HospitalInspections.org

Based on observation and staff interviews on February 9, 2017 between 0900-1830 the facility failed to maintain the fire resistance rating of the construction of the facility. This could lead to the rapid spread of smoke and products of combustion from one smoke compartment to the other.

The findings include, but are not limited to:

The Old Emergency Department West Storage room was missing ceiling tiles.
The Clean Room in Sterile Processing had a 3 inch penetration in the fire wall.
Emergency Room IT 0188.00013 room has several penetrations in the fire wall.

The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews, on February 9, 2017 between 0900-1830, the facility failed to equipe all required doors with self-closers. This could lead to the spread of fire and products of combustion when doors do not automatically shut in the event of the fire alarm or sprinkler activation.

The findings include, but are not limited to:

IT Clean room had a rated door with no self-closure.

The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between 0900-1830 the facility failed to maintain a record of the monthly and annual emergency lighting testing.

The findings include, but are not limited to:

The facility was unable to produce a record of their monthly and annual emergency lighting testing.


The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between 0900-1830 the facility failed to ensure all exit signs were illuminated. This could lead to confusion in the event of an emergency.

The findings include, but are not limited to:

Exit sign by room 908 was out.


The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between 0900-1830 the facility failed to maintain the sprinkler system as required by NFPA 25. This could lead to the sprinkler heads not activating as they should.

The findings include, but are not limited to:

The following locations had excessively dirty sprinkler heads. NFPA 25 5.2.1.1.1.
8th floor custodian's closet.
5th floor conference room, custodian room, and storage room.
ICU staff bathroom.
PCU med room/clean utility.

Imaging writing room had sprinkler head pushed into the ceiling. NFPA 25 5.2.1.1.7.

The following locations had storage within 18 inches of the sprinkler head. NFPA 25 5.2.1.2.6.
Pathology storage area.
9th floor unit manager's office.
Laboratory waiting room sprinkler head blocked by television. NFPA 25

The ACC in the second floor corridor had wires wrapped around the sprinkler pipes. NFPA 25 5.2.2.2.


The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between 0900-1830 the facility failed to maintain fire extinguishers as required by NFPA 10. This could lead to staff being unable to access the extinguishers in the event of a fire.

The following extinguishers were above the 5 feet as required by NFPA 10.

By room 202.
PCU med room/clean utility room.


The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between the hours of 0900-1830 the facility failed to maintain the integrity of fire rated doors. This could allow fire and smoke to more easily pass from one compartment to the other, endangering the lives of patients, visitors, and staff.

The findings include, but are not limited to:

The 5th floor medical storage room fire door was missing the locking core. (Fixed at time of inspection).
9th floor Doctor's office was held open with a door wedge.
NICU clean utility room not latching.
Staff room by Nurses station on the 8th floor was held open with a garbage can and did not latch.
3rd floor cross corridor doors in breezeway did not latch.
PCU cross corridor doors did not latch.

The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between the hours of 0900-1830 the facility failed to restrict the use of powerstrips to UL 1363 and UL 1363A. This could result in a fire from an overheated powerstrip or too much draw on the electrical system endangering patients, visitors, and staff.

The findings include, but are not limited to:

Extension cords in use at Chemistry Station in Laboratory.
Extension cord in use in Robotics operating room for the lens heater.
9th floor Custodian's closet.
9th floor 1118 Social Workers office had non-UL listed powerstrips.
9th floor Medical Director had a non-UL powerstrip.
9th floor Nurses station had daisy chaining.
8th floor Custodian's closet by kitchen.
5th floor Nurses station had daisy-chaining.
ICU staff lounge had a non-UL powerstrip and multiple appliances plugged into the powerstrip.
ICU Secretary station had two non-UL powerstrips
PCU by room 201 had a non-UL powerstrip.
Clean room in Sterile Processing had a multi-plug adapter.
Echo Reading room had multiple appliances in powerstrip.
An extension cord was in use in the read room as permanent wiring.
Ultrasound Imaging room had appliances plugged into the powerstrip.
Echo Station had an appliance plugged into a powerstrip.
Emergency Room Doctor's workroom had multiple appliances plugged into a powerstrip.
Laboratory staff room had multiple appliances plugged into powerstrips.
Back T of laboratory had daisychaining.
Automation line in the Laboratory had non-UL powerstrips (x2).
Pharmacy had non UL powerstips.
Biomed break room had appliances plugged into powerstrips.
Storage Receiving desk had an appliance plugged into a powerstrip.
OR Staff Lounge has an appliance plugged into a powerstrip.


The above was discussed with the maintenance staff who accompanied us on the facility tour.

Based on observation and staff interviews on February 9, 2017 between the hours of 0900-1830 the facility failed to maintain a remote stop for the generators. This could lead to the endangerment of staff if they had to stop the generator.

The findings include, but are not limited to: the facility does not have remote stop for the generator.

NFPA 101 9.1.3.1, NFPA 99 15.5.1.3, NFPA 110 5.6.5.6.

The above was discussed with the maintenance staff who accompanied us on the facility tour.