HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, on two of five total floors.

Findings include:

1. Observation of various aspects of building construction between 9:09 a.m. and 12:33 p.m. on July 17, 2013, revealed the below deficiencies:

a. Combustible tabs were noted on insulating materials within fourth floor Patient Room 416 at 9:09 a.m.
b. Structural steel required spray fireproofing within the fourth floor corridor, closest to the 1951 south stair tower entrance at 9:20 a.m.
c. Structural steel required spray fireproofing, closest to the first floor Micro-Biology entrance area at 12:03 p.m.
d. The large return air duct, located within first floor Dietary, lacked a fusible link fire damper. 12:33 p.m.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the building construction deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor door openings in two locations, on two of five total floors.

Findings include:

1. Observation of various corridor openings between 11:23 a.m. on July 16, 2013, and 08:50 a.m. on July 17, 2013, revealed the following deficiencies:

a. The third floor Staff Lounge door lacked positive latching hardware. 11:23 a.m. on July 16, 2013.
b. The fourth floor Clean Utility door required adjustment in order to fully latch within the door frame assembly. 08:50 a.m. on July 17, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to construct smoke barrier separation walls in one location, on one of five floors.

Findings include:

1. Observation of the third floor smoke barrier separation wall, located within the Nursing Supervisor's Office, at 1:55 p.m. on July 16, 2013, revealed an approximate four foot by six foot section was sheathed in gypsum board on one side only. Note: non-use window opening where old and new construction meet.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the incomplete smoke barrier separation wall.

Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, on one of five total floors.

Findings include:

1. Observation of the third floor smoke barrier separation doors, closest to the Elevator Lobby, at 1:32 p.m. on July 16, 2013, revealed a gap greater than 1/8th inch between the meeting edges of the doors.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the doors required an adjustment.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two locations, on two of five total floors.

Findings include:

1. Observation of various hazardous area enclosures between 11:17 a.m. on July 16, 2013, and 12:04 p.m. on July 17, 2013, revealed the below deficiencies:

a. The basement-level Food Storage Room door required adjustment in order to fully latch. 11:17 a.m. on July 17, 2013
b. The first floor Bio-Hazard Room door required adjustment in order to fully latch. 12:04 p.m. on July 17, 2013

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the doors required an adjustment.

Based on observation and interview, it was determined the facility failed to maintain stair tower enclosures in two locations, on one of five total floors.

Findings include:

1. Observation of various stair enclosures between 9:01 a.m. and 9:36 a.m. on July 17, 2013, revealed the below deficiencies:

a. The fourth floor west stair tower door required adjustment in order to fully latch within the door frame assembly. 9:01 a.m.
b. Two unsealed penetrations, located above the ceiling access panel, within the 1951 North stairtower at 9:36 a.m.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the stair tower enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in one location, on one of five total floors.

Findings include:

1. Observation of the third floor shelled space/OB entrance at 2:07 p.m. on July 16, 2013, revealed the OB entrance area lacked illuminated exit signage.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the lack of illuminated exit signage.

Based on documentation review, observation and interview, it was determined the facility failed to install, and maintain the piped-in medical gas system in seven locations, on one of five total floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas system between 10:50 a.m. and 11:01 a.m. on July 16, 2013, revealed the below deficiencies:

a. Medical gas piping lacked color coded identification labels within the basement-level corridor, closest to the Sterilizer Room. 10:50 a.m. on July 16, 2013.
b. Medical gas piping was in contact with dissimilar metals within the basement-level Information Services Entrance at 10:55 a.m. on July 16, 2013.
c. Medical gas piping lacked color coded labels within the basement-level corridor, closest to Radiology Storage. 11:01 a.m. on July 16, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the medical gas system deficiencies.

2. Documentation review at 10:50 a.m. on July 17, 2013, revealed the following medical gas system deficiencies as identified in the annual inspection report:

a. The bulk oxygen pressure switch and gauge were located upstream of the main valve.
b. The emergency oxygen supply connection (EOSC) lacked a pressure relief valve.
c. The nitrous oxide manifold lacked a dual line regulator.
d. A gas-specific demand check valve was not installed on the alarm switch and gauge.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the medical gas system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one of two generator sets supplying emergency power for the facility.

Findings include:

1. Observation of the basement-level generator set room at 10:44 a.m. on July 16, 2013, revealed the door lacked a self-closing device.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the generator room door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in three locations, on two of five total floors.

Findings include:

1. Observation of various electrical junction boxes and wiring between 11:08 a.m. on July 16, 2013, and 12:01 p.m. on July 17, 2013, revealed the below deficiencies:

a. Wiring, located above the suspended ceiling assembly, in the basement-level corridor, closest to the Sterilizer Room, lacked a junction box. 12:45 p.m. on July 16, 2013.
b. A junction box located within the second floor corridor, closest to the 1951 south stair tower entrance, lacked a cover plate. 09:20 a.m. on July 17, 2013.
c. A junction box located within the first floor Receiving Area, closest to the Micro-Biology entrance, lacked a cover plate. 12:01 p.m. on July 17, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the electrical system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, on two of five total floors.

Findings include:

1. Observation of various aspects of building construction between 9:09 a.m. and 12:33 p.m. on July 17, 2013, revealed the below deficiencies:

a. Combustible tabs were noted on insulating materials within fourth floor Patient Room 416 at 9:09 a.m.
b. Structural steel required spray fireproofing within the fourth floor corridor, closest to the 1951 south stair tower entrance at 9:20 a.m.
c. Structural steel required spray fireproofing, closest to the first floor Micro-Biology entrance area at 12:03 p.m.
d. The large return air duct, located within first floor Dietary, lacked a fusible link fire damper. 12:33 p.m.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the building construction deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor door openings in two locations, on two of five total floors.

Findings include:

1. Observation of various corridor openings between 11:23 a.m. on July 16, 2013, and 08:50 a.m. on July 17, 2013, revealed the following deficiencies:

a. The third floor Staff Lounge door lacked positive latching hardware. 11:23 a.m. on July 16, 2013.
b. The fourth floor Clean Utility door required adjustment in order to fully latch within the door frame assembly. 08:50 a.m. on July 17, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to construct smoke barrier separation walls in one location, on one of five floors.

Findings include:

1. Observation of the third floor smoke barrier separation wall, located within the Nursing Supervisor's Office, at 1:55 p.m. on July 16, 2013, revealed an approximate four foot by six foot section was sheathed in gypsum board on one side only. Note: non-use window opening where old and new construction meet.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the incomplete smoke barrier separation wall.

Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, on one of five total floors.

Findings include:

1. Observation of the third floor smoke barrier separation doors, closest to the Elevator Lobby, at 1:32 p.m. on July 16, 2013, revealed a gap greater than 1/8th inch between the meeting edges of the doors.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the doors required an adjustment.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two locations, on two of five total floors.

Findings include:

1. Observation of various hazardous area enclosures between 11:17 a.m. on July 16, 2013, and 12:04 p.m. on July 17, 2013, revealed the below deficiencies:

a. The basement-level Food Storage Room door required adjustment in order to fully latch. 11:17 a.m. on July 17, 2013
b. The first floor Bio-Hazard Room door required adjustment in order to fully latch. 12:04 p.m. on July 17, 2013

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the doors required an adjustment.

Based on observation and interview, it was determined the facility failed to maintain stair tower enclosures in two locations, on one of five total floors.

Findings include:

1. Observation of various stair enclosures between 9:01 a.m. and 9:36 a.m. on July 17, 2013, revealed the below deficiencies:

a. The fourth floor west stair tower door required adjustment in order to fully latch within the door frame assembly. 9:01 a.m.
b. Two unsealed penetrations, located above the ceiling access panel, within the 1951 North stairtower at 9:36 a.m.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the stair tower enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in one location, on one of five total floors.

Findings include:

1. Observation of the third floor shelled space/OB entrance at 2:07 p.m. on July 16, 2013, revealed the OB entrance area lacked illuminated exit signage.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the lack of illuminated exit signage.

Based on documentation review, observation and interview, it was determined the facility failed to install, and maintain the piped-in medical gas system in seven locations, on one of five total floors.

Findings include:

1. Observation of various aspects of the piped-in medical gas system between 10:50 a.m. and 11:01 a.m. on July 16, 2013, revealed the below deficiencies:

a. Medical gas piping lacked color coded identification labels within the basement-level corridor, closest to the Sterilizer Room. 10:50 a.m. on July 16, 2013.
b. Medical gas piping was in contact with dissimilar metals within the basement-level Information Services Entrance at 10:55 a.m. on July 16, 2013.
c. Medical gas piping lacked color coded labels within the basement-level corridor, closest to Radiology Storage. 11:01 a.m. on July 16, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the medical gas system deficiencies.

2. Documentation review at 10:50 a.m. on July 17, 2013, revealed the following medical gas system deficiencies as identified in the annual inspection report:

a. The bulk oxygen pressure switch and gauge were located upstream of the main valve.
b. The emergency oxygen supply connection (EOSC) lacked a pressure relief valve.
c. The nitrous oxide manifold lacked a dual line regulator.
d. A gas-specific demand check valve was not installed on the alarm switch and gauge.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the medical gas system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one of two generator sets supplying emergency power for the facility.

Findings include:

1. Observation of the basement-level generator set room at 10:44 a.m. on July 16, 2013, revealed the door lacked a self-closing device.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the generator room door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in three locations, on two of five total floors.

Findings include:

1. Observation of various electrical junction boxes and wiring between 11:08 a.m. on July 16, 2013, and 12:01 p.m. on July 17, 2013, revealed the below deficiencies:

a. Wiring, located above the suspended ceiling assembly, in the basement-level corridor, closest to the Sterilizer Room, lacked a junction box. 12:45 p.m. on July 16, 2013.
b. A junction box located within the second floor corridor, closest to the 1951 south stair tower entrance, lacked a cover plate. 09:20 a.m. on July 17, 2013.
c. A junction box located within the first floor Receiving Area, closest to the Micro-Biology entrance, lacked a cover plate. 12:01 p.m. on July 17, 2013.

Exit interview with the Director of Facility Services between 12:45 p.m. and 1:00 p.m. on July 17, 2013, confirmed the electrical system deficiencies.