HospitalInspections.org

Based on observation, a review of architectural design drawings and interview, it was determined one of one Gift Shop exceeded 500 Square Feet and was considered a Hazardous Area/Combustible Storage Room/Space which was not protected by sprinkler system. The failed practice did not ensure the Exit Access Corridor and adjacent areas were protected from a fire or related smoke event from the Gift Shop/hazardous area. Failure to protect the corridor and adjacent areas from a fire in the Gift Shop had the potential to harm patients, visitors and staff. The findings were:

A. While on tour of the on 04/30/19 between 9:00 AM to 11:00 AM, in the area of the South-Main 1st Floor entrance (exit access corridor) area, it was observed the Gift Shop was relatively new construction. During the tour, a discussion with the Director of Maintenance showed a renovation project had been done which resulted in the construction of a new Gift Shop. The Gift Shop exceeded 500 square feet. Gift Shops can be open to an Exit Access Corridor and exempted from hazardous area protection requirements if they were less than 500 square feet in area and protected throughout by an approved automatic sprinkler system.
B. Review of the Gift Shop architectural design drawings showed they did not demonstrate the Gift Shop was protected as a hazardous area or provide any information regarding the fire rating of the walls surrounding the Gift Shop or Corridor Wall. It was determined the Gift Shop was not less than 500 square feet and was not protected by a sprinkler system. The issues were discussed on 04/30/19 with the Director of Maintenance and no additional code compliance information concerning the Gift Shop and related fire protection was provided.

Based on observation, a review of architectural design drawings and interview, it could not be determined that one of one window and door opening in the corridor wall were fire rated in accordance with the barrier requirements. The failed practice did not ensure the corridor wall and related window openings adequately protected the Exit Access Corridor for use in the event of a fire or related smoke event. Failure to maintain the barrier has the potential to harm patients, visitors and staff. The findings were:

A. While on tour on 04/30/19 between 9:00 AM to 11:00 AM, in the area of the South-Main 1st Floor entrance area, a discussion with the Director of Maintenance showed that a renovation project had been done which resulted in the relocation of the Gift Shop. It could not be determined if the window in the Gift Shop and related Exit Access Corridor wall was a rated Fixed Fire Window Assembly. The door to the Gift Shop was tagged as a 20-minute rated door.
B. Review of the Gift Shop architectural design drawings showed they did not demonstrate the Gift Shop was a hazardous area or provided information regarding fire rating considerations of the walls, related window and door openings surrounding the Gift Shop or Corridor Wall. Information found on the window did not address its fire rating.
C. On 04/30/19, the issues were discussed with the Director of Maintenance and no additional code compliance information concerning construction of the Gift Shop was provided.

Based on observation and review of manufacture's directions for use, one of one decorative electric resistance wall heater was found to be in use in a waiting room area which was not in accordance with the manufacturer's safety warnings . The failed practice did not ensure the safety of patients and visitors that could come in contact with the heater or protect the exit access corridor in the event of a fire or related smoke event. Failure to maintain the barrier has the potential to harm patients, visitors and staff.

A. Review of the manufacturer's operating manual showed:
1) The heater, had a 1500-watt electric resistance heating element component.
2) Important Safety Warning! This Fireplace Is Hot When In Operation And Can Cause Severe Burns.
3) Do not operate fireplace before reading and understanding operating instructions. Failure to operate fireplace according to operating instructions could cause fire or injury.
4) Young children should be carefully supervised when they are in same room with fireplace. Toddlers, young children and others may be susceptible to accidental contact burns.
5) A physical barrier was recommended if there are at risk individuals in the house.
6) To restrict access to the fireplace, install an adjustable safety gate to keep toddlers, young children and other at risk individuals away from the fireplace and hot surfaces.
B. While on tour of the on 04/30/19, between 9:00 AM and 11:00 AM, in the area of the South - Main 1st Floor entrance (exit access corridor) area, it was observed some construction work was being done. At the time of the tour, the Director of Maintenance was questioned concerning the installation of a decorative electric resistance wall heater (faux Electric Fireplace). During interview was this as the same time as tour for the date and time with the Director of Maintenance about the heater installation, a manufacturer's owner's manual was provided for review.
C. On 04/30/19,the issues were discussed with the Director of Maintenance. No additional information concerning the use of the wall heater was provided.

Based on observation, it was determined power strips (Multiple Outlet Connection devices) were found to be in use in two (#1 and #4) of (#1-#4) ?Operating Rooms (OR's) that were not installed on movable patient care related electrical equipment (PCREE) assemblies. The failed practice did not ensure the power strips could be overloaded resulting in a loss of power to PCREE. The failed practice had the potential to harm patients or staff due to the potential for loss of power or overloading by PCREE,

A. While on tour of the Surgical Unit on 04/29/19 between 1:00 PM to 3:00 PM, the use of power strips mounted on IV (intravenous) poles were observed in OR #1 and #4. The power strips were not permanently attached to a dedicated equipment assembly of PCREE; the power strips could be used without regard to appliances or capacity.
B. During interview on 04/29/19 at 1:00 PM to 3:00 PM, the power strips were discussed with the Director of Maintenance. The Director of Maintenance did not present any additional information.