HospitalInspections.org

Based on observations and interview, the facility failed to maintain building separation opening protectives.

The findings include:

On 06/28/2017 at 03:02 pm, the fire separation wall doors between the lobby at third floor nurse's station and third floor lab did not have positive latching hardware installed at the bottom of the door. The doors did not have a label installed indicating the rating of the doors.

On 06/28/2017 at 01:55 pm, penetrations of the fire rated separation wall were observed and fire stopping not provided at the sprinkler pipe above the double doors on the second floor catwalk on the catwalk side.

The Maintenance Director acknowledged the findings.

Based on observations and interview, the facility failed to maintain the structural fire rating of the structure.

The findings include:

On 06/28/2017 at 01:55 pm, It was observed that fire proofing is missing in areas in OP - mechanical room 4.
.
On 06/28/2017 at 02:16 pm, It was observed that fire proofing is missing in areas of the air handler mechanical room 9.
.
On 06/28/2017 at 02:22 pm, It was observed that fire proofing is missing in areas of mechanical room 13.

On 06/28/2017 at 02:23 pm, It was observed that fire proofing is missing in areas of the emergency prep room.

On 06/28/2017 at 02:25 pm, It was observed that fire proofing is missing in areas of the shell space on the third floor.

On 06/28/2017 at 02:26 pm, It was observed that fire proofing is missing in areas of the electrical room in the shell space.

On 06/28/2017 at 02:29 pm, It was observed that fire proofing is missing in areas of the APCA electrical room.

On 06/28/2017 at 11:00 am, It was observed that fire proofing is missing in areas of the 2nd floor communications room.

On 06/28/2017 at 02:58 pm, It was observed that fire proofing is missing in the stairway 1 access corridor, at hanger locations for piping above ceiling.

On 06/28/2017 at 03:00 pm, It was observed that fire proofing is missing in the stairway 1 access corridor, at hanger locations for piping above ceiling.

On 06/28/2017 at 03:30 pm, It was observed that fire proofing is missing on a steel beam above the ceiling, at the 1st floor kitchen near the black sink.

On 06/28/2017 at 04:22 pm, It was observed that fire proofing is missing above ceiling on right hand side in doctors lounge.

On 06/28/2017 between 10 am and 04:30 pm identified multiple locations were observed that the fire rating of the structure had been damaged where fire proofing materials had been removed to attach pipe hangers, wall stiffeners to stabilize wall partitions throughout the facility.

The Maintenance Director acknowledged the above findings.

Based on observations and interview, the facility failed to provide unobstructed egress from the building at all times.

The findings include:

On 06/28/2017 between 09:30 am and 09:45 am, the exit discharge doors from the hospital through OB and from OB to outside exit corridor on both sides of OB suite, do not meet the requirements for special needs locking arrangements.

On 06/28/2017 at 10:29 am, there was a large amount of combustible storage in the supply department / receiving / loading dock corridor.

On 06/28/2017 at 11:07 am, the egress sensor at the exit door from the MDF - IT room would not release the door.

On 06/28/2017 at 11:31 am, there was combustible storage in the DI corridor outside of ultrasound 1.

On 06/28/2017 at 10:21 am, there was a bed located in the corridor near Cardio Pulmonary on the second floor.

The Maintenance Director acknowledged the above findings.

Based on observations and interview, the facility failed to provide signage on a delayed egress door.

The findings include:

On 06/28/2017 at 09:58 am, The OB - employee exit door by room 192 does not have signage displayed stating "PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS". The Maintenance Director acknowledged the findings.

Based on observations and interview, the facility failed to maintain doors in opening protectives.

The findings include:

On 06/28/2017 at 02:00 pm, the left side leaf of the rated door in cross corridor PCS at the clean utility room is not latching.

On 06/28/2017 at 02:12 pm, the right leaf of the rated cross corridor door is not latching in the ER at the IDF room.

On 06/28/2017 at 02:28 pm, the left leaf of the rated door at the third floor lab is not latching.

On 06/28/2017 at 10:30 am, the right leaf of fire rated cross corridor double doors on the second floor near room 2-01, are not latching.

On 06/28/2017 at 10:35 am, the fire rated double doors on the second floor near room 2-21, are not latching.

On 06/28/2017 at 10:40 am, the fire rated double doors at the second floor catwalk are not latching.

On 06/28/2017 at 03:40 pm, the first floor mechanical room has two doors that open into the stairwell that are being held open with unapproved hold open devices.

On 06/28/2017 at 09:45 am, the fire door to the morgue was not closing and latching.

On 06/28/2017 at 10:12 am, the fire rated door to the OB soiled utility room door by the nursery ,did not close and latch.

On 06/28/2017 at 12:01 pm, the fire rated OR soiled utility door was not latching.

On 06/28/2017 at 03:21 pm, the fire rated first floor triage door is missing a door closure.

The Maintenance Director acknowledged the above findings.

Based on observation and interview, the facility failed to provide continuous exit sign illumination.

The findings include:

On 06/28/2017 at 11:23 am, the exit sign located outside of the command center, was not illuminated.
The Maintenance Director acknowledged the findings.

Based on observation and interview the facility failed to maintain the rating of the vertical enclosure.

The findings include:

On 06/28/2017 at 02:50 pm, penetrations were observed and fire stopping not provided above the door and at the top of wall to the roof deck above in the first floor back stairway.

On 06/28/2017 at 02:52 pm, penetrations were observed and fire stopping was not provided on the third floor located in stairway 4, above door at the top of wall to the roof deck above.
.
On 06/28/2017 at 02:53 pm, penetrations were observed and fire stopping not provided on the second floor located in stairway 4, above door at the top of wall to the roof deck above.

On 06/28/2017 at 11:30 am, penetrations were observed and fire stopping not provided at a 6 inch x 6 inch opening in the 2 hour fire rated wall at second floor stair in the respiratory tech office over the desk midway of the space.

On 06/28/2017 at 10:55 am, penetrations were observed and fire stopping not provided around a 1/2 inch conduit to the light fixture at stair #2 on the 4th floor.

Based on observation and interview, the facility failed to maintain hazardous area enclosures.

The findings include:

On 06/28/2017 at 09:40 am, there was a penetration of the rated wall at the F/A conduit, in the rear of the boiler / mechanical room. The room is located outside of the maintenance shop.

On 06/28/2017 between 09:00 am and 05:00 pm, bathrooms originally located in patient rooms in multiple locations throughout the building are being used to store combustible materials.

On 06/28/2017 at 01:55 pm, the supply room door located in the Emergency Department does not have a label installed on the door indicating the rating of the door.

The Maintenance Director acknowledged the above findings.

Based on observation and interview, the facility failed to maintain the kitchen hood fire suppression system.

The findings include:

On 06/28/2017 at 10:40 am, the kitchen range hood fire suppression system service tag showed the last bi-annual service was performed in August 2016.

The Maintenance Director acknowledged the findings.

Based on observation and interview, the facility failed to maintain the fire alarm system.

The findings include:

On 06/28/2017 at 01:56 pm, a ceiling smoke detector outside of command center was observed to be installed too close to the wall.

The Maintenance Director acknowledged the findings.

Based on observation and interview, the facility failed to maintain the sprinkler protection in the entire building.

The findings include:

On 06/28/2017 at 11:10 am, sprinkler protection was not provided in the employee health office at an alcove in the corner of the office space.

The Maintenance Director acknowledged the findings.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system.

The findings include:

On 06/28/2017 at 02:06 pm, it was observed that there was a sprinkler escutcheon missing in ER medical director area.

On 06/28/2017 at 10:00 am, it was observed that there was a loaded sprinkler head on the second floor soiled linen room.

On 06/28/2017 at 10:05 am, it was observed that there was a loaded sprinkler head near the window of the second floor break room.

On 06/28/2017 at 10:09 am, it was observed that there was a loaded sprinkler head in the second floor waiting room.

On 06/28/2017 at 10:21 am, it was observed that there was a loaded sprinkler head in the second floor Cardio Director's office.

On 06/28/2017 at 10:22 am, it was observed that there was a loaded sprinkler head in second floor room 2-27.

On 06/28/2017 at 10:25 am, it was observed that there was a ceiling tile missing in the second floor janitor's closet.

On 06/28/2017 at 10:31 am, it was observed that there was a loaded sprinkler head in room 2-01 on the second floor.

On 06/28/2017 at 11:02 am, it was observed that there was a loaded sprinkler head in the ICU locker room on the second floor.

On 06/28/2017 at 11:33 am, it was observed that there was a loaded sprinkler head in room 2-13 on the second floor.

On 06/28/2017 at 11:35 am, it was observed that there was loaded sprinkler heads in rooms 2-19 and 2-21 on the second floor.

On 06/28/2017 at 11:48 am, it was observed that there was loaded sprinkler heads in room 2-24 on the second floor.

On 06/28/2017 at 01:50 pm, it was observed that there are combustible materials stored within 18 inches of sprinkler head deflector in the volunteers storage room on the third floor.

On 06/28/2017 at 01:55 pm, it was observed that the sprinkler head in bulk IV storage room on the third floor, is recessed too far within the escutcheon which does not allow proper coverage of room.

On 06/28/2017 at 01:56 pm, it was observed that the sprinkler head in the compounding area, of the pharmacy on the third floor, is not oriented parallel to the ceiling and a surface mounted light fixture obstructs the sprinkler head.

On 06/28/2017 at 02:35 pm, it was observed that there was a loaded sprinkler head in room 3-05 on the third floor.

On 06/28/2017 at 02:40 pm, it was observed that there was a loaded sprinkler head in room 3-30 on the third floor.

On 06/28/2017 between 10:00 am and 04:00 pm, it was observed that electrical wires were found in contact with sprinkler piping in several areas throughout the building.

On 06/28/2017 at 09:48 am, it was observed that there was combustible storage within 18 inches of the bottom of sprinkler head deflectors in the EVS break room.

On 06/28/2017 at 10:47 am, it was observed that there were ceiling tiles missing in the old HIM office by human resources.

On 06/28/2017 at 11:05 am, it was observed that there was a sprinkler head escutcheon missing in the chapel.

On 06/28/2017 at 11:24 am, there are ceiling tiles missing throughout the building in various areas.

On 06/28/2017 at 11:38 am, it was observed that sprinkler heads are recessed into the ceiling at DI in the women's dressing room.

On 06/28/2017 at 11:58 am, it was observed that sprinkler heads are recessed into the ceiling in the OR Suite closet, behind the autoclave.

On 06/28/2017 at 12:02 pm, it was observed that sprinkler heads are recessed into the ceiling in the OR Suite Managers Office.

On 06/28/2017 at 12:09 pm, it was observed that there is a sprinkler head escutcheon missing in room 8 of the OR Suite.

The Maintenance Director acknowledged the above findings.

Based on observations on interview, the facility failed to maintain doors as required in smoke and fire rated areas.

The findings include:

On 06/28/2017 at 02:08 pm, it was observed that label was not found on the the glass in the fire rated door at office opening through fire rated wall to the corridor in the ICU wing.

On 06/28/2017 at 02:07 pm, it was observed that the double fire rated doors at the fire rated wall separating the ICU from the elevator lobby were not latching when closed.

On 06/28/2017 at 11:41 am, it was observed that the DI corridor door by MRI would not close and latch.

The Maintenance Director acknowledged the above findings.

Based on observations and interview, the facility failed to maintain smoke barriers.

The findings include:

On 06/28/2017 at 02:23 pm, penetrations were observed and fire stopping not provided for rated wall assembly penetrations in the emergency prep room.

On 06/28/2017 at 02:23 pm, penetrations were observed and fire stopping not provided above the ceiling in the second floor janitors closet.

On 06/28/2017 at 03:20 pm, penetrations were observed and fire stopping not provided in the first floor dining room, rated wall assembly has MC cable above ceiling penetration that is not being sealed.

On 06/28/2017 at 03:28 pm, penetrations were observed and fire stopping not provided in first floor dietary director's office,above ceiling that is not fully sealed.

On 06/28/2017 at 02:00 pm, penetrations were observed and fire stopping not provided around the conduit penetrations of the communications room on the second floor.

On 06/28/2017 at 02:30 pm, penetrations were observed and fire stopping not provided at the 4 inch sprinkler piping above the ceiling of the men's first floor bathroom. Penetrations were observed and fire stopping not provided at the lobby and at the bottom of the stair to the first floor lobby.

On 06/28/2017 between 03:00 pm and 04:30 pm, penetrations were observed and fire stopping not provided for several holes penetrating the half hour smoke barrier wall above the ceiling at HIM, AED outside of the cafeteria. An approximate two foot section of wall had been removed above the cafeteria double doors from the corridor.

On 06/28/2017 at 10:08 pm, penetrations were observed and fire stopping not provided above the ceiling in the OB clean utility / kitchen IT closet.

On 06/28/2017 at 03:25 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the security office door.

On 06/28/2017 at 03:43 pm, penetrations were observed and fire stopping not provided on the first floor in the corridor outside the door and above the ceiling at the doctor's workspace beside the security office.

On 06/28/2017 at 03:45 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling in the doctor's workspace in the one hour separation wall.

On 06/28/2017 at 03:52 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 14 in ER.

On 06/28/2017 at 03:59 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 10, where conduit penetrates the rear wall in ER.

On 06/28/2017 at 04:02 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling at the rear wall in room 9 in ER.

On 06/28/2017 at 04:19 pm, penetrations were observed and fire stopping not provided on the first floor above the ceiling in the doctor's lounge.

The Maintenance Director acknowledged the above findings.

Based on observation and interview the facility failed to maintain the smoke barrier.

The findings include:

On 06/28/2017 at 02:55 pm, it was observed that the smoke door in the smoke barrier between HIM and the copier was not self closing.

Based on observation and interview, the facility failed to comply with applicable sections of the National Electric Code (NFPA 70).

The findings include:

On 06/28/2017 at 02:05 pm, it was observed that there is a waste water line located above the electric panel ECLP2 in the second floor electrical room in ICU.

On 06/28/2017 at 02:06 pm, it was observed that there is a 4 inch x 4 inch junction box without a cover located above the ceiling at the fire rated doors on the second floor at the elevators to the ICU wing on the ICU side.

On 06/28/2017 at 02:10 pm, it was observed that there is a temporary light fixture and wiring was located above the ceiling in the ICU waiting room.

The Maintenance Director acknowledged the above findings.

Based on observations and interview, the facility failed to comply with applicable sections of NFPA 99 and the NFPA 70.

The findings include:

On 06/28/2017 at 11:26 am, it was observed that there is open wiring in the wall at the restroom in the old lab.

On 06/28/2017 at 11:28 am, it was observed that there is a multi plug adapter in use at back tech area in Diagnostic Imaging.

On 06/28/2017 at 11:34 am, it was observed that there is a multi plug adapter in use in Ultrasound 2 in Diagnostic Imaging.

On 06/28/2017 at 12:08 pm, it was observed that there is a multi plug adapter in use in OR 6 of the Operating Suite.

The Maintenance Director acknowledged the above findings.

Based on observations and interview, the facility failed to comply with NFPA 99 prohibiting the use of extension cords or unapproved relocatable power taps.

The findings include:

On 06/28/2017 at 02:30 pm, it was observed that there was an unapproved type extension cord in use in room 3-09 of the third floor storage room. The cord was removed by staff during inspection.

On 06/28/2017 at 11:03 am, it was observed that a recalled power strip was in use at the mail room desk.

On 06/28/2017 at 11:57 am, it was observed that an unapproved cord reel was in use in OR 1 in the Operating Suite.

On 06/28/2017 at 11:57 am, it was observed that an unapproved power strip was in use in room 1 on an OB cart that was not attached to the cart.

On 06/28/2017 at 11:59 am, it was observed that an unapproved power strip was in use in OR 3, that was not attached to the cart.

On 06/28/2017 at 01:47 pm, it was observed that an unapproved non-medical grade power strip was in use at the ER blood draw area.

On 06/28/2017 at 01:17 pm, it was observed that there were power strips connected to each other in classroom A at the computers on the fourth floor.

On 06/28/2017 at 01:17 pm, it was observed that there were extension cords in use on the fourth floor at the computers in Classroom A.

The Maintenance Director acknowledged the above findings.

Based on observations and interview the facility failed to comply with the requirements for the handling of oxygen in NFPA 99.

The findings include:

On 06/28/2017 at 10:20 am, it was observed that there was a full oxygen tank that was not secured and standing upright on the 2nd floor in storage room 2-29.

On 06/28/2017 at 11:41 am, it was observed that there was an unsecured single oxygen cylinder in the second floor corridor by the stairway.

The Maintenance Director acknowledged the above findings.