HospitalInspections.org

Based on observation and interview, the facility failed to ensure the penetration in 4 of 4 fire barrier walls that separated health care from business occupancies was maintained to ensure the fire resistance of the barrier, failed to maintain the building type of II (222) construction by ensuring through penetrations in 1 of 2 two-hour fire floor/ceiling barrier assemblies were maintained to ensure the fire resistance of the two-hour barrier, failed to ensure 2 of 15 horizontal-sliding room doors in ICU and the Emergency Department were provided with means for keeping the door closed, failed to meet the clear width requirement for 1 of 1 CCU corridors or met an exception per 19.2.3.4(5), failed to ensure the corridor doors to 1 of 1 imaging storage rooms and 2 of 4 surgery center storerooms was protected as a hazardous area, had latching doors, and contained smoke resisting partitions and doors, failed to ensure 2 of 2 rooms with unfinished interior walls used materials in accordance with LSC 19.3.3.1. and 10.2.3.4, failed to maintain the ceiling construction of 1 of 1 communication rooms accordance LSC and NFPA 13, 2010 edition, at 8.5.4.11., and failed to ensure 1 of 1 sprinkler heads in the morgue were not loaded and covered with foreign material in accordance with LSC and NFPA 25, 2011 edition, at 5.2.1.1.1, failed to ensure 1 of 1 alcoves with a large quantity of combustible storage open to the corridor was not used as hazardous storage, failed to ensure the penetrations caused by the passage of wire and/or conduit through 13 of 17 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier, failed to conduct fire drills on each shift for 1 of 4 quarters, failed to ensure 1 of 3 smoke barrier doors on the 200-hall were routinely inspected and repaired as part of the facility maintenance program, failed to ensure 4 of 4 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw or were daisy chained according to LSC/2012 chapter 19 and NFPA-70/2011, 400.8, and failed to ensure 3 of 3 oxygen storage rooms were provided with a precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure 2 of 15 horizontal-sliding room doors in ICU and the Emergency Department were provided with means for keeping the door closed. LSC 19.3.6.3.5 stated doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. LSC 19.2.2.2.10.1 states horizontal-sliding doors, as permitted by 7.2.1.14, that are not automatic-closing shall be limited to a single leaf and shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed.

Findings include:

Based on observation during a tour of the facility with the Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 between 10:00 a.m. and 3:00 p.m., room #1 in ICU and room #9 in the Emergency Department contained horizontal-sliding doors. The doors did contain a latch, but when tested the doors did not latch into the frame. Based on interview during observation, the Facilities Manager agreed the doors did not latch into the door frames when tested and stated the door latches will need to be repaired.

Based on observation, records review, and interview, the facility failed to ensure 2 of 2 rooms with unfinished interior walls used materials in accordance with LSC 19.3.3.1. and 10.2.3.4.

Findings include:

Based on observations with the Director of Facilities, Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/17/23 between 10:00 a.m. and 11:30 a.m., in the EVS storeroom and storeroom OR 4 had unfinished walls with exposed insulation and metal studs and 2 walls in OR 4 were completely covered with plastic. Based on records review at 1:25 p.m., there was no documentation of the flame spread rating for the exposed insulation. Based on interview at the time of observation, the Facilities Manager agreed both rooms had unfinished walls with exposed insulation and metal studs with plastic covering 2 of the walls and there was not a plan to finish the walls.

Based on observation and interview, the facility failed to ensure 1 of 1 alcoves with a large quantity of combustible storage open to the corridor was not used as hazardous storage. LSC 19.3.6.1(7) states Spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 at 11:45 a.m., the alcove by the supply room in CCU wing was open to the corridor and was being used to store combustible material such as seven plastic totes of gowns. This condition does not protect the corridor from a hazardous storage area. Based on interview at the time of observation, the Facilities Manager agreed the alcove was open to the corridor, contained combustible storage, and stated the seven totes will be removed form the corridor.

Based on observation, records review, and interview; the facility failed to ensure 1 of 3 smoke barrier doors on the 200-hall were routinely inspected and repaired as part of the facility maintenance program.

Findings include:

Based on observations with Facilities Supervisor and the Safety Coordinator on 11/16/23 at 1:30 p.m., one door leaf of the smoke doors by room 216 was damaged due to 12 small screw holes down the inner edge of the door leaf. Based on records review Between 1:00 p.m. and 3:00 p.m., the fire/smoke door testing form dated 11/14/23 indicated all smoke and fire doors passed inspection. Based on interview at the time of observation, the Facilities Supervisor stated the aforementioned smoke door contained small holes due to some type of astragal was removed at an unknown date.

Based on observation and interview, the facility failed to ensure 4 of 4 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw or were daisy chained according to LSC/2012 chapter 19 and NFPA-70/2011, 400.8.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 between 10:00 a.m. and 3:00 p.m.,
the following areas had improper use of power strips:
A.) A refrigerator and a microwave (high power draw equipment) were plugged into and supplied power by a power strip in the Physician Lounge.
B.) A refrigerator and a coffee pot (high power draw equipment) were plugged into and supplied power by a power strip in the EVS lounge.
C.) In the Bio-med Office a power strip was plugged into and supplied power by another power strip.
Based on interview at the time of observations, the Facilities Manager agreed there were improper use of power strips.

The findings were reviewed with the Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, Director of Facilities and the Safety Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure the penetration in 4 of 4 fire barrier walls that separated health care from business occupancies was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/17/23 between 11:00 a.m. and 1:00 p.m., the following separation fire walls had unsealed penetrations.
A.) Above the drop ceiling of the second-floor separation fire barrier by lab room A224 had an unsealed one-inch hole through the wall.
B.) Above the drop ceiling of the second-floor separation fire barrier in the lab had an unsealed 1/4-inch gap between two pieces of drywall.
C.) Above the drop ceiling of the second-floor separation fire barrier to Imaging had two 3-inch pipe sleeve ends that were not sealed.
D.) Above the drop ceiling of the second-floor separation fire barrier in the Imaging work room there was a drywall patch covering a hole, but the patch was not sealed leaving a 1/8th of an inch gap between the wall and patch.
E.) Above the drop ceiling of the second-floor separation fire barrier by room A239 there were three unsealed 1-inch holes.
F.) Above the drop ceiling of the second-floor separation fire barrier by room A202 there was an unsealed 2-inch hole.
G.) Above the drop ceiling of the second-floor separation fire barrier by MRI control room had a ½-inch gap around duct work.
H.) Above the drop ceiling of the ER area separation fire barrier by the ER lounge had an unsealed 2-inch hole.
I.) Above the drop ceiling by the rolling fire door of the ER area separation fire barrier had an unsealed 2-inch hole.
J.) Above the drop ceiling of the ER area separation fire barrier by triage had a 6-inch pipe sleeve end that was not sealed.
K.) Above the drop ceiling of the ER area separation fire barrier by public safety had a 3-inch pipe sleeve that was not sealed around the sleeve and at the end of the sleeve.
L.) Above the drop ceiling of the north medical office separation fire barrier had a 3-inch pipe sleeve end that was not sealed.
M.) Above the drop ceiling of the MOB separation fire barrier had a 6-inch by 4-inch hole/cutout in the wall.
Based on interview at the time of observation, the Facilities Supervisor, the Facilities Manager, and Director of Facilities agreed all four separation fire barriers had unsealed penetrations.

Based on observation and interview, the facility failed to maintain the building type of II (222) construction by ensuring through penetrations in 1 of 2 two-hour fire floor/ceiling barrier assemblies were maintained to ensure the fire resistance of the two-hour barrier. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/17/23 at 12: 30 p.m., on the first floor above the drop ceiling by the triage firewall there was an unsealed 2-inch penetration around a drainage pipe in the two-hour floor/ceiling fire barrier. Based on interview at the time of observation, the Facilities Manager agreed the floor/ceiling fire barrier was not maintained as a two-hour barrier due to the unsealed hole through the barrier.

Based on observation and interview, the facility failed to meet the clear width requirement for 1 of 1 CCU corridors or met an exception per 19.2.3.4(5). LSC 19.2.3.4(5) states where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) the fixed furniture is securely attached to the floor or to the wall.
(b) the fixed furniture does not reduce the clear unobstructed corridor width to less than six feet, except as permitted by 19.2.3.4(2).
(c) the fixed furniture is located only on one side of the corridor.
(d) the fixed furniture is grouped such that each grouping does not exceed an area of 50 square feet.
(e) the fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 feet.
(f) the fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurse's station or similar space.
(h) the smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 between 11:50 a.m., there were two chairs and an end table in the CCU hall, extended about two feet into the corridor, and were not affixed to the floor or to the wall when tested. Based on interview at the time of the observations, the Facilities Manager agreed the chairs and table were not securely attached to the floor or to the wall when tested.

Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 imaging storage rooms and 2 of 4 surgery center storerooms was protected as a hazardous area, had latching doors, and contained smoke resisting partitions and doors.

Findings include:

A.) Based on observations with Facilities Supervisor and the Safety Coordinator on 11/16/23 at 2:00 p.m., the imaging storeroom contained large amounts of combustible supply boxes, was greater than 50 square feet, and was not protected as a hazardous room. The room was equipped with double set of doors. There was about a ½ inch gap between the doors when the doors were in the closed position. This condition would allow smoke to escape the room in event of a fire. Also, the right door leaf of the set of doors did not have a positive latching device, and the left door leaf latched into the right door leaf which did not latch into the frame. Based on interview at the time of observation, the Facilities Supervisor agreed the room was used as storage, was larger than 50 square feet, stated there was a large gap between the doors when closed, and the doors did not latch into the frame.

B.) Based on observations with the Director of Facilities, Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/17/23 between 10:00 a.m. and 11:30 a.m., the OR and EVS storerooms contained over 20 boxes of supplies, were greater than 50 square, therefore making the rooms hazardous areas. The storerooms were not protected as a hazardous area because the corridor doors to the rooms were not self-closing or automatic closing. Based on interview at the time of observation, the Facilities Manager agreed the storerooms contained large amount of combustible storage, was larger than 50 square feet, and the corridor doors to the rooms were not self-closing.

Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 communication rooms accordance LSC and NFPA 13, 2010 edition, at 8.5.4.11., and failed to ensure 1 of 1 sprinkler heads in the morgue were not loaded and covered with foreign material in accordance with LSC and NFPA 25, 2011 edition, at 5.2.1.1.1.

Findings include:

A.) NFPA 13, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 at 1:23 p.m., in the suspended ceiling IT room 229 there was a ceiling tile missing and exposed the ceiling about one to two feet above the suspended ceiling. This condition could delay the activation of the sprinklers installed on the suspended ceiling. Based on interview at the time of the observations, the Facilities Supervisor agreed there was a missing ceiling tile and exposed the ceiling above the drop ceiling.


B.) NFPA 25, 5.2.1.1.1 states sprinklers shall not show signs of leakage and are free of corrosion, foreign materials, paint, and physical damage. Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 at 11:30 a.m., the one sprinkler head in the morgue was heavily loaded with foreign materials. Based on interview at the time of observation, the Facilities Manager, confirmed the sprinkler head in the morgue was loaded with foreign materials.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 13 of 17 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/17/23 between 11:00 a.m. and 1:00 p.m., above the drop ceiling of the following smoke walls had unsealed penetrations and/or was sealed with material not meeting ASTM E 814:
A.) The smoke wall by the OR nurses' station had a 1-inch unsealed gap between a vent and the drywall and had four unsealed holes in the wall.
B.) The smoke wall by PACU had penetrations filled with Joint Compound.
C.) The smoke wall by the OR consultation room had a penetration sealed with Joint Compound and the end of a 1-inch pipe sleave was not sealed.
D.) The smoke wall by surgical services had a 1/4-inch unsealed gap around wires.
E.) The smoke wall by room 315 had an unsealed 4-inch hole in the wall.
F.) The smoke wall by room 309 had an unsealed 4-inch hole in the wall.
G.) The smoke wall by room 209 had penetrations filled with Joint Compound.
H.) The smoke wall by room 215 had a 5x6 inch area where the cement was broken leaving 1/8-inch cracks in the wall.
I.) The OB lobby smoke wall had three unsealed 1/4-inch gaps around pipes.
J.) The Pharmacy smoke wall had three unsealed 1/4-inch gaps around pipes and Joint Compound was used to seal penetrations.
K.) The smoke wall by room A-286 had an unsealed 1/4-inch gap around a wire.
L.) The smoke wall by Respiratory had an unsealed 1/4-inch gap around a wire.
M.) The smoke wall by Hospitality Services had an unsealed 1-inch hole and Joint Compound was used to seal penetrations.
Based on interview at the time of observation, the Facilities Supervisor, the Facilities Manager, and Director of Facilities agreed the aforementioned smoke barriers had unsealed penetrations or were sealed with material that did not meet ASTM E 814.

Based on record review and interview, the facility failed to conduct fire drills on each shift for 1 of 4 quarters. LSC 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Findings include:

Based on records review with the Facilities Manager and the Safety Coordinator on 11/16/23 at 2:52 p.m., no documentation was available to show a second shift fire drill for the first quarter of 2023 was conducted. Based on interview at the time of record review, the Safety Coordinator agreed the aforementioned drill was missed, and stated the facility has implement an audit system to ensure drills are not missed.

Based on observation and interview, the facility failed to ensure 3 of 3 oxygen storage rooms were provided with a precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED.

Findings include:

Based on observations with Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, and the Safety Coordinator on 11/16/23 between 10:00 a.m. and 3:00 p.m., the Main oxygen storeroom, and the two respiratory storerooms were used as storage for oxygen cylinders. The doors to the rooms were not provided with precautionary signs which states "CAUTION: OXIDIZING GAS(ES) STORED." Based on interview at the time of observation, the Maintenance Director stated each storeroom did not have precautionary signs indicating storage of oxidizing gasses.

The findings were reviewed with the Facilities Supervisor, the Facilities Manager, Nursing Quality Specialist, Director of Facilities and the Safety Coordinator during the exit conference.

Based on observation and interview, the facility failed to provide required emergency equipment in 2 of 3 surgical areas toured.

Findings Include:

1. On tour of the surgery department on 11/09/23 at 10: 40 am, this surveyor noted instruments to perform a tracheostomy, but no tracheostomy tubes.

2. Interview on 11/09/23 at 10:50 am with A7 (Nursing Manager Surgery/Surgical Admission/Pre-Admission Testing/Central Sterile Management) confirmed lack of tracheostomy tubes in or around the crash cart or department.