HospitalInspections.org

Based upon observation it was determined that facility failed to maintain the two (2) hour common fire barrier wall, with a non-conforming building, in accordance with regulations on one of three floors.

Findings include:

Observation on May 13, 2014 at 9:00 am revealed G basement fire wall with service building has multiple unsealed blue data wire penetrations (both side of the fire barrier wall).

Interview with Director of Facilities on May 13, 2014 at 9:00 am confirmed the unsealed fire barrier penetrations.

Based upon observation and interview, it was determined the facility failed to maintain building construction type and height to meet regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 12:35 pm revealed first floor x-ray development room has an unsealed pipe penetration through the fire rated ceiling assemble.

Interview with Director of Facilities on May 12, 2014 at 12:35 pm confirmed the unsealed penetration of the fire rated ceiling assembly.

Based upon observation and interview, it was determined the facility failed to maintain the doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:35 pm revealed that the second floor Rehab Services corridor door that was connected to the fire alarm system lacked positive latching with the self-closer.

Interview with the Maintenance Technician on May 12, 2014 at 12:35 am confirmed the corridor door lacked positive latching with the self-closer.

2. Observation on May 12, 2014 at 10:05 am revealed third floor room 326 door could not close due to an overabundance of wheelchairs stored inside.

Interview with Director of Facilities on May 12, 2014 at 10:05 am confirmed the wheelchairs blocked door closure, and the subsequent correction of this item during the time of the survey.

3. Observation on May 13, 2014 at 8:30 am revealed basement Snyder Institute housekeeping door lacks positive latching with the self-closure.

Interview with Director of Facilities on May 13, 2014 at 8:30 am confirmed the housekeeping door lacks positive latching with the self-closure.

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

Findings include:

Observation on May 12, 2014 at 10:15 am revealed the second floor smoke barrier wall by stairwell "A" had an unsealed penetration at the smoke doors above the suspended ceiling.

Interview with the Maintenance Technician on May 12, 2014 at 10:15 am confirmed the unsealed penetration of the smoke barrier wall.

Based upon observation and interview, the facility failed to maintain smoke barrier door assemblies to comply with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 10:10 am revealed the second floor Behavioral Health smoke doors by stairwell "A" do not close completely creating a gap at the top of the doors.

Interview with the Maintenance Technician on May 12, 2014 at 10:10 am confirmed the smoke barrier doors did not close completely leaving a gap at the top of the doors.

Based upon observation and interview, the facility failed to maintain smoke barrier door assemblies to comply with regulations on three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:45 pm revealed the second floor dietary storeroom door by the #5 elevator lacked positive latching with the self-closer.

Interview with the Maintenance Technician on May 12, 2014 at 12:45 pm confirmed the storage room door lacked positive latching with the self-closer.

2. Observation on May 12, 2014 at 8:50 am revealed penthouse elevator room door (access to roof) was tied in the open position.

Interview with Maintenance Mechanic on May 12, 2014 at 8:50 am confirmed the door is held in the open position, and the subsequent correction of this item during the time of the survey.

3. Observation on May 13, 2014 at 7:50 am revealed first floor soiled utility room door (pain clinic side) lacks positive latching with the self-closure.

Interview with Director of Facilities on May 13, 2014 at 7:50 am confirmed the door lacks positive latching with the self-closure.

Based upon observation and interview, the facility failed to maintain exit egress components to have a fire resistive rating of at least one hour, in accordance with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 11:55 am revealed first floor stair tower door between stair and M.R.I. lacks indication that the hardware installed is fire exit hardware.

Interview with Director of Facilities on May 12, 2014 at 11:55 am confirmed facility shall verify the installed hardware is fire exit hardware.

Based upon observation and interview, the facility failed to provide a continuous path of egress as per regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 12:30 pm revealed first floor, right side of fire exit double doors to the outside (behind back of MRI area) does not open.

Interview with Director of Facilities on May 12, 2014 at 12:30 pm confirmed the exit door will not release from the frame to open, and the subsequent correction of this item during the time of the survey.

Based upon observation and interview, the facility failed to maintain horizontal exits in accordance with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 11:55 am revealed first floor laboratory fire door near break room is blocked open with a large table.

Interview with Director of Facilities on May 12, 2014 at 11:55 am confirmed the fire door is blocked open, and the subsequent correction of this item during the time of the survey.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually, and 30 seconds monthly in accordance with regulations in all anesthetization and generator locations.

Findings include:

Document review on May 13, 2014 at 11:00 am revealed facility lacks documentation that the battery back-up lighting in all anesthetizing and generator locations are tested in accordance with regulations:
A. 30 seconds per month.
B. 1-1/2 hour drain per year.

Interview with Director of Facilities on May 13, 2014 at 11:00 am confirmed the battery back-up lighting testing is not documented.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination and also served by the emergency lighting system on one of three floors.

Findings include:

Observation on May 12, 2014 at 10:00 am revealed the exit sign in 2A group room on the second floor is not illuminated.

Interview with the Maintenance Technician on May 12, 2014 at 10:00 am confirmed the exit sign was not illuminated.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on three of three floors.

Findings include:

1. Observation on May 12, 2014 between 9:00 am and 1:10 pm revealed the following sprinkler concerns:
A. Third floor electrical room 3A has ceiling tile removed, and this condition may delay the function of the fire sprinkler head (9:00 am).
B. Third floor O. R. utility room sprinkler pipe valve lacks a permanent and secure identification sign (10:50 am).
C. First floor x-ray data room sprinkler pipe has a large load of blue data wires resting on top of pipe (12:40 pm).
D. First floor emergency department utility room sprinkler pipe valve lacks a permanent and secure identification sign (1:10 pm).

Interview with Director of Facilities on May 12, 2014 at 1:10 pm confirmed the above sprinkler concerns, and the subsequent correction of item A only, during the time of the survey.

2. Observation on May 13, 2014 at 8:30 am revealed the basement Snyder Institute housekeeping room has ceiling tile removed, and this condition may delay the function of the fire sprinkler head.

Interview with Director of Facilities on May 13, 2014 at 8:30 am confirmed the removed ceiling tile.

Based on documentation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on two of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:50 pm revealed that the K-type portable fire extinguisher in the second floor Kitchen was not inspected for the month of April 2014.

Interview with the Maintenance Technician on May 12, 2014 at 12:50 pm confirmed the portable fire extinguisher was not inspected for the month of April 2014.

2. Observation on May 12, 2014 at 10:35 am revealed that the gauge on the portable fire extinguisher on the second floor across from room 235 indicated a discharged condition.

Interview with the Maintenance Technician on May 12, 2014 at 10:35 am confirmed the portable fire extinguishers gauge indicated a discharged condition.

3. Observation on May 12, 2014 at 11:45 am revealed first floor gift shop corridor fire extinguisher (and illuminated locator light) is visually blocked by a gift display.

Interview with Director of Facilities on May 12, 2014 at 11:45 am confirmed the fire extinguisher (and illuminated locator light) is visually blocked, and the subsequent correction of this item during the time of the survey.

Based upon observation and interview, it was determined that facility failed to store medical gas in accordance with regulations on two of three floors.

Findings include:

1. Observation on May 12, 2014 at 10:55 am revealed third floor O.R. storage room does not meet requirements of a non-flammable compressed gas storage room storing over 300 cubic feet, and under 3000 cubic feet of nitrogen (four H-sized nitrogen cylinders are stored within this room).
A. Electrical fixtures do not meet height requirements
B. Ventilation requirements not met.
C. Door lacks a self-closure and proper fire rating.

Interview with Director of Facilities on May 12, 2014 at 10:55 am confirmed the nitrogen storage room does not meet regulations for more than 300 cubic feet of non-flammable storage.

2. Observation on May 13, 2014 at 8:50 am revealed G basement oxygen storage room does not meet requirements of an oxygen storage room storing over 300 cubic feet, and under 3000 cubic feet of oxygen (more than 12 E-sized oxygen cylinders are stored within this room).
A. Electrical fixtures do not meet height requirements
B. Ventilation requirements not met.
C. Corridor door lacks a self-closure.

Interview with Director of Facilities on May 13, 2014 at 8:50 am confirmed the oxygen storage room does not meet regulations for more than 300 cubic feet of oxygen storage.

Based upon observation and interview, the laboratory fume hoods are not in accordance with regulations in one of one laboratory.

Findings include:

Observation on May 12, 2014 at 11:50 am revealed two laboratory fume hood inspection stickers attached to the hoods indicate hoods required an inspection in December, 2013. Facility shall verify this inspection was done in accordance with regulations.

Interview with Director of Facilities on May 12, 2014 at 11:50 am confirmed the hoods have past-due inspection stickers.

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 two floors.

Findings include:

Observation on May 12, 2014 at 2:00 pm revealed an open junction box in the basement mechanical room above the fire extinguisher.

Interview with the Maintenance Technician on May 12, 2014 at 2:00 pm confirmed the junction box was open.

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 three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:40 pm revealed the microwave oven in the second floor dining area was plugged into a homemade extension cord.

Interview with the Maintenance Technician on May 12, 2014 at 12:40 pm confirmed the microwave oven was plugged into an extension cord.

2. Observation on May 12, 2014 between 8:50 am and 1:20 pm revealed the following electrical concerns:
A. Penthouse D has a temporary light plugged into an extension cord (8:50 am).
B. Third floor I.V. team room has a microwave oven and toaster plugged into a surge protector (10:15 am).
C. First floor laboratory break room has a coffee maker plugged into a surge protector (11:57 am).
D. First floor laboratory specimen room surge protector is hanging off the floor by the cords plugged into it from above (12:05 pm).
E. First floor emergency department has two coffee makers plugged into a surge protector (1:00 pm).
F. First floor laboratory supervisor office has a surge protector plugged into another surge protector (1:20 pm).

Interview with Director of Facilities on May 12, 2014 at 1:20 pm confirmed the above electrical concerns, and the subsequent correction of items A, B, C, and E only, during the time of the survey.

3. Observation on May 13, 2014 at 7:55 am revealed first floor respiratory therapist lounge has an extension cord.

Interview with Director of Facilities on May 13, 2014 at 7:55 am confirmed the extension cord use, and the subsequent correction of this item during the time of the survey.

Based upon observation it was determined that facility failed to maintain the two (2) hour common fire barrier wall, with a non-conforming building, in accordance with regulations on one of three floors.

Findings include:

Observation on May 13, 2014 at 9:00 am revealed G basement fire wall with service building has multiple unsealed blue data wire penetrations (both side of the fire barrier wall).

Interview with Director of Facilities on May 13, 2014 at 9:00 am confirmed the unsealed fire barrier penetrations.

Based upon observation and interview, it was determined the facility failed to maintain building construction type and height to meet regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 12:35 pm revealed first floor x-ray development room has an unsealed pipe penetration through the fire rated ceiling assemble.

Interview with Director of Facilities on May 12, 2014 at 12:35 pm confirmed the unsealed penetration of the fire rated ceiling assembly.

Based upon observation and interview, it was determined the facility failed to maintain the doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:35 pm revealed that the second floor Rehab Services corridor door that was connected to the fire alarm system lacked positive latching with the self-closer.

Interview with the Maintenance Technician on May 12, 2014 at 12:35 am confirmed the corridor door lacked positive latching with the self-closer.

2. Observation on May 12, 2014 at 10:05 am revealed third floor room 326 door could not close due to an overabundance of wheelchairs stored inside.

Interview with Director of Facilities on May 12, 2014 at 10:05 am confirmed the wheelchairs blocked door closure, and the subsequent correction of this item during the time of the survey.

3. Observation on May 13, 2014 at 8:30 am revealed basement Snyder Institute housekeeping door lacks positive latching with the self-closure.

Interview with Director of Facilities on May 13, 2014 at 8:30 am confirmed the housekeeping door lacks positive latching with the self-closure.

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

Findings include:

Observation on May 12, 2014 at 10:15 am revealed the second floor smoke barrier wall by stairwell "A" had an unsealed penetration at the smoke doors above the suspended ceiling.

Interview with the Maintenance Technician on May 12, 2014 at 10:15 am confirmed the unsealed penetration of the smoke barrier wall.

Based upon observation and interview, the facility failed to maintain smoke barrier door assemblies to comply with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 10:10 am revealed the second floor Behavioral Health smoke doors by stairwell "A" do not close completely creating a gap at the top of the doors.

Interview with the Maintenance Technician on May 12, 2014 at 10:10 am confirmed the smoke barrier doors did not close completely leaving a gap at the top of the doors.

Based upon observation and interview, the facility failed to maintain smoke barrier door assemblies to comply with regulations on three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:45 pm revealed the second floor dietary storeroom door by the #5 elevator lacked positive latching with the self-closer.

Interview with the Maintenance Technician on May 12, 2014 at 12:45 pm confirmed the storage room door lacked positive latching with the self-closer.

2. Observation on May 12, 2014 at 8:50 am revealed penthouse elevator room door (access to roof) was tied in the open position.

Interview with Maintenance Mechanic on May 12, 2014 at 8:50 am confirmed the door is held in the open position, and the subsequent correction of this item during the time of the survey.

3. Observation on May 13, 2014 at 7:50 am revealed first floor soiled utility room door (pain clinic side) lacks positive latching with the self-closure.

Interview with Director of Facilities on May 13, 2014 at 7:50 am confirmed the door lacks positive latching with the self-closure.

Based upon observation and interview, the facility failed to maintain exit egress components to have a fire resistive rating of at least one hour, in accordance with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 11:55 am revealed first floor stair tower door between stair and M.R.I. lacks indication that the hardware installed is fire exit hardware.

Interview with Director of Facilities on May 12, 2014 at 11:55 am confirmed facility shall verify the installed hardware is fire exit hardware.

Based upon observation and interview, the facility failed to provide a continuous path of egress as per regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 12:30 pm revealed first floor, right side of fire exit double doors to the outside (behind back of MRI area) does not open.

Interview with Director of Facilities on May 12, 2014 at 12:30 pm confirmed the exit door will not release from the frame to open, and the subsequent correction of this item during the time of the survey.

Based upon observation and interview, the facility failed to maintain horizontal exits in accordance with regulations on one of three floors.

Findings include:

Observation on May 12, 2014 at 11:55 am revealed first floor laboratory fire door near break room is blocked open with a large table.

Interview with Director of Facilities on May 12, 2014 at 11:55 am confirmed the fire door is blocked open, and the subsequent correction of this item during the time of the survey.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually, and 30 seconds monthly in accordance with regulations in all anesthetization and generator locations.

Findings include:

Document review on May 13, 2014 at 11:00 am revealed facility lacks documentation that the battery back-up lighting in all anesthetizing and generator locations are tested in accordance with regulations:
A. 30 seconds per month.
B. 1-1/2 hour drain per year.

Interview with Director of Facilities on May 13, 2014 at 11:00 am confirmed the battery back-up lighting testing is not documented.

Based upon observation and interview, the facility failed to maintain exit and direction signs with continuous illumination and also served by the emergency lighting system on one of three floors.

Findings include:

Observation on May 12, 2014 at 10:00 am revealed the exit sign in 2A group room on the second floor is not illuminated.

Interview with the Maintenance Technician on May 12, 2014 at 10:00 am confirmed the exit sign was not illuminated.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on three of three floors.

Findings include:

1. Observation on May 12, 2014 between 9:00 am and 1:10 pm revealed the following sprinkler concerns:
A. Third floor electrical room 3A has ceiling tile removed, and this condition may delay the function of the fire sprinkler head (9:00 am).
B. Third floor O. R. utility room sprinkler pipe valve lacks a permanent and secure identification sign (10:50 am).
C. First floor x-ray data room sprinkler pipe has a large load of blue data wires resting on top of pipe (12:40 pm).
D. First floor emergency department utility room sprinkler pipe valve lacks a permanent and secure identification sign (1:10 pm).

Interview with Director of Facilities on May 12, 2014 at 1:10 pm confirmed the above sprinkler concerns, and the subsequent correction of item A only, during the time of the survey.

2. Observation on May 13, 2014 at 8:30 am revealed the basement Snyder Institute housekeeping room has ceiling tile removed, and this condition may delay the function of the fire sprinkler head.

Interview with Director of Facilities on May 13, 2014 at 8:30 am confirmed the removed ceiling tile.

Based on documentation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on two of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:50 pm revealed that the K-type portable fire extinguisher in the second floor Kitchen was not inspected for the month of April 2014.

Interview with the Maintenance Technician on May 12, 2014 at 12:50 pm confirmed the portable fire extinguisher was not inspected for the month of April 2014.

2. Observation on May 12, 2014 at 10:35 am revealed that the gauge on the portable fire extinguisher on the second floor across from room 235 indicated a discharged condition.

Interview with the Maintenance Technician on May 12, 2014 at 10:35 am confirmed the portable fire extinguishers gauge indicated a discharged condition.

3. Observation on May 12, 2014 at 11:45 am revealed first floor gift shop corridor fire extinguisher (and illuminated locator light) is visually blocked by a gift display.

Interview with Director of Facilities on May 12, 2014 at 11:45 am confirmed the fire extinguisher (and illuminated locator light) is visually blocked, and the subsequent correction of this item during the time of the survey.

Based upon observation and interview, it was determined that facility failed to store medical gas in accordance with regulations on two of three floors.

Findings include:

1. Observation on May 12, 2014 at 10:55 am revealed third floor O.R. storage room does not meet requirements of a non-flammable compressed gas storage room storing over 300 cubic feet, and under 3000 cubic feet of nitrogen (four H-sized nitrogen cylinders are stored within this room).
A. Electrical fixtures do not meet height requirements
B. Ventilation requirements not met.
C. Door lacks a self-closure and proper fire rating.

Interview with Director of Facilities on May 12, 2014 at 10:55 am confirmed the nitrogen storage room does not meet regulations for more than 300 cubic feet of non-flammable storage.

2. Observation on May 13, 2014 at 8:50 am revealed G basement oxygen storage room does not meet requirements of an oxygen storage room storing over 300 cubic feet, and under 3000 cubic feet of oxygen (more than 12 E-sized oxygen cylinders are stored within this room).
A. Electrical fixtures do not meet height requirements
B. Ventilation requirements not met.
C. Corridor door lacks a self-closure.

Interview with Director of Facilities on May 13, 2014 at 8:50 am confirmed the oxygen storage room does not meet regulations for more than 300 cubic feet of oxygen storage.

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 two floors.

Findings include:

Observation on May 12, 2014 at 2:00 pm revealed an open junction box in the basement mechanical room above the fire extinguisher.

Interview with the Maintenance Technician on May 12, 2014 at 2:00 pm confirmed the junction box was open.

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 three of three floors.

Findings include:

1. Observation on May 12, 2014 at 12:40 pm revealed the microwave oven in the second floor dining area was plugged into a homemade extension cord.

Interview with the Maintenance Technician on May 12, 2014 at 12:40 pm confirmed the microwave oven was plugged into an extension cord.

2. Observation on May 12, 2014 between 8:50 am and 1:20 pm revealed the following electrical concerns:
A. Penthouse D has a temporary light plugged into an extension cord (8:50 am).
B. Third floor I.V. team room has a microwave oven and toaster plugged into a surge protector (10:15 am).
C. First floor laboratory break room has a coffee maker plugged into a surge protector (11:57 am).
D. First floor laboratory specimen room surge protector is hanging off the floor by the cords plugged into it from above (12:05 pm).
E. First floor emergency department has two coffee makers plugged into a surge protector (1:00 pm).
F. First floor laboratory supervisor office has a surge protector plugged into another surge protector (1:20 pm).

Interview with Director of Facilities on May 12, 2014 at 1:20 pm confirmed the above electrical concerns, and the subsequent correction of items A, B, C, and E only, during the time of the survey.

3. Observation on May 13, 2014 at 7:55 am revealed first floor respiratory therapist lounge has an extension cord.

Interview with Director of Facilities on May 13, 2014 at 7:55 am confirmed the extension cord use, and the subsequent correction of this item during the time of the survey.