HospitalInspections.org

Based on observation, on June 5, 2013 at approximately 8:00am onward, doors are incomplete due to the following:

1. Lack of positive latching hardware - door between engineering office and corridor adjacent to materials management.

2. Lack of positive latching hardware - door serving C-section recovery room located on first floor Labor and Delivery Unit.

3. Door to nuclear medicine is wedged in the open position.

4. Louver in door to room 340B, pharmacy regional manager's office, is not installed to maintain required fire resistance rating. The facility is not equipped with a complete automatic sprinkler system that would allow a rating reduction.

5. Lack of positive latching hardware on Wickett doors located on resident room doors in second floor Psych unit - Women's Unit.

6. Lack of positive latching hardware on door to office in Med Psych Unit on second floor.

7. Dead-bolt lock serving social work office is greater than forty-eight inches above the finished floor - Second Floor Med Psych Unit.

8. Wedge under door to Clinical Dieticians office.(Second floor)

Based on observation, on June 4 -6, 2013, hazardous areas are incomplete in the following areas:

1. Medical Office Building - room containing hyberbaric chamber(s) is not enclosed with a minimum one hour enclosure that extends to the floor deck above.

2. Medical Office Building - room containing hyberbaric chamber(s) is not equipped with self-closing, 90 minute fire doors with required hardware.

3. Medical Office Building - storage room 001 has approximately a one inch gap between meeting edge of fire doors. The room greatly exceeds one hundred square feet in area.

Based on observation, on June 6, 2013 at approximately 8:00am onward, hazardous areas are incomplet in the following areas:

1. Materials management located on ground floor - fire doors, adjacent to corridor, do not close and latch properly.

2. Biohazard storage room - holes in enclosure walls. Located beside loading dock area.

3. Radioactive materials room - no lead lining identified in door.

4. Transformer room - no self-closing device on door enclosing room. Located off corridor between outpatient surgery and operating suite.

Based on observation, on June 5, 2013 at 8:00am onward, the exits are noncompliant due to the following:

1. the second exit route is not identified at the second floor elevator lobby formed by unit control doors.(Psych Unit)

2. there is no on/off master release switch for electromagnetic locks serving the Baby Place - the required switch is not provided at the nurse's station on first floor unit

Note: The facility must be protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101; 2000 LSC when utilizing special locking arrangements.

3. cross corridor control doors are single leaf doors, not double egress, where egress is required in both directions.(Second floor psychiatric unit)

Based on observation, on June 6, 2013 at approximately 8:00am onward, there are no stair identification signs provided within stair enclosures at each landing in accordance with section 7.2.2.5.4 of NFPA 101; 2000 LSC.(Medical Office Building)

Based on observation, on June 5, 2013 at 8:00am onward, exit access is incomplete due to the following:

1. exit access door added between renovation area and ICU is less than forty-four inches - located on third floor.

2. exit access area formed by control doors near second floor elevators contain a dead-end corridor greater than thirty feet.

3. exit access area near control doors to the Baby Place create a dead-end corridor exceeding thirty feet - there is no exit sign above doors at time of survey.(located on first floor)

4. there is no guardrail between means of egress and loading dock area.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the emergency lighting is incomplete due to the following:

1. exit discharge located on east wing of first floor Labor and Delivery unit - no emergency lighting extending from exit discharge to publicway.

2. east stairway exit discharge near front entrance - no emergency lighting extending from exit discharge to publicway.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the emergency light at the base of north stairway did not function during loss of normal power - Medical Office Building, near electrical room 003.

Based on observation, on June 6, 2013 at approximately 8:00am onward, exit signs are incomplete in the following areas:

1. Materials management area - exit egress is not equipped with an exit directional sign at area near metal gate - direction to exit discharge is not obvious.

2. Women's unit, second floor - there is no exit sign above door leading from women's unit to main corridor near elevators.

3. Med Surg emergency exit on north wing - there is no exit sign above door leading through construction renovation area.(Third Floor)

Based on observation, on June 6, 2013 at approximately 8:00am onward, there are no exit signs to direct occupants at basement level to the appropriate level of exit discharge - Medical Office Building.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the fire alarm system is incomplete in the Medical Office Building due to the following:

1. fire alarm system strobe lights would not function with loss of normal power to the main fire alarm control panel.

2. Circuit and panelboard supplying normal power to main fire alarm panel are not identified on fire alarm control panel - located in room 003 electrical room.

Based on observation, on June 6, 2013 at approximately 9:36am onward, the fire alarm system is noncompliant due to the following:

1. did not function with loss of normal power to the main fire alarm control panel.(Security station near ER)

2. manual pull station is located behind a wooden dish rack - located in the serving area beside the kitchen.

Based on observation, on June 5, 2013 at approximately 10:05am, the sprinkler systems in renovated areas is incomplete due to the following:

1. there is no sprinkler in transformer room - located beside corridor between outpatient surgery and main operating suite.

2. there is no sprinkler at base of lowest stair landing - west stair at ground floor.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the sprinkler standpipe in south stairway, fifth floor, has no pressure reading on gauge.

Based on observation, on June 5, 2013 at approximately 11:22am, the main sprinkler valve is not equipped with electrical supervision - located in valve pit beside street intersections.

Based on observation, on June 5, 2013 at approximately 9:12am, the upright sprinkler riser is not secured with strap or bracing - located in electrical room near the Baby Place.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the mechanical systems are incomplete due to the following:

1. there is no emergency shutdown switch for air handlers serving the second and third floors of the facility - switch could not be verified near supervised areas within either floor.

2. smoke damper did not close properly at barrier between OR and Outpatient Surgery located on the first floor.

Based on observation, on June 6, 2013 at approximately 8:00am onward, there is no manual shutdown switch for air handler serving wound care center and other hospital based provider spaces within the Medical Office Building - the switch shall be located at a supervised area within a designated hospital based provider space.

Based on observation, on June 5, 2013 at 8:00am onward, the range hood suppression system is incomplete due to the following:

1. air imbalance between the kitchen and adjacent egress corridor - doors to kitchen and dining are held in the open position due to air flow.

2. electrical outlets behind the range hood cooking equipment is not arranged to shut-off power with activation of range hood pull station.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the means of egress in the following areas are noncompliant:
1. ground floor corridor near sterile processing - carts, furniture and other impediments are stored in the corridor.

2. exit passageway located on first floor west wing near Labor and Delivery unit - a wheelchair equipped with oxygen cylinder is left unattended in front of the exit door serving the exit passageway.

3. Med Psych Unit located on second floor - furniture and other impediments stored in corridor near social work office.

4. Second floor Women's Psych Unit - furniture, and other impediments are stored in the exit corridor.

5. Second floor near room 232 - corridor is obstructed by chairs, and bedside tables.

6. Second floor Psych unit on west wing - corridor wall is equipped with large mirror and bracket that protrude inside required head clearance of six feet eight inches. The mirror and bracket extend greater than three and one half inches from wall surface.

7. Second floor corridor near Pharmacy storage, and old OB area - sink, plants, IV poles, and blanket warmer obstruct corridor.

8. ICU located on 300 hall - tables, receptacle junction boxes, and conduit obstruct corridor near renovation area.

9. Med Surg on third floor near room 333 - electric bug light protrudes greater than three and one half inches into required corridor.
10. Ground floor - corridor is obstructed by furniture beside dining and serving area.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the medical gas systems are incomplete due to the following:

1. Oxygen bank near loading dock - cylinders are not protected from extremes of weather. Cylinders are in direct contact with concrete slabs and are covered with rust.

2. Oxygen bank near loading dock - cylinders are not secured individually to support brackets.

3. Compressed air cylinders are intermingled with full oxygen cylinders - storage room beside loading dock.

4. Oxygen bank between main hospital and medical office building is not equipped with covers to protect cylinders from extremes of weather.

5. Ultrasound room #1 - piped medical gas systems are not identified on zone alarm panel behind nurse's station.(located in radiology area)

Based on observation, on June 5, 2013 at approximately 8:00am onward, the essential electrical system is incomplete due to the following:

1. Life Safety branch panelboard contains devices not permitted on the Life Safety Branch of the essential electrical system. Circuit directory has not been updated to include the exclusion of devices not in service.(Panel ISL located on first floor)

2. there is no means for testing the required audible signaling devices for generator annunciator panels located in the engineering office and security station near ER.

3. there is no required signaling, audible and visual, for less than three hour fuel operating supply in the main fuel tank serving the emergency generators of the essential electrical system.

Based on observation, on June 5, 2013 at approximately 1:42pm onward, the medical gas alarms required greater than a twenty percent drop in pressure to activate signaling device - alarm panel at Radiology nurse's station.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the facility electrical systems are incomplete due to the following:

1. standard duplex receptacles facing loading dock are not identified as ground fault interrupter protected.

2. Massage room located near the first floor Baby Place - there is a multioutlet power tap used to distribute power. The device is not listed for use in patient care areas of health care facilities.

3. Life Safety Panel 1SHA in first floor electrical equipment room located near the spa - equipment grounding conductor number six and smaller is not equipped with continuous green insulated conductor.

4. Electrical Panel 1NH in first floor electrical room located near the spa - equipment grounding conductor number six and smaller is not equipped with green insulated conductor.

5. There are no minimum #10 green insulated conductors for bonding emergency and normal power panelboards serving the same patient vicinity - panelboards located in first floor electrical equipment room near the spa.

6. Lack of tamperproof receptacles for all receptacles used in patient rooms - located in the second floor Psychiatric Women's Unit.

Based on observation, on June 5, 2013 at approximately 8:00am onward, doors are incomplete due to the following:

1. Lack of positive latching hardware - door between engineering office and corridor adjacent to materials management.

2. Lack of positive latching hardware - door serving C-section recovery room located on first floor Labor and Delivery Unit.

3. Door to nuclear medicine is wedged in the open position.

4. Louver in door to room 340B, pharmacy regional manager's office, is not installed to maintain required fire resistance rating. The facility is not equipped with a complete automatic sprinkler system that would allow a rating reduction.

5. Lack of positive latching hardware on Wickett doors located on resident room doors in second floor Psych unit - Women's Unit.

6. Lack of positive latching hardware on door to office in Med Psych Unit on second floor.

7. Dead-bolt lock serving social work office is greater than forty-eight inches above the finished floor - Second Floor Med Psych Unit.

8. Wedge under door to Clinical Dieticians office.(Second floor)

Based on observation, on June 4 -6, 2013, hazardous areas are incomplete in the following areas:

1. Medical Office Building - room containing hyberbaric chamber(s) is not enclosed with a minimum one hour enclosure that extends to the floor deck above.

2. Medical Office Building - room containing hyberbaric chamber(s) is not equipped with self-closing, 90 minute fire doors with required hardware.

3. Medical Office Building - storage room 001 has approximately a one inch gap between meeting edge of fire doors. The room greatly exceeds one hundred square feet in area.

Based on observation, on June 6, 2013 at approximately 8:00am onward, hazardous areas are incomplet in the following areas:

1. Materials management located on ground floor - fire doors, adjacent to corridor, do not close and latch properly.

2. Biohazard storage room - holes in enclosure walls. Located beside loading dock area.

3. Radioactive materials room - no lead lining identified in door.

4. Transformer room - no self-closing device on door enclosing room. Located off corridor between outpatient surgery and operating suite.

Based on observation, on June 5, 2013 at 8:00am onward, the exits are noncompliant due to the following:

1. the second exit route is not identified at the second floor elevator lobby formed by unit control doors.(Psych Unit)

2. there is no on/off master release switch for electromagnetic locks serving the Baby Place - the required switch is not provided at the nurse's station on first floor unit

Note: The facility must be protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101; 2000 LSC when utilizing special locking arrangements.

3. cross corridor control doors are single leaf doors, not double egress, where egress is required in both directions.(Second floor psychiatric unit)

Based on observation, on June 6, 2013 at approximately 8:00am onward, there are no stair identification signs provided within stair enclosures at each landing in accordance with section 7.2.2.5.4 of NFPA 101; 2000 LSC.(Medical Office Building)

Based on observation, on June 5, 2013 at 8:00am onward, exit access is incomplete due to the following:

1. exit access door added between renovation area and ICU is less than forty-four inches - located on third floor.

2. exit access area formed by control doors near second floor elevators contain a dead-end corridor greater than thirty feet.

3. exit access area near control doors to the Baby Place create a dead-end corridor exceeding thirty feet - there is no exit sign above doors at time of survey.(located on first floor)

4. there is no guardrail between means of egress and loading dock area.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the emergency lighting is incomplete due to the following:

1. exit discharge located on east wing of first floor Labor and Delivery unit - no emergency lighting extending from exit discharge to publicway.

2. east stairway exit discharge near front entrance - no emergency lighting extending from exit discharge to publicway.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the emergency light at the base of north stairway did not function during loss of normal power - Medical Office Building, near electrical room 003.

Based on observation, on June 6, 2013 at approximately 8:00am onward, exit signs are incomplete in the following areas:

1. Materials management area - exit egress is not equipped with an exit directional sign at area near metal gate - direction to exit discharge is not obvious.

2. Women's unit, second floor - there is no exit sign above door leading from women's unit to main corridor near elevators.

3. Med Surg emergency exit on north wing - there is no exit sign above door leading through construction renovation area.(Third Floor)

Based on observation, on June 6, 2013 at approximately 8:00am onward, there are no exit signs to direct occupants at basement level to the appropriate level of exit discharge - Medical Office Building.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the fire alarm system is incomplete in the Medical Office Building due to the following:

1. fire alarm system strobe lights would not function with loss of normal power to the main fire alarm control panel.

2. Circuit and panelboard supplying normal power to main fire alarm panel are not identified on fire alarm control panel - located in room 003 electrical room.

Based on observation, on June 6, 2013 at approximately 9:36am onward, the fire alarm system is noncompliant due to the following:

1. did not function with loss of normal power to the main fire alarm control panel.(Security station near ER)

2. manual pull station is located behind a wooden dish rack - located in the serving area beside the kitchen.

Based on observation, on June 5, 2013 at approximately 10:05am, the sprinkler systems in renovated areas is incomplete due to the following:

1. there is no sprinkler in transformer room - located beside corridor between outpatient surgery and main operating suite.

2. there is no sprinkler at base of lowest stair landing - west stair at ground floor.

Based on observation, on June 6, 2013 at approximately 8:00am onward, the sprinkler standpipe in south stairway, fifth floor, has no pressure reading on gauge.

Based on observation, on June 5, 2013 at approximately 11:22am, the main sprinkler valve is not equipped with electrical supervision - located in valve pit beside street intersections.

Based on observation, on June 5, 2013 at approximately 9:12am, the upright sprinkler riser is not secured with strap or bracing - located in electrical room near the Baby Place.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the mechanical systems are incomplete due to the following:

1. there is no emergency shutdown switch for air handlers serving the second and third floors of the facility - switch could not be verified near supervised areas within either floor.

2. smoke damper did not close properly at barrier between OR and Outpatient Surgery located on the first floor.

Based on observation, on June 6, 2013 at approximately 8:00am onward, there is no manual shutdown switch for air handler serving wound care center and other hospital based provider spaces within the Medical Office Building - the switch shall be located at a supervised area within a designated hospital based provider space.

Based on observation, on June 5, 2013 at 8:00am onward, the range hood suppression system is incomplete due to the following:

1. air imbalance between the kitchen and adjacent egress corridor - doors to kitchen and dining are held in the open position due to air flow.

2. electrical outlets behind the range hood cooking equipment is not arranged to shut-off power with activation of range hood pull station.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the means of egress in the following areas are noncompliant:
1. ground floor corridor near sterile processing - carts, furniture and other impediments are stored in the corridor.

2. exit passageway located on first floor west wing near Labor and Delivery unit - a wheelchair equipped with oxygen cylinder is left unattended in front of the exit door serving the exit passageway.

3. Med Psych Unit located on second floor - furniture and other impediments stored in corridor near social work office.

4. Second floor Women's Psych Unit - furniture, and other impediments are stored in the exit corridor.

5. Second floor near room 232 - corridor is obstructed by chairs, and bedside tables.

6. Second floor Psych unit on west wing - corridor wall is equipped with large mirror and bracket that protrude inside required head clearance of six feet eight inches. The mirror and bracket extend greater than three and one half inches from wall surface.

7. Second floor corridor near Pharmacy storage, and old OB area - sink, plants, IV poles, and blanket warmer obstruct corridor.

8. ICU located on 300 hall - tables, receptacle junction boxes, and conduit obstruct corridor near renovation area.

9. Med Surg on third floor near room 333 - electric bug light protrudes greater than three and one half inches into required corridor.
10. Ground floor - corridor is obstructed by furniture beside dining and serving area.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the medical gas systems are incomplete due to the following:

1. Oxygen bank near loading dock - cylinders are not protected from extremes of weather. Cylinders are in direct contact with concrete slabs and are covered with rust.

2. Oxygen bank near loading dock - cylinders are not secured individually to support brackets.

3. Compressed air cylinders are intermingled with full oxygen cylinders - storage room beside loading dock.

4. Oxygen bank between main hospital and medical office building is not equipped with covers to protect cylinders from extremes of weather.

5. Ultrasound room #1 - piped medical gas systems are not identified on zone alarm panel behind nurse's station.(located in radiology area)

Based on observation, on June 5, 2013 at approximately 8:00am onward, the essential electrical system is incomplete due to the following:

1. Life Safety branch panelboard contains devices not permitted on the Life Safety Branch of the essential electrical system. Circuit directory has not been updated to include the exclusion of devices not in service.(Panel ISL located on first floor)

2. there is no means for testing the required audible signaling devices for generator annunciator panels located in the engineering office and security station near ER.

3. there is no required signaling, audible and visual, for less than three hour fuel operating supply in the main fuel tank serving the emergency generators of the essential electrical system.

Based on observation, on June 5, 2013 at approximately 1:42pm onward, the medical gas alarms required greater than a twenty percent drop in pressure to activate signaling device - alarm panel at Radiology nurse's station.

Based on observation, on June 5, 2013 at approximately 8:00am onward, the facility electrical systems are incomplete due to the following:

1. standard duplex receptacles facing loading dock are not identified as ground fault interrupter protected.

2. Massage room located near the first floor Baby Place - there is a multioutlet power tap used to distribute power. The device is not listed for use in patient care areas of health care facilities.

3. Life Safety Panel 1SHA in first floor electrical equipment room located near the spa - equipment grounding conductor number six and smaller is not equipped with continuous green insulated conductor.

4. Electrical Panel 1NH in first floor electrical room located near the spa - equipment grounding conductor number six and smaller is not equipped with green insulated conductor.

5. There are no minimum #10 green insulated conductors for bonding emergency and normal power panelboards serving the same patient vicinity - panelboards located in first floor electrical equipment room near the spa.

6. Lack of tamperproof receptacles for all receptacles used in patient rooms - located in the second floor Psychiatric Women's Unit.