HospitalInspections.org

K-011

Based upon observation and interview it was determined the facility failed to ensure the two (2) hour common wall and/or doors as directed by regulations on three of four floors.

Findings include:

Observation on April 2, 2012, between 12:05 pm and 2:00 pm revealed the common wall doors at the following locations lacked a fire rating, fire rated hardware, and a self-closing device that released when the fire alarm was activated:
1. First floor door separating Hall 175 and Hall 121.
2. Second floor door separating Hall 277 and Hall 222.
3. Third floor door separating Hall 369 and Hall 329.

Interview with Facility Maintenance Manager (FMM) and Fire Marshal (FM) on April 2, 2012, at 2:00 pm confirmed the above listed doors lacked a fire rating, fire rated hardware, and a self-closing device.

K-018

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in one of three wings.

Findings include:

1. Observation on April 3, 2012, between 11:15 am and 11:17 am revealed that corridor doors had an inactive door leaf that was not latched preventing the active leaf from positive latching when the door is closed at the following locations:
A. Patient room 1100.
B. Patient room 1101.

Interview with Facility Maintenance Manager (FMM) and Fire Marchal (FM) on April 3, 2012, at 11:17 am confirmed the corridor doors listed above lacked positive latching with inactive door leaf.

2. Observation on April 3, 2012, at 11:20 am revealed corridor doors at the following locations have a large gap where the inactive leaf and active leaf meet:

A. Patient room 1100.
B. Patient room 1101.
C. Team Room.

Interview with FMM and FM on April 3, 2012, at 11:20 am confirmed the gap in the corridor doors listed above.

K-025

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls on two of four floors.

Findings include:

Observation on April 2, 2012, between 1:04 pm and 2:45 pm revealed the facility had unsealed penetrations of the smoke barrier at the following locations:
1. Second floor smoke barrier by patient room 286 (both sides of wall).
2. Second floor smoke barrier by patient room 261 (both sides of wall).
3. Third floor smoke barrier 322 by patient room 385 (both sides of wall).

Interview with FMM and FM on April 2, 2012, at 2:45 pm confirmed the unsealed penetrations in the smoke wall at the above listed locations.

K-027

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations in one of three wings.

Findings include:

Observation on April 3, 2012, at 11:00 am revealed smoke barrier door 1107 had a gap greater than 1/8 inch which will not resist the passage of smoke.

Interview with FMM and FM on April 3, 2012, at 11:00 am confirmed the gap in smoke barrier door 1107.

K-027

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on two of four floors.

Findings include:

1. Observation on April 2, 2012, between 1:20 pm and 2:35 pm revealed smoke barrier doors lacked positive latching with the closure at the following locations:
A. Second floor smoke barrier doors by patient room 211.
B. Second floor smoke barrier doors by patient room 240.
C. Third floor smoke barrier doors 300.
D. Third floor smoke barrier doors by patient room 339.
E. Third floor smoke barrier doors at Fire Code 213.

Interview with FMM and FM on April 2, 2012, at 2:35 pm confirmed the smoke barrier doors listed above lacked positive latching with the closure.

2. Observation on April 2, 2012, at 2:37 pm revealed smoke barrier door at Fire Code 313 had holes in the door which would allow the passage of smoke through the door.

Interview with FMM and FM on April 2, 2012, at 2:37 pm confirmed the smoke doors had holes which would allow the passage of smoke.

K-045

Based upon observation and interview, the illumination of the means of egress failed to meet requirements on one of four floors.

Findings include:

1. Observation on April 3, 2012, between 8:35 am and 9:00 am revealed the facility lacked emergency exit lighting in the exit corridors throughout the fourth floor North 3rd Section Hall and the fourth floor South 1st Section Hall.

Interview with FMM and FM on April 3, 2012, at 9:00 am confirmed the facility lacked emergency exit lighting in the areas listed above.

2. Observation on April 3, 2012, at 9:15 am revealed the fourth floor exit stair tower 456 had the emergency exit illumination burned out.

Interview with FMM and FM on April 3, 2012, at 9:15 am confirmed the emergency illumination in exit stair tower 456 was burned out.

K-052

Based upon documentation review and interview, the facility failed to install, test and maintain fire alarm systems in accordance with regulations in all areas of the entire building.

Findings include:

Documentation review on April 3, 2012, at 11:40 am revealed the facility lacks documentation of a semi-annual visual inspection of fire alarm devices.

Interview with FMM and FM on April 3, 2012, at 11:40 am confirmed the facility lacks documentation of semi-annual visual inspection of fire alarm devices.

K-072

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on one of four floors.

Findings include:

Observation on April 3, 2012, at 9:05 am revealed the facility had items stored in the exit corridor (exercise bikes and ping-pong table on the fourth floor 1st Section outside the Weight Room 413.)

Interview with FMM and FM on April 3, 2012, at 9:05 am confirmed the items in the exit corridor.

K-072

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on one of three wings.

Findings include:

Observation on April 3, 2012, at 10:35 am revealed the main exit corridor 1149 had items in the exit corridor (lifts, carts and chair) that impede on the required clear and unobstructed corridor width.

Interview with FMM and FM on April 3, 2012, at 10:35 am confirmed the items in the exit corridor.

K-147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of three floors.

Findings include:

1. Observation on April 2, 2012, between 11:10 am and 11:35 am revealed the facility is utilizing duplex electrical boxes as extension cords at the following locations:
A. First floor room 147.
B. First floor room 146.
C. First floor room 115.
D. First floor room 117.

Interview with FMM and FM on April 2, 2012, at 11:35 am confirmed the utilization of duplex electrical boxes as extension cords.

2. Observation on April 2, 2012, between 11:12 am and 11:55 am revealed the facility had unauthorized electrical devices plugged into surge protectors or extension cords at the following locations:
A. First floor room 147 - coffee pot and oven plugged into a surge protector.
B. First floor room 147 - surge protector plugged into an extension cord.
C. First floor room 115 - window air conditioner plugged into extension cord.
D. First floor room 131 - window air conditioner plugged into extension cord.
E. First floor room 117 - coffee pots and microwave oven plugged into extension cord.
F. First floor room 119 - window air conditioner plugged into extension cord.
G. First floor room 192 - window air conditioner plugged into surge protector.

Interview with FMM and FM on April 2, 2012, at 11:55 am confirmed the above listed electrical devices were plugged into surge protectors or extension cords.

3. Observation on April 2, 2012, between 11:20 am and 2:20 pm revealed the facility had surge protectors plugged into surge protectors ("diasy-chain") at the following locations:
A. First floor room 103.
B. First floor room 108.
C. First floor room 192.
D. Third floor room 321A.

Interview with FMM and FM on April 2, 2012, at 2:20 pm confirmed the above locations had surge protectors "daisy-chained".

4. Observation on April 2, 2012, at 11:35 am revealed first floor room 117 had a 3 x 1 electrical adapter plugged into an extension cord.

Interview with FMM and FM on April 2, 2012, at 11:35 am confirmed the 3 x 1 electrical adapter plugged into an extension cord.

5. Observation on April 2, 2012, at 11:57 am revealed the facility was utilizing a multiply outlet extension cord in first floor room 186.

Interview with FMM and FM on April 2, 2012, at 11:57 am confirmed the use of a multiple outlet extension cord.

6. Observation on April 3, 2012, at 8:50 am revealed the fourth floor Rooftop Cafe had coffee pots plugged into a surge protector.

Interview with FMM and FM on April 3, 2012, at 8:50 am confirmed the coffee pots were plugged into a surge protector in the Rooftop Cafe.

7. Observation on April 3, 2012, at 8:55 am revealed the facility was utilizing a duplex electrical outlet box as an extension cord in the fourth floor room 407.

Interview with FMM and FM on April 3, 2012, at 8:55 am confirmed the use of a duplex electrical outlet box as an extension cord in room 407.

K-211

Based upon observation and interview, alcohol based hand sanitizers (ABHS) are not installed or stored according to regulations in one of three wings.

Findings include:

Observation on April 3, 2012, at 10:40 am revealed the facility had an ABHS mounted above a light switch at the Nurse Station.

Interview with FMM and FM on April 3, 2012, at 10:40 am confirmed the ABHS was mounted above the light switch at the Nurse Station.

K-011

Based upon observation and interview it was determined the facility failed to ensure the two (2) hour common wall and/or doors as directed by regulations on three of four floors.

Findings include:

Observation on April 2, 2012, between 12:05 pm and 2:00 pm revealed the common wall doors at the following locations lacked a fire rating, fire rated hardware, and a self-closing device that released when the fire alarm was activated:
1. First floor door separating Hall 175 and Hall 121.
2. Second floor door separating Hall 277 and Hall 222.
3. Third floor door separating Hall 369 and Hall 329.

Interview with Facility Maintenance Manager (FMM) and Fire Marshal (FM) on April 2, 2012, at 2:00 pm confirmed the above listed doors lacked a fire rating, fire rated hardware, and a self-closing device.

K-018

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in one of three wings.

Findings include:

1. Observation on April 3, 2012, between 11:15 am and 11:17 am revealed that corridor doors had an inactive door leaf that was not latched preventing the active leaf from positive latching when the door is closed at the following locations:
A. Patient room 1100.
B. Patient room 1101.

Interview with Facility Maintenance Manager (FMM) and Fire Marchal (FM) on April 3, 2012, at 11:17 am confirmed the corridor doors listed above lacked positive latching with inactive door leaf.

2. Observation on April 3, 2012, at 11:20 am revealed corridor doors at the following locations have a large gap where the inactive leaf and active leaf meet:

A. Patient room 1100.
B. Patient room 1101.
C. Team Room.

Interview with FMM and FM on April 3, 2012, at 11:20 am confirmed the gap in the corridor doors listed above.

K-025

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls on two of four floors.

Findings include:

Observation on April 2, 2012, between 1:04 pm and 2:45 pm revealed the facility had unsealed penetrations of the smoke barrier at the following locations:
1. Second floor smoke barrier by patient room 286 (both sides of wall).
2. Second floor smoke barrier by patient room 261 (both sides of wall).
3. Third floor smoke barrier 322 by patient room 385 (both sides of wall).

Interview with FMM and FM on April 2, 2012, at 2:45 pm confirmed the unsealed penetrations in the smoke wall at the above listed locations.

K-027

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations in one of three wings.

Findings include:

Observation on April 3, 2012, at 11:00 am revealed smoke barrier door 1107 had a gap greater than 1/8 inch which will not resist the passage of smoke.

Interview with FMM and FM on April 3, 2012, at 11:00 am confirmed the gap in smoke barrier door 1107.

K-027

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on two of four floors.

Findings include:

1. Observation on April 2, 2012, between 1:20 pm and 2:35 pm revealed smoke barrier doors lacked positive latching with the closure at the following locations:
A. Second floor smoke barrier doors by patient room 211.
B. Second floor smoke barrier doors by patient room 240.
C. Third floor smoke barrier doors 300.
D. Third floor smoke barrier doors by patient room 339.
E. Third floor smoke barrier doors at Fire Code 213.

Interview with FMM and FM on April 2, 2012, at 2:35 pm confirmed the smoke barrier doors listed above lacked positive latching with the closure.

2. Observation on April 2, 2012, at 2:37 pm revealed smoke barrier door at Fire Code 313 had holes in the door which would allow the passage of smoke through the door.

Interview with FMM and FM on April 2, 2012, at 2:37 pm confirmed the smoke doors had holes which would allow the passage of smoke.

K-045

Based upon observation and interview, the illumination of the means of egress failed to meet requirements on one of four floors.

Findings include:

1. Observation on April 3, 2012, between 8:35 am and 9:00 am revealed the facility lacked emergency exit lighting in the exit corridors throughout the fourth floor North 3rd Section Hall and the fourth floor South 1st Section Hall.

Interview with FMM and FM on April 3, 2012, at 9:00 am confirmed the facility lacked emergency exit lighting in the areas listed above.

2. Observation on April 3, 2012, at 9:15 am revealed the fourth floor exit stair tower 456 had the emergency exit illumination burned out.

Interview with FMM and FM on April 3, 2012, at 9:15 am confirmed the emergency illumination in exit stair tower 456 was burned out.

K-052

Based upon documentation review and interview, the facility failed to install, test and maintain fire alarm systems in accordance with regulations in all areas of the entire building.

Findings include:

Documentation review on April 3, 2012, at 11:40 am revealed the facility lacks documentation of a semi-annual visual inspection of fire alarm devices.

Interview with FMM and FM on April 3, 2012, at 11:40 am confirmed the facility lacks documentation of semi-annual visual inspection of fire alarm devices.

K-072

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on one of four floors.

Findings include:

Observation on April 3, 2012, at 9:05 am revealed the facility had items stored in the exit corridor (exercise bikes and ping-pong table on the fourth floor 1st Section outside the Weight Room 413.)

Interview with FMM and FM on April 3, 2012, at 9:05 am confirmed the items in the exit corridor.

K-072

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on one of three wings.

Findings include:

Observation on April 3, 2012, at 10:35 am revealed the main exit corridor 1149 had items in the exit corridor (lifts, carts and chair) that impede on the required clear and unobstructed corridor width.

Interview with FMM and FM on April 3, 2012, at 10:35 am confirmed the items in the exit corridor.

K-144

Based upon documentation review and interview it was determined that the facility failed to comply with regulations for generators in all areas of the entire building.

Findings include:

Documentation review on April 3, 2012, at 11:50 am revealed the facility lacks documentation of an annual inspection and test of the emergency generator from an outside vendor.

Interview with FMM and FM on April 3, 2012, at 11:50 am confirmed the lack of an annual inspection and test of the emergency generator by an outside vendor.

K-147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of three floors.

Findings include:

1. Observation on April 2, 2012, between 11:10 am and 11:35 am revealed the facility is utilizing duplex electrical boxes as extension cords at the following locations:
A. First floor room 147.
B. First floor room 146.
C. First floor room 115.
D. First floor room 117.

Interview with FMM and FM on April 2, 2012, at 11:35 am confirmed the utilization of duplex electrical boxes as extension cords.

2. Observation on April 2, 2012, between 11:12 am and 11:55 am revealed the facility had unauthorized electrical devices plugged into surge protectors or extension cords at the following locations:
A. First floor room 147 - coffee pot and oven plugged into a surge protector.
B. First floor room 147 - surge protector plugged into an extension cord.
C. First floor room 115 - window air conditioner plugged into extension cord.
D. First floor room 131 - window air conditioner plugged into extension cord.
E. First floor room 117 - coffee pots and microwave oven plugged into extension cord.
F. First floor room 119 - window air conditioner plugged into extension cord.
G. First floor room 192 - window air conditioner plugged into surge protector.

Interview with FMM and FM on April 2, 2012, at 11:55 am confirmed the above listed electrical devices were plugged into surge protectors or extension cords.

3. Observation on April 2, 2012, between 11:20 am and 2:20 pm revealed the facility had surge protectors plugged into surge protectors ("diasy-chain") at the following locations:
A. First floor room 103.
B. First floor room 108.
C. First floor room 192.
D. Third floor room 321A.

Interview with FMM and FM on April 2, 2012, at 2:20 pm confirmed the above locations had surge protectors "daisy-chained".

4. Observation on April 2, 2012, at 11:35 am revealed first floor room 117 had a 3 x 1 electrical adapter plugged into an extension cord.

Interview with FMM and FM on April 2, 2012, at 11:35 am confirmed the 3 x 1 electrical adapter plugged into an extension cord.

5. Observation on April 2, 2012, at 11:57 am revealed the facility was utilizing a multiply outlet extension cord in first floor room 186.

Interview with FMM and FM on April 2, 2012, at 11:57 am confirmed the use of a multiple outlet extension cord.

6. Observation on April 3, 2012, at 8:50 am revealed the fourth floor Rooftop Cafe had coffee pots plugged into a surge protector.

Interview with FMM and FM on April 3, 2012, at 8:50 am confirmed the coffee pots were plugged into a surge protector in the Rooftop Cafe.

7. Observation on April 3, 2012, at 8:55 am revealed the facility was utilizing a duplex electrical outlet box as an extension cord in the fourth floor room 407.

Interview with FMM and FM on April 3, 2012, at 8:55 am confirmed the use of a duplex electrical outlet box as an extension cord in room 407.