HospitalInspections.org

The facility has failed to maintain the construction requirements for the classification of construction. This could allow for heat, smoke, and fire to travel from one area to another area and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 11:00am to 3:30pm, I observed unsealed penetrations in the following locations:

1. At 11:00am, I observed a penetration caused by electrical conduit on both sides of the fire wall by the elevator into surgery, above the ceiling tiles.
2. At 11:20am, I observed penetrations above the ceiling tiles at the fire doors by waiting room.
3. At 11:30am, I observed a penetration in the ceiling of the Endoscopy reception area.
4. At 12:45pm, I observed a penetration in the ceiling in the oxygen storage room.
5. At 1:52pm, 2nd floor surgery was observed to have penetration in the autoclave room created by electrical conduit.
6. At 3:08pm, I observed that the basement bio hazard room has a penetration in the ceiling.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility failed to provide corridor doors that closed and latched properly as required. This provides conditions that make the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly close and latch places patients, visitors, and staff at risk of the effects of smoke and heat.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 from 11:00am, to 3:30pm, I observed fire doors that did not close and latch when tested in the following locations:

1. At 1:06pm, I observed that the fire door on 1st floor corridor by elevator and outside of Admitting area has door missing. Interview with staff revealed that this is a fire wall separation and the door must be in place. Staff indicated that the fire door was possibly removed when the remodel was completed in 2010.
2. At 3:00pm, I observed that door from Central Supply into corridor did not close and latch properly when tested.
3. At 3:10pm, I observed that the back exit door out of the kitchen into the stair well did not close at all.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility failed to provide corridor doors that closed and latched properly as required. This provides conditions that make the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly close and latch places patients, visitors, and staff at risk of the effects of smoke and heat.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 from 11:00am, to 3:30pm, I observed fire doors that did not close and latch when tested in the following locations:

At 1:35pm, I observed that doors separating the existing and the new construction would not close and latch properly because of heavy air flow pressure.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility has failed to ensure that only approved portable heaters are used in non-sleeping staff and employee areas of the hospital. This could cause an environment where a fire could start and expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

At 1:25pm, I observed that the VA exam room #3 on the 1st floor has an unapproved heater. When tipped over this heater did not turn off. This heater does not have the automatic shut-off tip-over feature that is required.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that only approved portable heaters are used in non-sleeping staff and employee areas of the hospital. This could cause an environment where a fire could start and expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

At 2:45pm, I observed that the UR office across from the nurses station on the 1st floor has an unapproved heater. When tipped over this heater did not turn off. This heater does not have the automatic shut-off tip-over feature that is required.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that all pressurized gas cylinders, specifically oxygen tanks are secured from falling over at all times, whether the tanks are empty or full. Failure to secure oxygen tanks could allow for an oxygen tank to fall and cause a missile-like hazardous event and thus expose patients, visitors, and staff to the threat of such a hazard.

The findings include, but are not limited to:

At 12:45pm, an exterior assessment of the facility revealed that the oxygen storage room had several tanks that were not secured in place. Some had chains available, but not in place.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that Master Alarms for piped in medical gases are installed per NFPA 99 as required. This could allow for the system to become inoperable and the required personnel not advised and thus place patients, visitors, and staff at risk of an emergency event.

The findings include, but are not limited to:

During the facility tour on September 23, 2014, at approximately 3:25pm, I observed that a 2nd master alarm for the medical gas system was in the basement. This master alarm panel is in the new basement area constructed in 2010. However, this alarm panel is not located in the principle working area of the individual responsible for the maintenance of the medical gas piping system. Another alarm was observed to be in across from the nurses station on the first floor that is always manned.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.


NFPA 99 states in part:
4-3.1.2.2 (b) Master Alarms.

2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location.)

The facility has failed to maintain the construction requirements for the classification of construction. This could allow for heat, smoke, and fire to travel from one area to another area and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 11:00am to 3:30pm, I observed unsealed penetrations in the following locations:

1. At 11:00am, I observed a penetration caused by electrical conduit on both sides of the fire wall by the elevator into surgery, above the ceiling tiles.
2. At 11:20am, I observed penetrations above the ceiling tiles at the fire doors by waiting room.
3. At 11:30am, I observed a penetration in the ceiling of the Endoscopy reception area.
4. At 12:45pm, I observed a penetration in the ceiling in the oxygen storage room.
5. At 1:52pm, 2nd floor surgery was observed to have penetration in the autoclave room created by electrical conduit.
6. At 3:08pm, I observed that the basement bio hazard room has a penetration in the ceiling.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility failed to provide corridor doors that closed and latched properly as required. This provides conditions that make the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly close and latch places patients, visitors, and staff at risk of the effects of smoke and heat.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 from 11:00am, to 3:30pm, I observed fire doors that did not close and latch when tested in the following locations:

1. At 1:06pm, I observed that the fire door on 1st floor corridor by elevator and outside of Admitting area has door missing. Interview with staff revealed that this is a fire wall separation and the door must be in place. Staff indicated that the fire door was possibly removed when the remodel was completed in 2010.
2. At 3:00pm, I observed that door from Central Supply into corridor did not close and latch properly when tested.
3. At 3:10pm, I observed that the back exit door out of the kitchen into the stair well did not close at all.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility failed to provide corridor doors that closed and latched properly as required. This provides conditions that make the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly close and latch places patients, visitors, and staff at risk of the effects of smoke and heat.

The findings include, but are not limited to:

During the facility tour on September 23, 2014 from 11:00am, to 3:30pm, I observed fire doors that did not close and latch when tested in the following locations:

At 1:35pm, I observed that doors separating the existing and the new construction would not close and latch properly because of heavy air flow pressure.

These findings were observed and discussed with the Maintenance Director and Maintenance Staff.

The facility has failed to ensure that only approved portable heaters are used in non-sleeping staff and employee areas of the hospital. This could cause an environment where a fire could start and expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

At 1:25pm, I observed that the VA exam room #3 on the 1st floor has an unapproved heater. When tipped over this heater did not turn off. This heater does not have the automatic shut-off tip-over feature that is required.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that only approved portable heaters are used in non-sleeping staff and employee areas of the hospital. This could cause an environment where a fire could start and expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

At 2:45pm, I observed that the UR office across from the nurses station on the 1st floor has an unapproved heater. When tipped over this heater did not turn off. This heater does not have the automatic shut-off tip-over feature that is required.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that all pressurized gas cylinders, specifically oxygen tanks are secured from falling over at all times, whether the tanks are empty or full. Failure to secure oxygen tanks could allow for an oxygen tank to fall and cause a missile-like hazardous event and thus expose patients, visitors, and staff to the threat of such a hazard.

The findings include, but are not limited to:

At 12:45pm, an exterior assessment of the facility revealed that the oxygen storage room had several tanks that were not secured in place. Some had chains available, but not in place.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.

The facility has failed to ensure that Master Alarms for piped in medical gases are installed per NFPA 99 as required. This could allow for the system to become inoperable and the required personnel not advised and thus place patients, visitors, and staff at risk of an emergency event.

The findings include, but are not limited to:

During the facility tour on September 23, 2014, at approximately 3:25pm, I observed that a 2nd master alarm for the medical gas system was in the basement. This master alarm panel is in the new basement area constructed in 2010. However, this alarm panel is not located in the principle working area of the individual responsible for the maintenance of the medical gas piping system. Another alarm was observed to be in across from the nurses station on the first floor that is always manned.

This finding was observed and discussed with the Maintenance Director and the Maintenance Staff.


NFPA 99 states in part:
4-3.1.2.2 (b) Master Alarms.

2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location.)