HospitalInspections.org

Based on survey observations the hospital failed to maintain 2-hour separation and latching doors in the corridor. Findings include:

1. At approximately 3:30 PM on June 23, 2010, unsealed openings and penetrations were found in the 2-hour wall separating the medical staff office building from the hospital. (Women and Children's Division)

2. At approximately 3:33 PM on June 23, 2010, 90-minute doors separating the medical staff office building from the hospital were tested and found not to latch. (Women and Children's Division)

Based on survey observations the hospital failed to maintain corridor walls with at least 1/2 hour fire resistance rating and resistant to the passage of smoke. Findings include:

1. On June 22, 2010 at approximately 1:20 PM a wood type pass through window from pathology to the surgery egress corridor was found that fails to provide at least a 1/2 hour fire resistant rating. (Women and Children's Division)

2. At approximately 9:10 AM on June 22, 2010, the ventilation duct access closet on the fifth floor was found to have only one layer of dry wall on the egress corridor section of the wall. There are small visible openings around electrical junction boxes penetrating the wall.(Women and Children's Division)

3. At approximately 10:00 AM on June 22, 2010, the ventilation duct access closet on the 4th floor was found to have only one layer of dry wall behind the unit nourishment station which is open to the egress corridor. (Women and Children's Division)

4. At approximately 11:30 AM on June 22, 2010, the ventilation duct access closet on the third floor was found to have only one layer of dry wall on the egress corridor section of the wall. (Women and Children's Division)

2. On June 22, 2010, at approximately 11:20 AM. the corridor door serving room 312 was found to drag the frame when being closed. (Women and Children's Division)

3. On June 22, 2010, at approximately 1:30 PM the corridor door serving room 233 was found to have excessive space at the top of the door causing it not to be resistant to the passage of smoke. (Women and Children's Division)

4. On June 22, 2010, at approximately 2:05 PM the NICU Transport room also used for storing a very small quantity of oxygen was found to not have a latching device to keep the door closed. (Women and Children's Division)

Based on survey observations the hospital failed to maintain corridor doors with latching devices to keep the door closed, resistant to the passage of smoke and have no impediments to closing. Findings include:

1. On June 24, 2010, at approximately 9:55 PM the corridor door for surgical services was tested and found not to latch when in the closed position. (Memorial Division)

Based on survey observations the hospital failed to provide smoke barriers that have at least one half hour fire resistance rating. Findings include:

1. On June 28, 2010, at approximately 2:00 PM unsealed penetrations were found around a duct penetrating the smoke barrier wall at the elevator lobby. (Memorial Division)

2. On June 28, 2010, at approximately 2:15 PM unsealed penetrations were found around a duct penetrating the smoke barrier wall near rooms 2003 and 2006. (Memorial Division)

4. On June 22, 2010, at approximately 1:50 PM smoke barrier doors 2S12A&B were tested and found to not close flush/tightly in the frames. (Women and Children's Division)

5. On June 22, 2010, at approximately 3:10 PM smoke barrier doors 2S16A&B were found not to be provided with and astragal at the meeting edges. (Women and Children's Division)

Based on survey observations the hospital failed to maintain smoke barrier doors to have at least a 20-minute fire resistance rating. Finding include:

1. On June 24, 2010, at approximately 9:45 AM smoke barrier doors 2SBSD023 were found to not have an astragal to seal the meeting edges. (Memorial Division)

2. On June 28, 2010, at approximately 1:35 PM barrier doors near room 2055 were tested and found to have more than 1/8 inch space at the edges. (Memorial Division)

3. On June 28, 2010, at approximately 2:30 PM barrier doors 4109 and 4110 were found to not have astragals to seal the meeting edges. (Memorial Division)

Based on observations the hospital failed to maintain separation in hazardous areas. Findings include:

1. On June 22, 2010, at approximately 2:05 PM the NICU soiled utility room door was found not to latch and secure the door in the frame. (Women and Children's Division)

Based on document review the hospital failed to conduct fire drills at least quarterly on each shift. Findings include:

1. At approximately 4:45 PM on June 22, 2010, fire drill documentation failed to demonstrate that a fire drill was conducted for January, February, or March on the night shift. (Women and Children's Division)

Based on survey observations the hospital failed to provide a fire alarm pull station in the path of egress. Findings include:

1. At approximately 3:15 PM on June 22, 2010, the recovery unit was found not to have a fire alarm pull station near the nurse station or at exit points in the path of egress. (Women and Children's Division)

NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to maintain and provide automatic sprinkler coverage to all portions of the facility. Findings include:

1. On 06/29/10 at approximately 10:40 a.m., an inspection of three (3) south area was conducted. At this time, a communication closet approximately twenty-four (24) inches by eight (8) feet, located near the nurse station, was observed without sprinkler coverage. (Memorial Division)

NFPA (National Fire Protection Association) 10 Standard for Portable Fire Extinguishers

4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all fire extinguishers in accordance with NFPA 10. Findings include:

1. On 06/30/10 during the time frame of 10:00 a.m. and 3:00 p.m., twelve (12) fire extinguishers that have undergone a required maintenance test (six (6) year test or twelve (12) year hydro-test) and would require a "verification of service" collar were observed not to have one attached. (Memorial Division)

a. 3rd floor near room 357.
b. 5th floor patient simulation center corridor near main elevators.
c. ER (emergency room) waiting area.
d. ER near room 13.
e. ER near room 10.
f. 6th floor near fan room, near room 600, 603, 606, 607, 610, and 618.

2. On June 23, 2010, at approximately 3:50 PM soiled utility collection receptacles were observed in the women's center exit corridor creating an impediment in the means of egress. Upon interview, the Charge Nurse stated that the receptacles remain in the corridor at all times. (Women and Children's Division)

Based on survey observations and staff interview the hospital failed to assure that the means of egress is continuously maintained free of all obstructions or impediments. Findings include:

1. On June 28, 2010, at approximately 3:55 PM blanket warmers, linen carts, tables with office supplies and copy machines were observed being stored in the endoscopy means of egress creating obstructions and impediments in the means of egress. (Memorial Division)

Based on survey observations and staff interviews the hospital failed to store soiled linen and trash in containers not exceeding 32- gallon capacity located in a room protected as a hazardous area. Findings include:

1. On June 24, 2010, soiled linen and trash containers described by staff as trucks, having an estimated capacity of one hundred (100) or more gallons are stored in the sub sterile scrub sink area outside each operating room. The Nursing Director, in the afternoon, stated that the mobile containers are not moved until they are filled. (Memorial Division)

Based on survey observations the hospital failed to maintain medical gas systems compliant with NFPA 99.

NPFA 99 5.1.4.1 Gas and Vacuum Shutoff Valves. Shutoff valves shall be provided to isolate sections or portions of the piping system for maintenance, repair, or planned future expansion need, and to facilitate periodic testing.
5.1.4.2 Accessibility. All valves except valves in zone valve box assemblies shall be located in secured areas such as locked piped chases, or be locked or latched in their operating position, and be labeled as to gas supplied and the area(s) controlled. Findings include:

1. At approximately 2:05 PM on June 28, 2010, medical gas valves were found in the ceiling interstitial space not secured on the second floor Cath lab area. (Memorial Division)

A. Based on survey observation the hospital failed to provide protection for areas having a degree of hazard greater than that normal to the general occupancy.

NFPA101 8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. Findings include:

1. On June 22, 2010, at approximately 3:00 PM the patient access unit nourishment station was found to have a degree of hazards greater than that normal to the general occupancy. There is a toaster oven, four (4) crock pots, toaster, small electric grill and an electric skillet inthe unprotected nourishment station. (Women and Children's Division)

B. Based on survey observations the hospital failed to provide minimum clear working spaces for electrical panels 22079, 22080 and 22081 in the surgery suite janitors closet which is also a wet area.

NEC 70-E 1-8.1.1.1 Depth of Working Space.
The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 1-8.1.1. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening is such are enclosed.
Table 1-8.1.1 Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition
1 Condition
2 Condition
3
0 - 150 3 3 3
151 - 600 3 31/2 4

Findings include:

1. At approximately 1:30 PM on June 21, 2010, electrical breaker panels located in the surgery suite janitors closet failed to have clear unobstructed space in front of the panels. (Women and Children's Division)

2. At approximately 1:30 PM on June 21,2010, main surgery suite electrical breaker boxes and an equipment transformer were observed in the surgery suite janitors closet which contains a mop sink and hose bibbs for filling mop buckets causing it to be classified as a wet location. (Women and Children's Division)

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities

Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on documentation review it was determined the hospital failed to maintain the LIM (line isolation monitor) circuit in accordance with NFPA 99. Findings include:

1. During a review of documentation on 06/30/10 at approximately 8:50 a.m., there was no evidence found to indicate that Isolation Ground Testing/Certification was being conducted. (General Division)

2. During a review of documentation on 06/28/10 at approximately 9:30 a.m., there was no evidence that Isolation Ground Testing/Certification was being conducted. (Memorial Division)

Based on survey observations the hospital failed to maintain 2-hour separation and latching doors in the corridor. Findings include:

1. At approximately 3:30 PM on June 23, 2010, unsealed openings and penetrations were found in the 2-hour wall separating the medical staff office building from the hospital. (Women and Children's Division)

2. At approximately 3:33 PM on June 23, 2010, 90-minute doors separating the medical staff office building from the hospital were tested and found not to latch. (Women and Children's Division)

Based on survey observations the hospital failed to maintain corridor walls with at least 1/2 hour fire resistance rating and resistant to the passage of smoke. Findings include:

1. On June 22, 2010 at approximately 1:20 PM a wood type pass through window from pathology to the surgery egress corridor was found that fails to provide at least a 1/2 hour fire resistant rating. (Women and Children's Division)

2. At approximately 9:10 AM on June 22, 2010, the ventilation duct access closet on the fifth floor was found to have only one layer of dry wall on the egress corridor section of the wall. There are small visible openings around electrical junction boxes penetrating the wall.(Women and Children's Division)

3. At approximately 10:00 AM on June 22, 2010, the ventilation duct access closet on the 4th floor was found to have only one layer of dry wall behind the unit nourishment station which is open to the egress corridor. (Women and Children's Division)

4. At approximately 11:30 AM on June 22, 2010, the ventilation duct access closet on the third floor was found to have only one layer of dry wall on the egress corridor section of the wall. (Women and Children's Division)

2. On June 22, 2010, at approximately 11:20 AM. the corridor door serving room 312 was found to drag the frame when being closed. (Women and Children's Division)

3. On June 22, 2010, at approximately 1:30 PM the corridor door serving room 233 was found to have excessive space at the top of the door causing it not to be resistant to the passage of smoke. (Women and Children's Division)

4. On June 22, 2010, at approximately 2:05 PM the NICU Transport room also used for storing a very small quantity of oxygen was found to not have a latching device to keep the door closed. (Women and Children's Division)

Based on survey observations the hospital failed to maintain corridor doors with latching devices to keep the door closed, resistant to the passage of smoke and have no impediments to closing. Findings include:

1. On June 24, 2010, at approximately 9:55 PM the corridor door for surgical services was tested and found not to latch when in the closed position. (Memorial Division)

Based on survey observations the hospital failed to provide smoke barriers that have at least one half hour fire resistance rating. Findings include:

1. On June 28, 2010, at approximately 2:00 PM unsealed penetrations were found around a duct penetrating the smoke barrier wall at the elevator lobby. (Memorial Division)

2. On June 28, 2010, at approximately 2:15 PM unsealed penetrations were found around a duct penetrating the smoke barrier wall near rooms 2003 and 2006. (Memorial Division)

4. On June 22, 2010, at approximately 1:50 PM smoke barrier doors 2S12A&B were tested and found to not close flush/tightly in the frames. (Women and Children's Division)

5. On June 22, 2010, at approximately 3:10 PM smoke barrier doors 2S16A&B were found not to be provided with and astragal at the meeting edges. (Women and Children's Division)

Based on survey observations the hospital failed to maintain smoke barrier doors to have at least a 20-minute fire resistance rating. Finding include:

1. On June 24, 2010, at approximately 9:45 AM smoke barrier doors 2SBSD023 were found to not have an astragal to seal the meeting edges. (Memorial Division)

2. On June 28, 2010, at approximately 1:35 PM barrier doors near room 2055 were tested and found to have more than 1/8 inch space at the edges. (Memorial Division)

3. On June 28, 2010, at approximately 2:30 PM barrier doors 4109 and 4110 were found to not have astragals to seal the meeting edges. (Memorial Division)

Based on observations the hospital failed to maintain separation in hazardous areas. Findings include:

1. On June 22, 2010, at approximately 2:05 PM the NICU soiled utility room door was found not to latch and secure the door in the frame. (Women and Children's Division)

Based on document review the hospital failed to conduct fire drills at least quarterly on each shift. Findings include:

1. At approximately 4:45 PM on June 22, 2010, fire drill documentation failed to demonstrate that a fire drill was conducted for January, February, or March on the night shift. (Women and Children's Division)

Based on survey observations the hospital failed to provide a fire alarm pull station in the path of egress. Findings include:

1. At approximately 3:15 PM on June 22, 2010, the recovery unit was found not to have a fire alarm pull station near the nurse station or at exit points in the path of egress. (Women and Children's Division)

NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

This Standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to maintain and provide automatic sprinkler coverage to all portions of the facility. Findings include:

1. On 06/29/10 at approximately 10:40 a.m., an inspection of three (3) south area was conducted. At this time, a communication closet approximately twenty-four (24) inches by eight (8) feet, located near the nurse station, was observed without sprinkler coverage. (Memorial Division)

NFPA (National Fire Protection Association) 10 Standard for Portable Fire Extinguishers

4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain all fire extinguishers in accordance with NFPA 10. Findings include:

1. On 06/30/10 during the time frame of 10:00 a.m. and 3:00 p.m., twelve (12) fire extinguishers that have undergone a required maintenance test (six (6) year test or twelve (12) year hydro-test) and would require a "verification of service" collar were observed not to have one attached. (Memorial Division)

a. 3rd floor near room 357.
b. 5th floor patient simulation center corridor near main elevators.
c. ER (emergency room) waiting area.
d. ER near room 13.
e. ER near room 10.
f. 6th floor near fan room, near room 600, 603, 606, 607, 610, and 618.

2. On June 23, 2010, at approximately 3:50 PM soiled utility collection receptacles were observed in the women's center exit corridor creating an impediment in the means of egress. Upon interview, the Charge Nurse stated that the receptacles remain in the corridor at all times. (Women and Children's Division)

Based on survey observations and staff interview the hospital failed to assure that the means of egress is continuously maintained free of all obstructions or impediments. Findings include:

1. On June 28, 2010, at approximately 3:55 PM blanket warmers, linen carts, tables with office supplies and copy machines were observed being stored in the endoscopy means of egress creating obstructions and impediments in the means of egress. (Memorial Division)

Based on survey observations and staff interviews the hospital failed to store soiled linen and trash in containers not exceeding 32- gallon capacity located in a room protected as a hazardous area. Findings include:

1. On June 24, 2010, soiled linen and trash containers described by staff as trucks, having an estimated capacity of one hundred (100) or more gallons are stored in the sub sterile scrub sink area outside each operating room. The Nursing Director, in the afternoon, stated that the mobile containers are not moved until they are filled. (Memorial Division)

Based on survey observations the hospital failed to maintain medical gas systems compliant with NFPA 99.

NPFA 99 5.1.4.1 Gas and Vacuum Shutoff Valves. Shutoff valves shall be provided to isolate sections or portions of the piping system for maintenance, repair, or planned future expansion need, and to facilitate periodic testing.
5.1.4.2 Accessibility. All valves except valves in zone valve box assemblies shall be located in secured areas such as locked piped chases, or be locked or latched in their operating position, and be labeled as to gas supplied and the area(s) controlled. Findings include:

1. At approximately 2:05 PM on June 28, 2010, medical gas valves were found in the ceiling interstitial space not secured on the second floor Cath lab area. (Memorial Division)

A. Based on survey observation the hospital failed to provide protection for areas having a degree of hazard greater than that normal to the general occupancy.

NFPA101 8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. Findings include:

1. On June 22, 2010, at approximately 3:00 PM the patient access unit nourishment station was found to have a degree of hazards greater than that normal to the general occupancy. There is a toaster oven, four (4) crock pots, toaster, small electric grill and an electric skillet inthe unprotected nourishment station. (Women and Children's Division)

B. Based on survey observations the hospital failed to provide minimum clear working spaces for electrical panels 22079, 22080 and 22081 in the surgery suite janitors closet which is also a wet area.

NEC 70-E 1-8.1.1.1 Depth of Working Space.
The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 1-8.1.1. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening is such are enclosed.
Table 1-8.1.1 Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition
1 Condition
2 Condition
3
0 - 150 3 3 3
151 - 600 3 31/2 4

Findings include:

1. At approximately 1:30 PM on June 21, 2010, electrical breaker panels located in the surgery suite janitors closet failed to have clear unobstructed space in front of the panels. (Women and Children's Division)

2. At approximately 1:30 PM on June 21,2010, main surgery suite electrical breaker boxes and an equipment transformer were observed in the surgery suite janitors closet which contains a mop sink and hose bibbs for filling mop buckets causing it to be classified as a wet location. (Women and Children's Division)

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities

Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on documentation review it was determined the hospital failed to maintain the LIM (line isolation monitor) circuit in accordance with NFPA 99. Findings include:

1. During a review of documentation on 06/30/10 at approximately 8:50 a.m., there was no evidence found to indicate that Isolation Ground Testing/Certification was being conducted. (General Division)

2. During a review of documentation on 06/28/10 at approximately 9:30 a.m., there was no evidence that Isolation Ground Testing/Certification was being conducted. (Memorial Division)