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Based on interview and observation, the facility failed to ensure each door protecting a corridor opening had suitable means to keep it closed.

Findings:

On 07/24/12 at 10:33 A.M. on the 6th floor of the H building the corridor door between the nurses lounge and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/24/12 at 10:33 A.M. Staff DD verified the finding.

On 07/25/12 at 3:45 P.M. on the 2nd floor of the H building the corridor door between room H2 240A and the corridor was observed to not have a suitable means to keep it closed as tape had been applied to the latch to disable the latch.

On 07/25/12 at 3:45 P.M. Staff DD verified the finding.

Based on facility observation and staff verification, the facility failed to ensure that stairways and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted on Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have fire rated stair way doors in place.

1. Observation of the stair door on third floor of the M building, revealed the one hour fire rated door did not positively latch when the door was tested. Staff present on tour verified the observation.

Based on facility observation and staff verification, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, a required smoke detection system, and the automatic sprinkler system, if installed. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the S Building was conducted on 07/25/12 between the hours of 11:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following fire rated doors did not securely latch when tested by releasing from the magnetic hold open device.

1. Located on the ninth floor, fire rated doors were noted to separate the north side of the floor from the south. The door was located near room S9-996. When released from the magnetic hold the fire rated door failed to securely latch in a closed position.

2. Located on the second floor, fire rated doors ( S2-206) were noted to separate the S Building from the T Building. Release of the two-hour fire rated doors from the magnetic hold open, revealed the doors failed to latch when in the closed position. Staff present on tour verified the findings.









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Findings include:

Facility tour of building T took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor mechanical room identified as T5-04, observation was made of a one hour fire rated wall separating this mechanical room from two adjacent mechanical rooms. Within the fire rated wall was a door equipped with a self-closing device which was ineffective due to the door being propped open with an approximate three foot long two by four piece of wood.


This finding was verified by all staff members during tour on 07/25/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 1:30 P.M. and 4:00 P.M. tour of the Cole Eye Institute was conducted with Staff AA, FF and WW1. Tour of the first floor revealed the presence of an ambulatory surgical area with four operating rooms. Observation of the pre-operative and post-operative areas revealed there was no directional signs to show the way out of the area.

Interview of a staff nurse regarding how to locate the way out of the area, revealed the staff would show the patients the way out. Staff FF verified that directional exit signs were not in place to show the way out.

Based on facility observation and staff interview and verification, the facility failed to ensure door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing in accordance with 19.2.2.2.6. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have doors located in smoke barriers that did not close .

1. Observation of smoke barrier door located at 010431B was observed to fail to close when tested. Staff present on tour verified the observation.

Based on facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Crile Building was conducted on 07/31/12 between the hours of 9:05 A.M. and 5:00 P.M. with Staff FF, II and WW1. The following findings were noted in storage areas:

1. Located on the twelfth floor, a dirty utility room was observed. Observation of the room revealed the door had no self-closing device in place.

2. Located on the seventh floor, room A7-116D was observed to be a medical supply storage room. No self-closing device was on the door to the room.

3. A storage room identified as A6-401 was observed. The storage area had no self-closing device on the door.

4. Room A6-508 identified as the apprentice copier room was noted to have storage of paper products. The door to the storage room did not have a self closing device in place.

5. Room A5-420 was noted to be a storage room for medical records and other combustible items. The door to the room did not have a self-closing device.

6. Room A 5-507 was identified as a storage room. The door to the room had no self closing device in place.

7. Rooms A2-209, an x-ray department soiled utility room, A2-539, a storage room, A2-533 a storage room and A2-117, a storage area for miscellaneous combustible items did not have self closing devices on the doors.

8. Room A3-153 a storage room in the adult endoscopy center was noted to have no closer on the door.

9. Two soiled utility rooms, A3-185 and A3-138, were observed to have no self closing devices on the doors.

10. Room A1-172, a soiled utility room was noted to have no self closing device on the door to the room.

Staff present on tour verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, was conducted on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. with Staff BB, CC, DD, FF, PP, JJ, and QQ.

Tour of the seventh floor revealed a large area for patient rehabilitation services. The area was identified as the gym. Tour inside the gym revealed the presence of three exit doors. Located near the center of the room was an exit sign which noted the way out to the exit corridor.

Following the sign toward the door revealed the exit door was blocked by a table with items stacked on it. Other items in the exit way was a chair and additional boxes . Staff present on tour verified the way out of that exit door was blocked and inaccessible.

On 07/30/12 from 2:41 P.M. to 4:00 P.M. a tour was conducted of the 3rd floor of the Q building. The tour and schematic revealed the floor contained three suites: a non-sleeping procedure suite of 5478 square feet (1), a non-sleeping prep/recovery suite of 5914 square feet (2), and a waiting area of 705 square feet (3). By observation and review of the schematic, Suite #1 had one exit into corridor Q03 16, and the other into Suite #2. By observation and review of the schematic, Suite #2 had one exit into corridor Q03 14, another into Suite #1, and two others into Suite #3. By observation and review of the schematic, Suite #3 had one exit into lobby Q03 116, and another into Suite #2.

On 07/30/12 during the tour from 2:41 P.M. to 4:00 P.M. in an interview Staff DD confirmed the findings.




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Based on facility tour and staff interview it was determined this facility failed to ensure any suite of rooms greater than 1,000 sq. ft. has at least two exit access doors remote from each other and the exit accesses may not exit through an intervening suite. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 1,113.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor post anesthesia care unit (PACU Suite) which had a total of 5,250 sq. ft., observation was made of three exit accesses, two of which had egress access through intervening suites. The floor plan was reviewed and verified this finding. Staff BB stated on 08/01/12 during tour of the PACU that they were aware of this and were planning on applying for a waiver after a citation was issued.

Based on observation the facility failed to comply with NFPA 110 5-3, referenced in NFPA 101 7.9, referenced in NFPA 101 19.2.9.1, by failing to have battery powered emergency lighting in the generator room in building rr.

Findings:

On 07/26/12 at 3:44 P.M. a tour was conducted of the generator room. The room was observed to have emergency lighting, but the lighting did not have battery power backup.

On 07/26/12 at 3:44 P.M. Staff DD confirmed the room did not have battery power back up and said the generators themselves would run the lights in the room if power was lost.

Based on facility observation and staff interview and verification, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected periodically. This was with regards to continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that could prevent the pattern from fully developing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. The following areas were noted to have items stored to that could cause obstructions to the sprinkler flow.

1. Observation of storage room R3-087 revealed card board boxes stored significantly less than 18 inches from sprinkler deflectors.

2. Observation of storage room R4-063 was noted to have metal shelving with items stacked significantly closer than 18 inches from sprinkler deflectors.

Staff present on the tour verified the observations.

Based on facility tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were not mounted greater than five feet from the floor according to the National Fire Protection Association (NFPA) 10, Chapter 1-6.10.

Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the basement, specifically the pharmacy JB-122 and the radiochem room JB-124, two portable fire extinguishers, one in each room, was mounted higher than the five foot requirement.

This finding was verified by all staff members present during tour on 07/23/12.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire and smoke dampers complied with the provisions of NFPA 90A with regards to testing. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/27/12 between 8:30 A.M. and 2:00 P.M. review of facility documentation was completed with regards to fire and smoke damper testing. Present for documentation review was Staff DD1, GG,and ZZ4. Review of the fire/ smoke damper testing revealed that testing was completed between May 2008 and April 2012.

Review of the documented testing revealed that some dampers could not be tested due to obstructions or an accessibility issue that prevented testing. Building E was noted to have twenty-three dampers that could not be tested due to obstructions. Six of 23 dampers were located on the second floor and 17 dampers were located in the third floor.

Interview of staff present at the document review verified that obstructions due to construction had to be addressed before many of the dampers could be tested.

Based on facility observation and staff interview and verification the facility failed to ensure existing linen and trash chutes, including pneumatic rubbish and linen systems, that opens directly onto any corridor was sealed by fire resistive construction to prevent further use. Additionally, it was determined this facility failed to ensure all existing trash and linen chutes were equipped with a locking device in which a key is required to open the door. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of Building One, which consisted of Buildings G, H, and M, on 07/23/12 through 07/26/12 between the hours of 9:00 A.M. and 4:30 P.M. was conducted with Staff BB, CC, DD, FF, PP, JJ, and QQ. The following locations were noted to have trash or soiled linen chutes that were unlocked and accessible to the corridor.

1. On 07/23 between the hours of 12:45 P.M. and 4:40 P.M. and 07/24/12 between 9:00 A.M. and 4:00 P.M. tour of Building M was completed. The following floors of the M building were noted to have trash or linen chutes unlocked.;

1. Located on the sixth floor was an unlocked trash chute located in a corridor.

2. Located on the second floor was an unlocked room where trash and linen chutes were located. Both chute doors were observed to be unlocked. Staff present on tour verified the observations.


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Findings:

From 07/23/12 at 12:50 P.M. to 07/26/12 at 11:40 A.M., a tour of the H Building, also known as the Hospital Building, was completed. On floor 8, 7, 6, 5, 3, and 2 a chute room was observed on each floor. On each floor the door to the chute room was not locked. Each chute room was observed to have both a laundry and rubbish chute. Each chute room was observed to have neither door to each chute lock.

On 07/24/12 at 9:52 A.M. in an interview, Staff DD confirmed the door opening into the chute room did not lock, nor did the chute doors themselves.




21957


Findings include:

Facility tour took place on 07/23/12 with staff members BB, QQ, UU, and WW1. Observation was made on the first floor within the trash/linen chute room identified as G1-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the second floor within the trash/linen chute room identified as G2-213 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the fifth floor within the trash/linen chute room identified as G5-135 of the trash chute door lacking a key lock. It was also noted that the linen chute door was equipped with a key lock but was not secured. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.

Observation was made on the seventh floor within the trash/linen chute room identified as G7-59 of both chute doors lacking a key lock. Additionally, the door to the trash/linen room was equipped with a door lock but was also not secured.


These findings were verified by all staff members present during tour on 07/23/12.

Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen or trash collection receptacles did not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space was to not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a census of 1113 patients at the time of the survey.

Findings included:

Tour of the Cole Eye Building was conducted on 07/30/12 between the hours of 1:30 A.M. and 4:00 P.M. with Staff AA FF, and WW 1. Observation of a first floor surgical area revealed the presence of one soiled linen cart and two large trash receptacles sitting in a surgical area corridor. The three carts were large, wheeled receptacles verified by staff as being 16 cubic feet in size. Staff present from the surgical area verified the carts were kept in that area.

Staff present on tour observed the storage room and verified the finding.

Based on observations and staff interviews, the facility failed to ensure greater than 300 cubit feet (over 12 e-tanks) was stored in accordance with NFPA 99, 4.3.1.1.2. This involved two areas of the J building in patient care areas on the 6th floor. The total census during the survey was 1,113 patients.

Findings include:

During tour of the J building, with Staff JJ, oxygen exceeded 300 cubit feet in one smoke compartment and was not stored in a one hour fire rated separation which was vented to the outside. Ordinary electrical wall fixtures in this room were observed less than 5 ft above the floor.

a) On 07/27/12, at 11:35 AM, tour with Staff AA1 and JJ, the J6-1 smoke compartment was observed with 15 e-tanks of oxygen (360 cu. feet). It was verified with Staff JJ the amount of oxygen in this smoke compartment exceeded 300 cubit feet and was not stored in accordance with NFPA 99.

b) On 7/27/12, at 12:50 PM, room J6-621A was observed with 20 E tanks of oxygen. This room opened directly into the egress corridor. According to Staff JJ and BB1 (Manager of Respiratory Care for Heart Center), at the time of tour, this was an oxygen storage area for respiratory. The room was observed with electrical switches less than five feet above the floor. The room was verified not vented to the outside.






21957


Findings include:

Facility tour took place on 08/01/12 with staff members BB, QQ, UU, and WW1. During tour of the fifth floor corridor identified as J 5-66 and specifically in the one hour fire rate room J5-635 observation was made of one H cylinders of medical air, 18 cylinders of medical air, two of which were not secured. Additionally, the room was observed to not have a medical gas sign posted outside the door, no dedicated ventilation system and the electrical light switch and outlets were not located above the required five foot or greater level. Also, the room was utilized to store medical equipment.

These findings were verified by all staff during tour of the facility on 08/01/12.

39.2.1.1
All means of egress shall be in accordance with Chapter 7 and this chapter.

7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based on facility tour and staff interview and verification, the facility failed to ensure the facility exit egress was maintained in accordance with Chapter 7 with regards to furnishings and objects in an exit egress. The facility had a census of 1113 patients at the time of the survey.

Findings included:

On 07/30/12 between the hours of 9:30 A.M. and 12:00 P.M., tour of the R Building was conducted with Staff FF, TT and OO. Observation of the first floor revealed an exit corridor close to a pharmacy. A door was located at the end of the exit corridor. Review of the area revealed the exit corridor was used as a storage area.

The corridor contained a refrigerator, five steel shelves and boxes stored in the area. Passage through the corridor was narrowed to less than 36 inches. Staff from the pharmacy stated the corridor was shared with another business located across a hall. Both business used the corridor as storage.

Staff FF, present on tour, verified the corridor was not to be used as a storage area.

Based on observation of the 5th, 6th, and 7th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70, 110 3(b) and 400-7(b) in particular.

Findings:

On 07/23/12 at 3:00 P.M. on the 7th floor of the H building, in room H71 41 a power strip was observed with five devices and another power strip plugged into it. The second power strip had four appliances plugged into it.

On 07/23/12 at 3:00 P.M. Staff JJ confirmed the findings.

On 07/24/12 at 9:23 A.M. on the 6th floor of the H building, in room H60 117, a power strip was observed with six devices plugged into it, plus another power strip. The second power strip had two devices plugged into it.

On 07/24/12 at 9:23 A.M. in an interview Staff DD verified the observation.

On 07/24/12 at 10:57 A.M. on the 5th floor of the H building, in room H50 40, a coffee maker was observed plugged into an extension cord, which was then plugged into a power strip.

On 07/24/12 at 10:57 A.M. in an interview Staff DD verified the observation.