) An observation on 10/30/18 at approximately 3:47 p.m. revealed a set of ninety (90) minute corridor doors not latching near the Endoscopy Center entrance on the 2nd floor.

10) Interview on 10/30/18 at approximately 3:49 p.m. with the Environmental Safety Coordinator verified these findings. The findings were were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on record review and staff interview the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) Record review on 10/30/18 at approximately 3:07 p.m. revealed fire drills recorded during the first shift of the first quarter at 1:40 p.m. and the first shift of the second quarter at 1:00 p.m., which were held within one (1) hour of each other.

2) Record review on 10/30/18 at approximately 3:11 p.m. revealed fire drills recorded during the first shift of the third quarter at 1:00 p.m. and the first shift of the fourth quarter at 1:30 p.m., which were held within one (1) hour of each other.

3) Record review on 10/30/18 at approximately 3:12 p.m. revealed that the facility failed to involve facility personnel (nurses, interns, maintenance engineers and administrative staff) on quarterly drills that were held during the first shift of the first quarter of 2018 and the second shift of the second quarter of 2018.

4) Interview on 10/30/18 at approximately 3:14 p.m. with the Environmental Safety Coordinator verified these findings. The findings were were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 10:00 a.m. revealed a junction box cover loose in the interstitial space above the 1st floor near Room 1169.

2) An observation on 10/30/18 at approximately 10:19 a.m. revealed a ninety (90) degree conduit body with the cover hanging loose in the interstitial space above the 1st floor near Room 1001B.

3) An observation on 10/30/18 at approximately 11:08 a.m. revealed a ninety (90) degree conduit body missing the cover, a connector in a junction box that needs removed and recovered and a junction box with no cover bearing connections on the outside of the box in the Machine Room near the Laboratory on the 1st floor.

4) An observation on 10/30/18 at approximately 1:36 p.m. revealed a junction box missing a cover, a flexible conduit lacking the correct termination and an extension cord in the interstitial space above the 3rd floor near the Operating Room Staff Lounge.

5) An observation on 10/30/18 at approximately 2:59 p.m. revealed covers missing on both elevator motors in Penthouse 3 and 4 on the roof.

6) An observation on 10/30/18 at approximately 3:01 p.m. revealed covers missing on both elevator motors in Penthouse 1 and 2 on the roof.

7) An observation on 10/30/18 at approximately 3:05 p.m. revealed covers missing on the elevator door and main motors, conduit missing with wires exposed from the control cabinet to the door motor and the controls cabinet missing covers in the cart lift in Penthouse 1 on the roof.

8) An observation on 10/30/18 at approximately 3:34 p.m. revealed covers missing on both elevator motors in the South Tower Penthouse on the roof.

9) Interview on 10/30/18 at approximately 3:36 p.m. with the Director of Facilities Management verified these findings. The findings were were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on record review and staff interview the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with National Fire Protection Association (NFPA)101. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) Record review on 10/29/18 at approximately 2:01 p.m. revealed no documentation for testing of the physical integrity, continuity of the grounding circuit, correct polarity of the hot and neutral connections and the retention force of the grounding blade for each electrical receptacle at the patient bed locations in the facility.

2) Interview on 10/29/18 at approximately 2:03 p.m. with the Director of Facilities Management verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation, record review and staff interview the facility failed to ensure that maintenance and testing of the generator and transfer switches was performed in accordance with National Fire Protection Association (NFPA) 110. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) Record review on 10/29/18 at approximately 2:22 p.m. revealed a generator intake damper between generator 1 and generator 2 with a no motor fail. This failure had not been repaired as of the date of survey.

2) Interview on 10/2918 at approximately 2:24 p.m. with the Director of Facilities Management verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on observation and staff interview the facility failed to ensure that nonflammable medical gas cylinder and storage requirements were in accordance with National Fire Protection Association (NFPA) 99. This deficient practice could affect all residents, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) An observation on 10/30/18 at approximately 11:38 a.m. revealed seven (7) oxygen cylinders being stored without the appropriate precautionary sign on the door of the Physical Therapy Department on the 5th floor.

2) An observation on 10/30/18 at approximately 2:40 p.m. revealed oxygen cylinders being stored within five (5) feet of combustibles in the Respiratory Oxygen Soiled Utility Room on the 3rd floor.

3) An observation on 10/30/18 at approximately 2:43 p.m. revealed oxygen cylinders being stored within five (5) feet of combustibles in the Intensive Care Unit Clean Storage Room on the 3rd floor.

4) An observation on 10/30/18 at approximately 4:18 p.m. revealed storage of empty and partially full oxygen cylinders that were not properly segregated in Room 2202 of Radiology.

5) An observation on 10/31/18 at approximately 10:04 a.m. revealed oxygen cylinders being stored without the appropriate precautionary sign on the door of the Intensive Care Unit Clean Storage Room on the 3rd floor.

6) Interview on 10/31/18 at approximately 10:06 a.m. with the Environmental Safety Coordinator verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.

Based on record review and staff interview the facility failed to ensure that personnel had received the appropriate medical gas equipment qualifications and training in accordance with National Fire Protection Association (NFPA) 99. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census 85.

Findings include:

1) Record review on 10/30/18 at approximately 2:43 p.m. revealed no documentation of initial training or orientation education to all staff that handle oxygen cylinders during the previous twelve (12) months.

2) Interview on 10/30/18 at approximately 2:45 p.m. with the Environmental Safety Coordinator verified this finding. The finding was also acknowledged by the Chief Executive Officer at the exit interview on 10/31/18.