HospitalInspections.org

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following building construction type was non-compliant, specific findings include:

1. Fifth floor - the marketing storage room ceiling is not complete as part of the ceiling is cut out as you enter the room on the left.

2. Ground floor - kitchen - openings not sealed in rated ceiling tile by the stove.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following corridor doors were non-compliant, specific findings include:

1. Fifth floor - the Behavioral Health room 573, the door is swinging in and is held open by a trashcan. There must be no impediment to closing doors.

2. Ground floor - central sterile has a dutch door that does not meet 19.3.6.3.6.

3. First floor rooms 167 and 172 has a gap grater than 1/8th of an inch and does not resist the passage of smoke.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following smoke barriers were non-compliant, specific findings include:

1. 1st floor - PCU - near room 172, the life safety plans show a smoke wall however the smoke wall was labeled "not a rated wall", verify smoke wall locations.

2. Ground floor - the smoke wall above cross corridor doors that lead to the laboratory has unsealed penetrations in conduit on the left hand side of the smoke wall.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following door opening in a smoke barrier was non-compliant, specific findings include:

Ground floor - birth place, the cross corridor smoke doors on the East Side had a gap greater than 1/8th of an inch and does not keep the doors smoke tight

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following hazardous area was non-compliant, specific findings include:

Fifth floor - the one hour Behavioral Health Unit (BHU) soiled linen/laundry room does not have a ? hour door installed.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following exit discharge illumination was non-compliant, specific findings include:

Ground floor, kitchen dry storage exit, the light fixture did not have a light bulb installed.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following fire alarm system and components were non-compliant, specific findings include:

1. Ground floor, the Fire Alarm Control Panel (FACP) at the control room was not properly labeled as to panel and circuit from which it is fed.

2. First floor, near room 172, the smoke damper did not close with activation of fire alarm system from either the pull station nor the duct detector.

3. Third floor, mechanical room, air handling units 862 and 861 are not equipped with access doors for maintenance of duct detectors.

4. First floor, smoke doors leading into the ICU did not close with activation of the fire alarm as the electric eye for the door did not deactivate with activation the fire alarm system.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following automatic sprinkler system and components were non-compliant, specific findings include:

1. The following areas were not equipped with an automatic sprinkler system:
a. Upper and lower levels of the north & south exit stairwell tower
b. Ground floor, ED office across from secondary security
c. Ground floor, registration station #2
d. Ground floor, trash compactor area cover
e. Ground floor, doctor's entrance cover
f. Second floor, south smoke chamber

2. Fire Pump House, main tank supply, the sprinkler tamper alarm did not function properly.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following maintenance for automatic sprinkler systems were non-compliant, specific findings include:

1. Ground floor, medical records, verify mixed sprinkler heads are compatible

2. The following areas were not equipped with sprinkler escutcheon plates:
a. Fifth floor, marketing storage room
b. Ground floor, materials management storage room
c. Ground floor, radiology pit area, "IT closet"
d. Forth floor, bathroom in staff break room

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include:

1.. Ground floor, Operating Rooms, the HVAC system did not shut down with fire alarm activation. It was confirmed with engineering staff that the system was not a smoke evacuating system and was designed to shut down on general alarm.

2. Verify HVAC shut down remote switches in the following areas:
a. Ground floor kitchen
b. Ground floor radiology
c. Ground floor lab

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following means of egress was non-compliant, specific findings include:

First floor, old PCU alcove, patient lift plugged into an electrical outlet charging in the corridor. The battery operated item was not in view of the nurses station.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following oxygen storage was non-compliant, specific findings include:

1. Hyperbaric chamber room, there was not empty and full signs for oxygen storage. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)]

2. Outside tank farm, there was not a cover over the tank farm cylinders to protect from inclement weather.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following relative humidity was non-compliant, specific findings include:

Ground floor, Operating Rooms 1 through 5, thirty five out of three hundred sixty five days of the year, a majority of three or more of the five available operating rooms were less than 20% relative humidity. Also see initial comments for high humidity.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following generators and its components were non-compliant, specific findings include:

A. Ground floor, switchboard location, Generator #3 did not have an audible signal when tested.

B. Ground floor, mechanical shop, ATS #1, Generator #3 took more than 10 seconds to transfer power.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following NFPA 70 items were non-compliant, specific findings include:

A. Ground floor, kitchen electrical room, Panel GKR3 had open spaces where blanks had been removed.

B. Fifth floor, north bedrooms, electrical outlet within six foot of a water source without GFI protection.

C. Birth Place, the environmental services closet had an exposed light bulb in the light fixture.

D. First floor, ICU med room, confirm electrical redundant grounding on the normal circuits. The emergency circuits in the same room showed a hospital grade outlet, however, the normal circuits did not.

Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following Alcohol Based Hand Rub (ABHR) was non-compliant, specific findings include:

Fifth floor, the doctors office has an ABHR installed over an ignition source.