HospitalInspections.org

Based on observation and interview, the facility failed to maintain two exits for every occupiable area on one of four building levels.

Findings include:

Observation on December 14, 2016, at 9:50 AM revealed storage was in the unoccupied attic space. This attic space has only one exit, and should remain unoccupiable.

Interview with Maintenance Director on December 14, 2016, at 9:50 AM confirmed the facility had storage in the unoccupiable attic area.

Based on observation and interview, the facility failed to maintain exit discharges to be obstruction-free at one of three ground floor Maintenance Department exits.

Findings include:

Observation on December 14, 2016, at 12:45 PM revealed ground floor Maintenance Department exit stairs from the sprinkler area to the outside were not cleared of snow accumulation.

Interview with Maintenance Director on December 14, 2016, at 12:45 PM confirmed the stairs were not cleared of snow accumulation.

Based on observation and interview, the facility failed to maintain vertical openings at one of six exit stair towers.

Findings include:

Observation on December 14, 2016, at 11:27 AM revealed an unsealed stair tower penetration above the door of Original Building exit stair tower near the Dietary Department.

Interview with Maintenance Director on December 14, 2016, at 11:27 AM confirmed the unsealed stair tower penetration.

Based on observation and interview, the facility failed to maintain hazardous areas in accordance with regulations on two of four building levels.

Findings include:

Observation on December 14, 2016, between 10:10 AM and 1:05 PM revealed the following hazardous areas are not properly separated from other areas:
A. Second floor laundry door across from SP2 lacked positive latching with the self-closure. (10:10 AM)
B. Ground floor elevator equipment room "B" door near Radiology lacked positive latching with the self-closure. (11:20 AM)
C. Ground floor gift shop door lacked positive latching with the self-closure. (12:50 PM)
D. Ground floor records storage room (unsprinklered location) near Main Entrance had an unrated door frame, and the corridor walls were not properly sealed. (1:05 PM)

Interview with Maintenance Director on December 14, 2016, at 1:05 PM confirmed the above hazardous areas do not meet regulations.

Based on document review and interview, the facility failed to maintain the fire alarm system for one of one fire alarm system.

Findings include:

Document review on December 14, 2016, at 9:00 AM revealed the last two fire drills (October 13, 2016, and November 25, 2016) documented the E. D. Department bell signal was weak and difficult to hear.

Interview with Maintenance Director on December 14, 2016, at 9:00 AM confirmed the fire alarm notification signal in the E. D. Department was difficult to hear.

Based on document review and interview, the facility failed to maintain a policy to address out-of-service fire alarm systems for one of one fire alarm system.

Findings include:

Observation on December 14, 2016, at 9:45 AM revealed the facility lacked a policy to address a fire alarm that is not in service for more than four hours in a 24 hour period, which includes:
A. Notification of authority having jurisdiction.
B. Building evacuation - OR - fire watch in areas left unprotected by the shutdown until the fire alarm system has been returned to service.

Interview with Maintenance Director on December 14, 2016, at 9:45 AM confirmed the lack of fire alarm out-of-service policy.

Based on observation and interview, the facility failed to maintain the sprinkler system supervisory signals for one of one fire sprinkler system.

Findings include:

Observation on December 14, 2016, at 1:15 PM revealed the fire sprinkler post indicator valve outside of Employee entrance was not equipped with an electrical tamper switch connected to the fire alarm system.

Interview with Maintenance Director on December 14, 2016, at 1:15 PM confirmed the lack of a tamper switch on the post indicator valve.

Based on observation and interview, the facility failed to maintain the fire sprinkler system on one of one fire sprinkler system.

Findings include:

Observation on December 14, 2016, at 9:55 AM revealed the attic area had storage within 18" of the fire sprinkler head behind the elevator.

Interview with Maintenance Director on December 14, 2016, at 9:55 AM confirmed the storage within 18" of the fire sprinkler head.

Based on document review and interview, the facility failed to maintain a policy to address out-of-service fire sprinkler systems for one of one fire sprinkler system.

Findings include:

Observation on December 14, 2016, at 9:47 AM revealed the facility lacked a policy to address a fire sprinkler system that is not in service for more than 10 hours in a 24 hour period, which includes:
A. Notification of authority having jurisdiction.
B. Building evacuation - OR - fire watch in areas left unprotected by the shutdown until the fire sprinkler system has been returned to service.

Interview with Maintenance Director on December 14, 2016, at 9:47 AM confirmed the lack of fire sprinkler out-of-service policy.

Based on observation and interview, the facility failed to maintain corridor walls to be constructed with at least 1/2 hour fire resistance rating on one of four building levels.

Findings include:

Observation on December 14, 2016, at 11:30 AM revealed a corridor conduit penetration above the door to the Dietary Department was filled with fabric.

Interview with Maintenance Director on December 14, 2016, at 11:30 AM confirmed the corridor wall conduit penetration was not sealed with an approved product for use in corridor walls.

Based on observation and interview, the facility failed to maintain smoke barrier construction for one of four smoke barrier walls.

Findings include:

Observation on December 14, 2016, at 11:00 AM revealed first floor resident room #101 smoke barrier wall had an unsealed medical gas line penetration.

Interview with Maintenance Director on December 14, 2016, at 11:00 AM confirmed the unsealed smoke barrier penetration.

Based on document review and interview, the facility failed to maintain emergency generators for one of two generators.

Findings include:

Document review on December 14, 2016, at 9:15 AM revealed the last annual generator inspection of November 18, 2016 noted, "Generator Olympian fuel leaks, injection pump needs repaired ASAP."

Interview with Maintenance Director on December 14, 2016, at 9:15 AM confirmed the emergency generator deficiency.

Based on observation and interview, the facility failed to maintain power cords, used with general precautions, on two of four building levels.

Findings include:

Observation on December 14, 2016, between 10:20 AM and 11:45 AM revealed the following areas had unauthorized devices plugged into surge protectors, and not plugged directly into an electrical outlet.
A. Second floor Coding/Conference room, microwave oven and toaster. (10:20 AM)
B. Ground floor E. R. breakroom, coffee maker. (11:15 AM)
C. Ground floor Stereotactic room, patient procedure table. (11:45 AM)

Interview with Maintenance Director on December 14, 2016, at 11:45 AM confirmed the above items were plugged into surge protectors.

Based on observation and interview, the facility failed to maintain medical gas cylinder storage in one of one main medical gas storage room.

Findings include:

Observation on December 14, 2016, at 1:30 PM revealed ground floor main medical gas storage room had empty cylinders that were not segregated from full cylinders.

Interview with Maintenance Director on December 14, 2016, at 1:30 PM confirmed the oxygen cylinders were not segregated between full and empty.