HospitalInspections.org

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the former emergency room drive. The corridor door was not equipped with positive latching hardware. Findings include:

1. Observation at 3:45 p.m. on 9/03/13 revealed the corridor door to the former emergency room drive was not provided with positive latching hardware. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated it appeared the door had never had latching hardware installed since the original construction.

Based on observation and interview, the provider failed to maintain the fire resistive rating of smoke barrier walls. The smoke barrier wall at the north side of the second floor nurses station had two unsealed wiring penetrations above the lay-in acoustical ceiling. Findings include:

1. Observation at 1:30 p.m. on 9/04/13 revealed the smoke barrier wall at the north side of the second floor nurses station had two unsealed wiring penetrations (approximately 2 inches in diameter) above the lay-in acoustical ceiling. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated the contractors must not have finished sealing after installing new computer wiring.

Based on observation, testing, and interview, the provider failed to maintain a suitable storage location for control of infectious material. The closer for the soiled linen room door in the OR suite was not working. Findings include:

1. Observation and testing at 8:45 a.m. on 9/04/13 revealed the closer for the soiled linen room door in the OR suite was not working. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated the door closer would be repaired or replaced as soon as possible.

Based on observation and interview, the provider failed to maintain similar levels for the path of egress on both sides of one randomly observed exit door for the southwest exit stair discharge. The exterior side of that exit door had a six inch step-down when exiting the building. Findings include:

1. Observation at 4:00 p.m. on 9/03/13 revealed the exit door for the southwest exit stair discharge did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation, testing, and interview, the provider failed to ensure four randomly observed designated exits were readily accessible at all times and were not equipped with signage that indicated how to open a magnetically locked door in an emergency, one at the west side of same day surgery on the ground floor, three at the third floor stair enclosures. Findings include:

1. Observation beginning at 9:00 a.m. on 9/04/13 revealed four marked exit doors were equipped with magnetically locking hardware, one at the west side of same day surgery on the ground floor, three at the third floor stair enclosures. Testing of the doors revealed they were delayed egress-type magnetically locked doors with 15 second delays. The correct signage indicating the doors were delayed egress type was not posted. Interview with the plant operations director at the time of the observation confirmed those findings. Interview with the administrator at 2:30 p.m. revealed the third floor magnetic locks were on the Hugs door locking system as a deterrent from removing an infant from the facility.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit on the emergency power system at the generator transfer switch locations. Power must be supplied from the emergency system for those items. Findings include:

1. Observation at 10:00 a.m. on 9/04/13 revealed the provider failed to install emergency battery powered lighting units on the emergency power system at the generator transfer switch locations. Interview with the director of plant operations at the time of observation confirmed that finding.

Based on observation and interview, the provider failed to install permanent wiring for the microwave at the ground floor vending area for same day surgery. An extension cord was used for the microwave. (See attached (NFPA 70) Article 305 Temporary Wiring.) Findings include:

1. Observation at 8:45 a.m. on 9/04/13 revealed an extension cord was used for the microwave at the vending area for same day surgery on the ground floor. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the former emergency room drive. The corridor door was not equipped with positive latching hardware. Findings include:

1. Observation at 3:45 p.m. on 9/03/13 revealed the corridor door to the former emergency room drive was not provided with positive latching hardware. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated it appeared the door had never had latching hardware installed since the original construction.

Based on observation and interview, the provider failed to maintain the fire resistive rating of smoke barrier walls. The smoke barrier wall at the north side of the second floor nurses station had two unsealed wiring penetrations above the lay-in acoustical ceiling. Findings include:

1. Observation at 1:30 p.m. on 9/04/13 revealed the smoke barrier wall at the north side of the second floor nurses station had two unsealed wiring penetrations (approximately 2 inches in diameter) above the lay-in acoustical ceiling. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated the contractors must not have finished sealing after installing new computer wiring.

Based on observation, testing, and interview, the provider failed to maintain a suitable storage location for control of infectious material. The closer for the soiled linen room door in the OR suite was not working. Findings include:

1. Observation and testing at 8:45 a.m. on 9/04/13 revealed the closer for the soiled linen room door in the OR suite was not working. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated the door closer would be repaired or replaced as soon as possible.

Based on observation and interview, the provider failed to maintain similar levels for the path of egress on both sides of one randomly observed exit door for the southwest exit stair discharge. The exterior side of that exit door had a six inch step-down when exiting the building. Findings include:

1. Observation at 4:00 p.m. on 9/03/13 revealed the exit door for the southwest exit stair discharge did not have similar level surfaces on both sides of the door. The exterior side of that exit door had a six inch step-down when exiting the building. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation, testing, and interview, the provider failed to ensure four randomly observed designated exits were readily accessible at all times and were not equipped with signage that indicated how to open a magnetically locked door in an emergency, one at the west side of same day surgery on the ground floor, three at the third floor stair enclosures. Findings include:

1. Observation beginning at 9:00 a.m. on 9/04/13 revealed four marked exit doors were equipped with magnetically locking hardware, one at the west side of same day surgery on the ground floor, three at the third floor stair enclosures. Testing of the doors revealed they were delayed egress-type magnetically locked doors with 15 second delays. The correct signage indicating the doors were delayed egress type was not posted. Interview with the plant operations director at the time of the observation confirmed those findings. Interview with the administrator at 2:30 p.m. revealed the third floor magnetic locks were on the Hugs door locking system as a deterrent from removing an infant from the facility.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit on the emergency power system at the generator transfer switch locations. Power must be supplied from the emergency system for those items. Findings include:

1. Observation at 10:00 a.m. on 9/04/13 revealed the provider failed to install emergency battery powered lighting units on the emergency power system at the generator transfer switch locations. Interview with the director of plant operations at the time of observation confirmed that finding.

Based on observation and interview, the provider failed to install permanent wiring for the microwave at the ground floor vending area for same day surgery. An extension cord was used for the microwave. (See attached (NFPA 70) Article 305 Temporary Wiring.) Findings include:

1. Observation at 8:45 a.m. on 9/04/13 revealed an extension cord was used for the microwave at the vending area for same day surgery on the ground floor. Interview with the director of plant operations at the time of the observation confirmed that finding.