HospitalInspections.org

Based on observation and interview, the facility failed to assure corridor fire doors closed to a positive latch.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 at 9:45 a.m. confirmed the lower rod on corridor fire doors on 8North by rooms 8126 and 8148 would not close to a positive latch.
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure exits were identified with readily visible signs in the means of egress.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 20, 2012 confirmed the exit by 3rd floor Ancillary west to the courtyard, the outside courtyard, and the exit to the loading dock were not provided with exit signs.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure fire walls are being maintained.

The findings include:

Observation on June 19, 2012 between the times of 9:30 a.m. and 10:30 a.m. revealed penetrations in fire walls in the following locations:
1. Ground floor telecommunication room has three (3) penetrations of four (4) inch conduits that are not sealed with fire proofing.
2. Above the fire doors in the area called the "New Section".
3. Above room 8809 in the area called the "New Section".

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure hazardous area ' s one (1) hour fire rated construction is maintained.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 between at 10:00 a.m. and 4:15 p.m. confirmed unsealed penetrations in the following locations:
1) 5th floor NICU electrical room and communication room
2) 5 West had a round open duct through a 1-hour wall in the mechanical room
3) 5 East mechanical room had Hilti sleeves that were not closed
4) 3rd floor by rehab services had unsealed sleeve above ceiling at the fire doors
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation the facility failed to assure fire walls in hazardous areas are being maintained.

The findings include:

Observation on June 19, 2012 at 2:16 p.m. in the telecommunication room revealed penetrations on the wall and above ceiling.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure exit access and exit discharge was readily accessible.

The findings include:

Observation on June 19, 2012 at 8:39 a.m. revealed the exit in the corridor before entering the Operation Room "O.R." the exit access and exit discharge was not readily accessible by the following:
1. The exit door would not open upon testing of the door.
2. From the exit access the exit discharge was to a grass lawn with no hard surface leading to the public way.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure corridors were clear and unobstructed.

The findings include:

Observation on June 19, 2012 at 9:30 a.m. and 11:00 a.m. on the ground floor corridor at the Women's Services revealed a linen cart and portable trash can.

The finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure exits paths were lighted such that the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 at 11:00 a.m. confirmed the outside lights at 6 of 9 floor's exit discharges from the building stairwell exits of the smoking tower were not provided with multiple fixtures (bulbs).
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure that the exit discharge was provided with a two (2) bulb light fixture so that the failure of any single bulb will not leave the area in total darkness.

The findings include:

Observation on June 19, 2012 at 2:45 p.m. and 3:31 p.m. revealed the following locations were not provided with a two bulb light fixture to provide illumination for the path of egress:
1. Outside of exit at Patient Hallway South.
2. Outside of exit by Mechanical Room

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure that the exit discharge was provided with a two (2) bulb light fixture so that the failure of any single bulb will not leave the area in total darkness.

The findings include:

Observation on June 20, 2012 at 8:39 a.m. revealed the exit discharge from the corridor before entering the Operation Room "O.R." has no two bulb fixture for the illumination for the path of egress.

The finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure smoke detectors were located at least 3 feet from an air supply (NFPA 72, 2-3.5.1).
The findings include:
Observation and interview with the Maintenance Supervisor, on June 20, 2012 at 11:15 a.m. confirmed the smoke detectors in the microbiology specimen room and 5th floor North clean utility room. were located 1-foot from an air supply.This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure sprinkler heads were at least six (6) feet apart (NFPA 13, 5-6.3.4).
The findings include:
Observation and interview with the Maintenance Supervisor, in the kitchen dry storage area on June 20, 2012 at 1:30 p.m. confirmed two (2) of two (2) sprinkler heads were four (4) feet apart.
NFPA 25, 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall).
Based on observation and interview, the facility failed to assure sprinkler heads were free of foreign material
The findings include:
Observation and interview with the Maintenance Supervisor, in the kitchen on June 20, 2012 at 1:30 p.m. confirmed 12 of 42 sprinkler heads were had an excessive buildup of lint and dirt.

Based on observation and interview, the facility failed to assure Sprinkler piping or hangers were not used to support non-system components. (NFPA 13, 9-1.1.7)
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19 and 20, 2012 through the tour confirmed low voltage and communication wiring above the lay in ceiling was attached to or supported by sprinkler piping in the following locations: By 9129, stairwell by 8145, 6 North at south end outside electrical room, 5 West outside mechanical room, 7 West by 7081, and 4 North outside mechanical room 419.
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure fire extinguishers had complied with their 6-year maintenance requirement (NFPA 10, 4-4.3).
The findings include:Observation and interview with the Maintenance Supervisor, at the 5th floor of 1938 building near elevator D Nurses station on June 19, 2012 at 3:30 p.m. confirmed an ABC dry chemical extinguisher was last Hydrostatically tested in 2003 and failed to have its 6-year maintenance performed.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure fire extinguishers complied with requirements of NFPA 10

The findings include:

Observation on June 19, 2012 at 3:24 p.m. and 3:30 p.m. revealed were obstructed at the following locations:
1. In the Respiratory Therapy Storage Room a supply cart was place in front of the fire extinguisher.
2. In the CT Room the fire extinguisher was located behind the door.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure the No Smoking signs were provided in areas where oxygen is used or stored (NFPA 99, 8.6.4.2).
The findings include:
Observation and interview with the Maintenance Director, on June 19, 2012 at 11:15 a.m. confirmed the 6 North clean linen storage rooms having Oxygen cylinders stored and no " NO smoking " sign was provided on the door.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure corridor fire doors closed to a positive latch.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 at 9:45 a.m. confirmed the lower rod on corridor fire doors on 8North by rooms 8126 and 8148 would not close to a positive latch.
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure exits were identified with readily visible signs in the means of egress.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 20, 2012 confirmed the exit by 3rd floor Ancillary west to the courtyard, the outside courtyard, and the exit to the loading dock were not provided with exit signs.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure fire walls are being maintained.

The findings include:

Observation on June 19, 2012 between the times of 9:30 a.m. and 10:30 a.m. revealed penetrations in fire walls in the following locations:
1. Ground floor telecommunication room has three (3) penetrations of four (4) inch conduits that are not sealed with fire proofing.
2. Above the fire doors in the area called the "New Section".
3. Above room 8809 in the area called the "New Section".

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure hazardous area ' s one (1) hour fire rated construction is maintained.
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 between at 10:00 a.m. and 4:15 p.m. confirmed unsealed penetrations in the following locations:
1) 5th floor NICU electrical room and communication room
2) 5 West had a round open duct through a 1-hour wall in the mechanical room
3) 5 East mechanical room had Hilti sleeves that were not closed
4) 3rd floor by rehab services had unsealed sleeve above ceiling at the fire doors
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation the facility failed to assure fire walls in hazardous areas are being maintained.

The findings include:

Observation on June 19, 2012 at 2:16 p.m. in the telecommunication room revealed penetrations on the wall and above ceiling.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure exit access and exit discharge was readily accessible.

The findings include:

Observation on June 19, 2012 at 8:39 a.m. revealed the exit in the corridor before entering the Operation Room "O.R." the exit access and exit discharge was not readily accessible by the following:
1. The exit door would not open upon testing of the door.
2. From the exit access the exit discharge was to a grass lawn with no hard surface leading to the public way.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure corridors were clear and unobstructed.

The findings include:

Observation on June 19, 2012 at 9:30 a.m. and 11:00 a.m. on the ground floor corridor at the Women's Services revealed a linen cart and portable trash can.

The finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure exits paths were lighted such that the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19, 2012 at 11:00 a.m. confirmed the outside lights at 6 of 9 floor's exit discharges from the building stairwell exits of the smoking tower were not provided with multiple fixtures (bulbs).
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure that the exit discharge was provided with a two (2) bulb light fixture so that the failure of any single bulb will not leave the area in total darkness.

The findings include:

Observation on June 19, 2012 at 2:45 p.m. and 3:31 p.m. revealed the following locations were not provided with a two bulb light fixture to provide illumination for the path of egress:
1. Outside of exit at Patient Hallway South.
2. Outside of exit by Mechanical Room

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation, the facility failed to assure that the exit discharge was provided with a two (2) bulb light fixture so that the failure of any single bulb will not leave the area in total darkness.

The findings include:

Observation on June 20, 2012 at 8:39 a.m. revealed the exit discharge from the corridor before entering the Operation Room "O.R." has no two bulb fixture for the illumination for the path of egress.

The finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure smoke detectors were located at least 3 feet from an air supply (NFPA 72, 2-3.5.1).
The findings include:
Observation and interview with the Maintenance Supervisor, on June 20, 2012 at 11:15 a.m. confirmed the smoke detectors in the microbiology specimen room and 5th floor North clean utility room. were located 1-foot from an air supply.This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure sprinkler heads were at least six (6) feet apart (NFPA 13, 5-6.3.4).
The findings include:
Observation and interview with the Maintenance Supervisor, in the kitchen dry storage area on June 20, 2012 at 1:30 p.m. confirmed two (2) of two (2) sprinkler heads were four (4) feet apart.
NFPA 25, 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall).
Based on observation and interview, the facility failed to assure sprinkler heads were free of foreign material
The findings include:
Observation and interview with the Maintenance Supervisor, in the kitchen on June 20, 2012 at 1:30 p.m. confirmed 12 of 42 sprinkler heads were had an excessive buildup of lint and dirt.

Based on observation and interview, the facility failed to assure Sprinkler piping or hangers were not used to support non-system components. (NFPA 13, 9-1.1.7)
The findings include:
Observation and interview with the Maintenance Supervisor, on June 19 and 20, 2012 through the tour confirmed low voltage and communication wiring above the lay in ceiling was attached to or supported by sprinkler piping in the following locations: By 9129, stairwell by 8145, 6 North at south end outside electrical room, 5 West outside mechanical room, 7 West by 7081, and 4 North outside mechanical room 419.
These findings were verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation and interview, the facility failed to assure fire extinguishers had complied with their 6-year maintenance requirement (NFPA 10, 4-4.3).
The findings include:Observation and interview with the Maintenance Supervisor, at the 5th floor of 1938 building near elevator D Nurses station on June 19, 2012 at 3:30 p.m. confirmed an ABC dry chemical extinguisher was last Hydrostatically tested in 2003 and failed to have its 6-year maintenance performed.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.

Based on observation, the facility failed to assure fire extinguishers complied with requirements of NFPA 10

The findings include:

Observation on June 19, 2012 at 3:24 p.m. and 3:30 p.m. revealed were obstructed at the following locations:
1. In the Respiratory Therapy Storage Room a supply cart was place in front of the fire extinguisher.
2. In the CT Room the fire extinguisher was located behind the door.

These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on June 20, 2012

Based on observation and interview, the facility failed to assure the No Smoking signs were provided in areas where oxygen is used or stored (NFPA 99, 8.6.4.2).
The findings include:
Observation and interview with the Maintenance Director, on June 19, 2012 at 11:15 a.m. confirmed the 6 North clean linen storage rooms having Oxygen cylinders stored and no " NO smoking " sign was provided on the door.
This finding was verified by the Maintenance Supervisor and acknowledged during the exit conference on June 20, 2012.