HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances throughout the facility.

Findings Include:

Observation from 10/25/10 to 10/27/10 revealed the following:

a) On 10/25/10 at 9:56am, the corridor door to room 610 was not capable of closing and latching due to medical equipment.
b) On 10/25/10 at 10:21am, the corridor door to room 426 was not capable of closing and latching due to medical equipment.
c) On 10/27/10 at 10:02am, the morgue door lacked positive latching.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain smoke walls in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 10:42am, the smoke wall was not complete in the 4th floor Echo Tech Room.
b) At 12:42pm, there were smoke wall penetrations in room 343 and 344.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

A) At 10:20 am, The door to the dietary storage room # 20043B lacks automatic closure.
B) At 11:00 am, There was a penetration around a steam pipe in the machine room S3 that was not sealed.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance throughout the facility.

Findings Include:

Observation on 10/26/10 at 9:40am revealed the following:

The materials management room 349 door was being taped open.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in one instance throughout the facility.

Findings Include:

Observation on 10/26/10 revealed the following:

a) At 1:00 pm, the double doors exiting out of stairtower "C" on the 1st floor, does not meet the minimum requirements for door openings.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in three instances throughout the facility.

Findings Include:

Observation on 10/26/10 revealed the following:

a) At 10:20am, the doors in the 2nd floor surgical unit did not swing in the direction of egress.
b) At 11:00am, the cage at the kitchen delivery dock was being locked against egress.
c) At 1:33pm, there were exit signs directing people to exit through the ER consultation room.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain sprinkler requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 10:00 am, there were red cables attached to the sprinkler piping in the overhead above smoke wall near room 609.
b) On 10/26/10 at 9:27am, there were wire attached to the sprinkler piping in the overhead in the 2nd floor connector bridge.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.




26275

Based on observation and interview, it was determined the facility failed to maintain sprinkler requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:40pm, there were sprinkler heads spaced closer than six feet in the corridor by room 339.
b) On 10/26/10 at 9:27am, the informational signs obstruct the sprinkler heads in the 3rd floor connecting walkway.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in one instance throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 9:00 am, exit discharge from the basement level was being blocked by equipment and beds. There were [10] hospital beds being stored in the corridor under signs which read
" Life safety regulations require this corridor to remain clear".

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

a) At 10:01am, exit discharge from the ground level biohazard area was being blocked by equipment and snow removal supplies.
b) At 10:20am, exit discharge from the PT area was blocked by overgrown plants.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain medical gas requirements in one instance throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 9:00 am, there was an unsecured oxygen cylinder being stored on an bed in the corridor in the basement near the machinery space stairs.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain medical gas requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:47pm, there was an unsecured oxygen cylinder being transported on an bed through the corridor near the mechanical space.
b) On 10/26/10 at 1:35pm, there were unsecured carbon dioxide cylinders in the ER beverage center.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain piped in medical gases in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

A) At 1:00 pm, There is a 2" oxygen pipe passing through the main 800 amp switchgear room in the basement.
B) At 11:00 am, There was no power to the medical gas zone alarm panel at NCU/EMG corridor.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

There was an open junction box above the ceiling near radiology room # 20043B


Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in three instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:17pm, there were multiple extension cords in the gift shop.
b) On 10/26/10 at 11:19am, there was an extension cord in use in the president's office
c) On 10/26/10 at 1:00pm, there was an extension cord in the auditorium AV room.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances throughout the facility.

Findings Include:

Observation from 10/25/10 to 10/27/10 revealed the following:

a) On 10/25/10 at 9:56am, the corridor door to room 610 was not capable of closing and latching due to medical equipment.
b) On 10/25/10 at 10:21am, the corridor door to room 426 was not capable of closing and latching due to medical equipment.
c) On 10/27/10 at 10:02am, the morgue door lacked positive latching.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain smoke walls in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 10:42am, the smoke wall was not complete in the 4th floor Echo Tech Room.
b) At 12:42pm, there were smoke wall penetrations in room 343 and 344.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

A) At 10:20 am, The door to the dietary storage room # 20043B lacks automatic closure.
B) At 11:00 am, There was a penetration around a steam pipe in the machine room S3 that was not sealed.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance throughout the facility.

Findings Include:

Observation on 10/26/10 at 9:40am revealed the following:

The materials management room 349 door was being taped open.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in one instance throughout the facility.

Findings Include:

Observation on 10/26/10 revealed the following:

a) At 1:00 pm, the double doors exiting out of stairtower "C" on the 1st floor, does not meet the minimum requirements for door openings.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in three instances throughout the facility.

Findings Include:

Observation on 10/26/10 revealed the following:

a) At 10:20am, the doors in the 2nd floor surgical unit did not swing in the direction of egress.
b) At 11:00am, the cage at the kitchen delivery dock was being locked against egress.
c) At 1:33pm, there were exit signs directing people to exit through the ER consultation room.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain sprinkler requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 10:00 am, there were red cables attached to the sprinkler piping in the overhead above smoke wall near room 609.
b) On 10/26/10 at 9:27am, there were wire attached to the sprinkler piping in the overhead in the 2nd floor connector bridge.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.




26275

Based on observation and interview, it was determined the facility failed to maintain sprinkler requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:40pm, there were sprinkler heads spaced closer than six feet in the corridor by room 339.
b) On 10/26/10 at 9:27am, the informational signs obstruct the sprinkler heads in the 3rd floor connecting walkway.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in one instance throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 9:00 am, exit discharge from the basement level was being blocked by equipment and beds. There were [10] hospital beds being stored in the corridor under signs which read
" Life safety regulations require this corridor to remain clear".

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain exiting requirements in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

a) At 10:01am, exit discharge from the ground level biohazard area was being blocked by equipment and snow removal supplies.
b) At 10:20am, exit discharge from the PT area was blocked by overgrown plants.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain medical gas requirements in one instance throughout the facility.

Findings Include:

Observation on 10/25/10 revealed the following:

a) At 9:00 am, there was an unsecured oxygen cylinder being stored on an bed in the corridor in the basement near the machinery space stairs.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain medical gas requirements in two instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:47pm, there was an unsecured oxygen cylinder being transported on an bed through the corridor near the mechanical space.
b) On 10/26/10 at 1:35pm, there were unsecured carbon dioxide cylinders in the ER beverage center.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain piped in medical gases in two instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

A) At 1:00 pm, There is a 2" oxygen pipe passing through the main 800 amp switchgear room in the basement.
B) At 11:00 am, There was no power to the medical gas zone alarm panel at NCU/EMG corridor.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in instances throughout the facility.

Findings Include:

Observation on 10/27/10 revealed the following:

There was an open junction box above the ceiling near radiology room # 20043B


Interview with facility representative #1 confirmed the condition existed on the time and date stated above.



26275

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in three instances throughout the facility.

Findings Include:

Observation on 10/25/10 and 10/26/10 revealed the following:

a) On 10/25/10 at 12:17pm, there were multiple extension cords in the gift shop.
b) On 10/26/10 at 11:19am, there was an extension cord in use in the president's office
c) On 10/26/10 at 1:00pm, there was an extension cord in the auditorium AV room.

Interview with facility representative #1 confirmed the condition existed on the time and date stated above.