HospitalInspections.org

K-222 Based on observations made it the presences of the plant manager on 12-11-2017 it was determined that the facility did not maintain egress doors in the required means of egress, egress doors shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the special locking arrangements per. NFPA 101 19.2.2.2.5.1, 19.2.2.2.6, 19.2.2.2.5.2, TIA 12-4

This deficiency affected 1 of several doors.

Findings include:

During the facility tour it was observed that once that you entered the emergency department seclusion room that if the door was locked from the outside thumb latch that a key was needed to exit, I ask staff if they carried a key to open the door from the inside of the room to exit and they said they did not.

K-0293 Based upon observations made in the presence of the plant manager on 12-12-2017, it was determined that the facility did not maintain exit and directional signs in accordance with NFPA 101 19.2.10.1

The deficiency affected 1 of several stairwells.

Findings include:

During the facility tour it was discovered that there was no signage in stairwell #2 new building to the penthouse stating this not an exit and was not in accordance with NFPA 101 19.2.10.1, 7.10.8.3.1, 7.10.8.3.2

K-0321 Based upon observations made in the presence of the plant manager on 12-11-2017, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2, 19.3.2.1.

This deficiency affected

Findings include:

1-During the facility tour it was observed that there was penetrations in the medical records storage room and not in accordance with NFPA 101 19.3.2.1.

2-During the facility tour it was observed that there was penetrations in the storage closet across from I.S. department that was filled with a non-rated expanding foam and not in accordance with NFPA 101 19.3.2.1.
3- During the facility tour it was observed that there was penetrations in the housekeeping storage room in the basement and not in accordance with NFPA 101 19.3.2.1.
4- During the facility tour it was observed that the main door into the housekeeping storage room "door #46" would not close to the latching position and was not in accordance with 19.3.2.1.3
5- During the facility tour it was observed that there was penetrations in the electrical room by receiving and not in accordance with NFPA 101 19.3.2.1.
6- During the facility tour it was observed that the door closure had been removed from the door on storage room #9 and would not close to the latching position and was not in accordance with 19.3.2.1.3

K-351 Based upon observations made in the presence of the plant manager on 12-12-2017, it was determined that the facility did not provide a fire sprinkler system in accordance with NFPA 101 19.3.5.3,

This deficiency affected 2 of 2 walk in refrigerators.

Findings include:

During the facility tour it was observed that the fire sprinkler heads in both walk in refrigerator were blocked/obstructed and not in in accordance with NFPA 19.3.5.3, 9.7, 13 7.7.1.4, NFPA 25 5.2.1.1.1

K-0353 Based upon observations made in the presence of the plant manager on 12-13-2017, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 9.7.5.

This deficiency affected 2 of several sprinkler heads.

Findings include

1- During the facility tour it was observed that 1 of the fire sprinkler heads in the stairwell had paint on the body of the head and not in accordance with NFPA 25 5.2.1.1.1 and NFPA 101 9.7.5.
2- During the facility tour it was observed that 1 of the sprinkler heads in the old CT area had paint on the body of the head and not in accordance with NFPA 25 5.2.1.1.1 and NFPA 101 9.7.5.

K-372 Based upon observations made in the presence of the plant manager on 12-12-2017, it was determined that the facility did not maintain the smoke barriers to provide at least a one-half hour fire resistance rating in accordance with NFPA 101 19.3.7.

The deficiency affected

Findings include:
1-During the tour of the facility it was observed that there was penetrations in the C.S. Housekeeping closet wall in accordance with NFPA 101 19.3.7.3, 8.5
2-During the tour of the facility it was also observed that there was 2 penetrations in the walls in the fire riser room #4 and not in accordance with NFPA 101 19.3.7.3, 8.5
3- During the tour of the facility it was also observed that there was penetrations in the vacant room next to the dietary department and not in accordance with NFPA 101 19.3.7.3, 8.5
4- During the tour of the facility it was also observed that there was penetrations in the ceiling in the house keeping closet and not in accordance with NFPA 101 19.3.7.3, 8.5

K-0374 Based upon observations made in the presence of the plant manager on 12-12-2017, it was determined that the facility did not maintain the door openings in smoke barriers to have at least a 20 minute fire protective rating. The doors shall be self-closing or automatic closing in accordance with 19.3.7.8.

The deficiency affected: 1 of several doors.

Findings include:
During the facility tour it was discovered that the door entering the E.R. physician lounge had a wedge blocking the door in the open position and not in accordance with NFPA 101 19.3.7.8, 8.5.4

K-0511 Based upon observations made in the presence of the plant manager on 12-13-2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

The deficiency affected 3 of several electrical panels.

1- During the facility tour it was observed during the building tour that 1 of the electrical service panels in the I.V. therapy hallway were unlocked allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-27
2- During the facility tour it was observed that 3 electrical service panels had storage racks in front of them blocking access to the electrical service panels in accordance with NFPA table 110-26 (a). Service panels are to have a clear working space of 36" maintained in front of them at all times. NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)
3- During the facility tour it was observed that the line isolation monitor service panels in labor and delivery did not have the breaker labeled and was not in accordance with Electric panel labeling NFPA 70 110.22
4- During the facility tour there were several outlets that were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7),

K-920. Based upon observations made in the presence of the plant manager on 12-13-2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 19.5.1

The deficiency affected 3 of several outlets

Findings include:

1-During the facility tour it observed that there was 2 daisy chained plug strips plugged in the Radiology office viewing room. The power strip was removed at the time of the tour. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 19.5.1, 70 110-3b, 99 10.2.3.6
2--During the facility tour it observed that there was 2 daisy chained plug strips plugged in the ultra sound nurse's station. The power strips were removed at the time of the tour. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 19.5.1, 70 110-3b, 99 10.2.3.6

K-923 Based upon observations made in the presence of the plant manager on 12-13-2017, it was determined that the facility did not maintain cylinder storage in accordance with NFPA 101 19.3.2.4

The deficiency affected 3 of the cylinder storage areas.

Findings include:

1- During the facility tour unsecured cylinders of carbon dioxide were observed to be unsecured in the cylinder storage room. Provisions shall be made to protect cylinders from accidental damage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.
2- During the facility tour unsecured cylinders of CO 2 were observed in the dietary area. Provisions shall be made to protect cylinders from accidental damage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.
3- During the facility tour unsecured cylinders of nitrogen were observed in the L&D medical gas storage room. Provisions shall be made to protect cylinders from accidental damage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.