HospitalInspections.org

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Based on observation and interview the facility failed to ensure fire rated doors entering a corridor were maintained and functioned as designed. Specifically, the facility failed to ensure fire rated doors shut and latched. This placed occupants, using the corridor as a means of egress, at risk to a smoke and fire environment. Findings:

Observation on the pediatric unit on 9/14/15 at 2:20 pm revealed a fire rated door that did not shut and latch in room 236.

Observation on 9/15/15 at 11:06 am revealed a fire rated door (1W406) did not close and latch.

Observation of an electrical room on 9/15/15 at 12:50 pm revealed a fire rated door (1E489) failed to close and latch.

During an interview on 9/15/15 at 12:50 pm the Hospital Engineer confirmed the doors should have shut completely and latched.

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Based on observation and interview the facility failed to ensure a directional exit sign was maintained to provide appropriate illumination and a directional indicator. This failed practice placed occupants, using the stairwell from the fourth floor, at risk for delay in egress and prolonged exposure to a undesirable environment in the event of an emergency. Findings:

Observation of the fourth floor on 9/15/15 at 9:41 am revealed an exit sign located near the east exit stairwell. Additional observation revealed the exit sign lacked illumination and no directional chevron indicating what direction occupants were to egress.

During an interview on 9/15/15 at 9:41 am the Facilities Manager confirmed the exit sign lacked appropriate illumination.

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Based on observation and interview the facility failed to ensure penetrations through a fire barrier were protected from the passage of smoke and fire. This failed practice placed occupants of the building at risk for exposure to a smoke and fire environment. Findings:

Observation on 9/15/15 at 10:51 am revealed an unprotected four inch waste pipe penetration through a one hour fire barrier above door A-104 C.

During an interview on 9/15/15 at 10:51 am the Hospital Engineer confirmed the finding.

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Based on observation and interview the facility failed to ensure adequate sprinkler coverage was installed to provide protection to all areas of the day surgery area. This failed practice placed the occupants of day surgery at risk for a smoke and fire environment as a result from inadequate sprinkler protection. Findings:

Observation of the day surgery area on 9/14/15 at 1:09 pm revealed one sprinkler head protecting bay #9 and #10. A partition wall was constructed between the two bays that caused the sprinkler head in bay #9 to be obstructed and hindered the spray pattern from reaching a large portion of bay #10.

During an interview on 9/14/15 at 1:09 pm both the Hospital Engineer and the Facilities Manager confirmed the finding.

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Based on record review, interview and observation the facility failed to ensure the sprinkler system was maintained. Specifically, the facility failed to conduct required inspections, maintain escutcheon plates and ensure sprinkler heads were free from paint, dust and debris. This failed practice placed occupants of the facility at risk for exposure to a smoke and fire environment. Findings:

Sprinkler System Inspections:

Record review on 9/14/15 revealed no 15 year obstruction inspection on the dry sprinkler systems.

During random interviews from 9/15-16/15 the Hospital Engineer confirmed the facility did have dry sprinkler systems and no obstruction inspection had been conducted.

Observation of the data center on 9/16/15 at 2:40 pm revealed a pre-action sprinkler system with an inspection tag dated 7/2014.

During an interview on 9/16/15 at 2:41 pm the Hospital Engineer stated the pre-action system must have been missed during the previous sprinkler inspection.


Escutcheon Plates:

Observation of the post-partum unit on 9/14/15 at 2:07 pm revealed an escutcheon plate was not properly in place around a sprinkler head in room 264.

Observation of the pharmacy on 9/14/15 at 2:31 pm revealed escutcheon plates were not properly in place around two sprinkler heads.

Observation of the fast track waiting room on 9/15/15 at 1:13 pm revealed an escutcheon plate was not properly in place around a sprinkler head. In addition, a separate sprinkler head was missing an escutcheon plate.

Observation of the facility's lab on 9/15/15 at 1:36 pm revealed an escutcheon plate was not properly in place around five sprinkler heads.


Painted/Dirty Sprinkler Heads:

Observation on 9/15/15 at 10:00 am revealed a sprinkler head in the east penthouse with significant accumulation of dust and debris.

During an interview on 9/15/15 at 10:00 am the Facilities Manager confirmed the finding.

Observation of the third floor mechanical area on 9/15/15 at 10:19 am revealed a painted sprinkler head in the third floor paint booth.

Observation of the third floor mechanical area on 9/15/15 at 10:40 am revealed a painted sprinkler head above exhaust fan unit EF07.

During an interview on 9/15/15 from 10:19 - 10:40 am the Hospital Engineer and the Facilities Manger confirmed the sprinkler heads should not be painted

Observation on the first floor of the acute hospital on 9/15/14 at 10:48 am revealed a sprinkler head in room 1W407 with significant accumulation of dust and debris.

During an interview on 9/15/15 at 10:48 am the Facilities Manager confirmed the finding.

Observation on the first floor of the acute hospital in exam room 1 (1E245) on 9/16/15 at 12:30 pm revealed a sprinkler head with significant accumulation of dust and debris.

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Based on observation and interview the facility failed to ensure hood suppression systems were maintained appropriately and free from grease buildup. This failed practiced placed occupants of the building at risk for loss of dietary services and/or a smoke and fire environment. Findings:

Observation of the serve line cooking area on 9/15/15 at 2:10 pm revealed two nozzles of the hood suppression system did not have blow-off caps correctly in place.

Observation of the central kitchen's grill area on 9/15/15 at 2:15 pm revealed sprinkler heads making up the hood suppression system contained a significant about of grease residue. Additional observation revealed the hood system was covered in a thick and consistent layer of grease residue.

Cook #1 and the Kitchen Manager acknowledged the findings at the time of discovery.

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Based on observation the facility failed to ensure privacy curtains were maintained in a manner to allow adequate sprinkler protection coverage. This failed practice placed occupants of the day surgery at risk for a prolonged exposure to a smoke and fire environment. Findings:

Observation on 9/16/15 at 12:51 pm revealed a privacy curtain was mounted flush with the ceiling. The curtain did not provide any mesh to allow sprinkler water discharge to reach all areas of exam room 1E117.

Observation of the day surgery unit on 9/16/15 at 12:52 pm revealed a privacy curtain in exam room 6 contained a mesh size less than 1/2 inch.

The Program Director #1 acknowledged findings at the time of discovery.

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Based on observations and interviews the facility failed to ensure medical gas valves were labeled to reflect the common names of room served by the system. This failed practice had the potential to delay the cessation of medical gases and placed occupants at risk to an accelerated or prolonged exposure to a smoke and fire environment. Findings:

Labor and Delivery:

Observation of the labor and delivery unit on 9/14/15 at 1:20 pm revealed medical shut-off valves that were labeled Isolation Room and Delivery Room (2W437).

During an interview on 9/14/15 at 1:20 pm the Hospital Engineer confirmed the shut-off valves controlled rooms titled PAR 2/PAR 1 and C-Section 1.

Random observations on 9/14/15 revealed door frames were identified by an alphanumeric number. The number was usually located at the top of the door frame on the corridor side. Multiple identification numbers were painted over to match the same color as the door frames.

During an interview on 9/14/15 at 2:30 pm the Hospital Engineer stated most hospital staff were not familiar with the door frame numbers. In addition, he stated these are primarily used by facility maintenance personal as a form of identification.

Cardiology Clinic:

Observation on 9/15/15 at 11:10 am revealed medical gas shut-off valves that served medical gases to E09R, E09S and E09N.

During an interview on 9/15/15 at 11:10 am Nurse Manger #1 was unable to identify which rooms were entitled E09R, E09S and E09N.

Emergency Room:

Observation of the emergency room on 9/15/15 at 1:00 pm revealed medical gas shut-off valves indicating door frame numbers and site locators.

During an interview on 9/15/15 at 1:00 pm Staff #1 was asked to identify the medical gas shut-valves for the individual rooms. The staff was able to only locate and identify Trauma 1 and 2 shut-off valves.

Orthopedic Clinic:

Observation of the orthopedic clinic on 9/16/15 at 12:10 pm revealed medical gas shut-off valves labeled ortho exam rooms 1E208 and 1E223.

During an interview on 9/16/15 at 12:10 pm Staff #5 stated he/she was not familiar with the room numbers indicated on the medical gas shut-off valves.

During an interview on 9/16/15 at 12:13 pm Staff #6 stated it was the responsibility of facility maintenance staff to shut off the medical gas in the event of an emergency.

During an interview on 9/16/15 at 12:15 pm the Hospital Engineer stated it was not the responsibility of the facility maintenance staff and the first staff responders should have a better understanding of who is responsible for shutting off the medical gases during an emergency. In addition, he stated additional training needed to be in place.

During an interview on 9/16/15 at 12:20 pm the Facilities Manager stated medical gas shut-off procedure training needed to occur more frequently in relation to valves and room names matching.

Day Surgery:

Observation on 9/16/15 at 12:55 pm revealed the medical gas shut-off valves were labeled 1E106, 1E109 and 1E124.

During an interview on 9/16/15 at 12:55 pm Staff #7 was asked to identify the rooms listed on the medical gas shut-off valves. Staff #7 reviewed the labels and stated shut-off valves do not match the room names.

During an interview on 9/16/15 at 1:05 pm Nurse Manager #2 stated the medical gas shut-off valves are for exam rooms 1, 2 and 6. In addition, the Nurse Manager stated he or she sees the value of ensuring the medical gas shut-off vales are labeled with the room names as opposed to the door frame numbers. The Nurse Manager continued to state the identifying numbers on the door frame were painted and difficult to see.

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(a) Building Construction:

Based on observation and interview the facility failed to ensure the fire rated construction of the acute care hospital was maintained as designed to resist damage in a fire environment. This placed all occupants of the building at risk for structural instability during a fire emergency. Findings:

Observation of the third floor mechanical area on 9/15/15 at 10:34 am revealed a steal support beam with a significant depletion in the fire resistant coating due to the travel path of facility maintenance staff. The construction design caused facility maintenance staff to walk over beam. The coating was depleted to the point of bare metal exposure.

During an interview on 9/15/15 at 10:34 am the Hospital Engineer and Facilities Manager confirmed staff walk over the area causing the fire resistant coating to be worn down exposing bare metal.

(b) Generator Room:

Based on observation and interview the facility failed to ensure the emergency lighting units in the generator room were functioning. As a result, this deficient practice had the potential to provide inadequate lightning and delay the facility staff to evaluate the generators during an emergency generator failure. This failed practice placed occupants of the facility at risk for loss or delay of electrical services during a power outage. Findings:

Observation on 9/16/15 at 1:55 pm revealed a emergency light mounted on the wall with a note that stated the test switch was broken since 6/9/15 and "failed 6-10-15."

During an observation on 6/19/15 at 1:56 pm the emergency light failed when the Facilities Manager tested it for functionality.
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Based on observations and interviews the facility failed to ensure: 1) electronic devices were provided electricity in a safe manner; 2) power strips were used in a safe manner; 3) electrical panels were labeled and/or free from obstruction; 4) electrical equipment was maintained free from dust and debris; and 5) outlets near a water source were ground fault interrupter protected. This failed practice placed occupants of the facilities at risk for exposure to a smoke and fire environment or loss of electrical services. Findings:

Main Hospital:

Observation of the critical care unit on 9/14/15 at 12:50 pm revealed a mobile computer cart plugged into an outlet. Further observation revealed a significant amount of tension was being applied to the plug-in and outlet causing it to partially pull plug-in device out of the outlet.

Observation of the labor and delivery unit on 9/14/15 at 2:05 pm revealed electrical panels FACP#06, DA21, and TCV21 were located in an electrical room and blocked by three bi-fold ladders.

Observation on the fifth floor on 9/15/15 at 8:44 am revealed 4 active power strips with an excessive accumulation of dust and debris located at the 5-west nurse's station. The power strips were located through an opening in the wall construction of the desks.

Observation on the fifth floor on 9/15/15 at 9:07 am revealed 1 active power strip with an excessive accumulation of dust and debris located at the 5-east nurse's station. The power strip was located through an opening in the wall construction of a desk.

Observation on the fourth floor on 9/15/15 at 9:28 am revealed 2 active power strips with an excessive accumulation of dust and debris located at the 4-west nurse's station. The power strips were located through an opening in the wall construction of the desks.

Observation in the cardiology/surgical center on 9/15/15 at 11:03 am revealed an unlabeled electrical panel.

Observation of the mammogram room on 9/15/15 at 11:32 am revealed a refrigerator plugged directly into a power strip.

Observation of the teleradiology room (1E421) on 9/15/15 at 11:39 am revealed a computer tower air intake panel with significant accumulation of dust and debris. Additional observation revealed the tower was very warm to the touch. Further observation revealed an active power strip with excessive accumulations of dust and debris.

Observation of the oncology department on 9/15/15 at 1:17 pm revealed an active power strip suspended in air supported only by the plugged in cords.

Observation of the admitting department on 9/15/15 at 2:45 pm revealed a coffee pot, hot plate water warmer, microwave and refrigerator plugged directly into a power strip.

During an interview on 9/15/15 at 2:45 pm Staff #3 stated the staff often trip the breaker when they attempt to use two of the items at once.

Observation of the Ears, Nose and Throat (ENT) Clinic on 9/16/15 at 12:32 pm revealed a power strip plugged directly into another power strip.

Observation of ENT room (1E278) on 9/16/15 at 12:33 pm revealed a refrigerator plugged into a powers strip.

Observation on 9/16/15 at 12:51 pm revealed an active power strip suspended in air supported only by the plugged in cords in exam room 1E117.

Observation of the paint shop on 9/16/15 at 2:10 pm revealed a water cooler was plugged into a power strip.


Primary Care Center (PCC):

Observation of 3-West Pod C on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 2-West Pod A on 9/16/15 revealed an active power strip suspended in air supported only by the plugged in cords. Additional observation revealed a microwave ,plugged into the power strip, had a white and black cord spliced together.

Observation of 2-West Pod C on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 3-East Pod C on 9/16/15 revealed a refrigerator, coffee pot and microwave plugged into a power strip.

Observation of 2-East Pod A on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 1-East Reception Waiting Area on 9/16/15 revealed an active power strip suspended in air, supported only by the plugged in cords.

Observation of 1-West Pod A on 9/16/15 revealed a refrigerator, microwave, toaster and coffee pot plugged into a power strip.

Observation of 1-West Pod B on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 1-West Pod C on 9/16/15 revealed a power strip plugged into another power strip which was supplying electricity to a refrigerator.

During an interview on 9/16/15 Staff #4 stated staff are not able to run more than one device because the breaker will trip every time.

Observation of the southeast corner of obstetrics office on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of the north center pod of the obstetrics office on 9/16/15 revealed an active power strip suspended in air, supported only by the plugged in cords. Additional observation revealed a refrigerator plugged into the suspended power strip.

Observation of the southwest corner of the obstetric office on 9/16/15 revealed a refrigerator plugged into a power strip.


ANMC ENT, Audiology, and Ophthalmology Clinic:

Observation of the waiting area on 9/16/15 at 3:15 pm revealed a water cooler plugged into a non ground fault interrupter protected outlet.

The Institute Environmental Health Manager acknowledged the finding at the time of discover
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Based on observation and interview the facility failed to ensure fire rated doors entering a corridor were maintained and functioned as designed. Specifically, the facility failed to ensure fire rated doors shut and latched. This placed occupants, using the corridor as a means of egress, at risk to a smoke and fire environment. Findings:

Observation on the pediatric unit on 9/14/15 at 2:20 pm revealed a fire rated door that did not shut and latch in room 236.

Observation on 9/15/15 at 11:06 am revealed a fire rated door (1W406) did not close and latch.

Observation of an electrical room on 9/15/15 at 12:50 pm revealed a fire rated door (1E489) failed to close and latch.

During an interview on 9/15/15 at 12:50 pm the Hospital Engineer confirmed the doors should have shut completely and latched.

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Based on observation and interview the facility failed to ensure a directional exit sign was maintained to provide appropriate illumination and a directional indicator. This failed practice placed occupants, using the stairwell from the fourth floor, at risk for delay in egress and prolonged exposure to a undesirable environment in the event of an emergency. Findings:

Observation of the fourth floor on 9/15/15 at 9:41 am revealed an exit sign located near the east exit stairwell. Additional observation revealed the exit sign lacked illumination and no directional chevron indicating what direction occupants were to egress.

During an interview on 9/15/15 at 9:41 am the Facilities Manager confirmed the exit sign lacked appropriate illumination.

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Based on observation and interview the facility failed to ensure penetrations through a fire barrier were protected from the passage of smoke and fire. This failed practice placed occupants of the building at risk for exposure to a smoke and fire environment. Findings:

Observation on 9/15/15 at 10:51 am revealed an unprotected four inch waste pipe penetration through a one hour fire barrier above door A-104 C.

During an interview on 9/15/15 at 10:51 am the Hospital Engineer confirmed the finding.

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Based on observation and interview the facility failed to ensure adequate sprinkler coverage was installed to provide protection to all areas of the day surgery area. This failed practice placed the occupants of day surgery at risk for a smoke and fire environment as a result from inadequate sprinkler protection. Findings:

Observation of the day surgery area on 9/14/15 at 1:09 pm revealed one sprinkler head protecting bay #9 and #10. A partition wall was constructed between the two bays that caused the sprinkler head in bay #9 to be obstructed and hindered the spray pattern from reaching a large portion of bay #10.

During an interview on 9/14/15 at 1:09 pm both the Hospital Engineer and the Facilities Manager confirmed the finding.

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Based on record review, interview and observation the facility failed to ensure the sprinkler system was maintained. Specifically, the facility failed to conduct required inspections, maintain escutcheon plates and ensure sprinkler heads were free from paint, dust and debris. This failed practice placed occupants of the facility at risk for exposure to a smoke and fire environment. Findings:

Sprinkler System Inspections:

Record review on 9/14/15 revealed no 15 year obstruction inspection on the dry sprinkler systems.

During random interviews from 9/15-16/15 the Hospital Engineer confirmed the facility did have dry sprinkler systems and no obstruction inspection had been conducted.

Observation of the data center on 9/16/15 at 2:40 pm revealed a pre-action sprinkler system with an inspection tag dated 7/2014.

During an interview on 9/16/15 at 2:41 pm the Hospital Engineer stated the pre-action system must have been missed during the previous sprinkler inspection.


Escutcheon Plates:

Observation of the post-partum unit on 9/14/15 at 2:07 pm revealed an escutcheon plate was not properly in place around a sprinkler head in room 264.

Observation of the pharmacy on 9/14/15 at 2:31 pm revealed escutcheon plates were not properly in place around two sprinkler heads.

Observation of the fast track waiting room on 9/15/15 at 1:13 pm revealed an escutcheon plate was not properly in place around a sprinkler head. In addition, a separate sprinkler head was missing an escutcheon plate.

Observation of the facility's lab on 9/15/15 at 1:36 pm revealed an escutcheon plate was not properly in place around five sprinkler heads.


Painted/Dirty Sprinkler Heads:

Observation on 9/15/15 at 10:00 am revealed a sprinkler head in the east penthouse with significant accumulation of dust and debris.

During an interview on 9/15/15 at 10:00 am the Facilities Manager confirmed the finding.

Observation of the third floor mechanical area on 9/15/15 at 10:19 am revealed a painted sprinkler head in the third floor paint booth.

Observation of the third floor mechanical area on 9/15/15 at 10:40 am revealed a painted sprinkler head above exhaust fan unit EF07.

During an interview on 9/15/15 from 10:19 - 10:40 am the Hospital Engineer and the Facilities Manger confirmed the sprinkler heads should not be painted

Observation on the first floor of the acute hospital on 9/15/14 at 10:48 am revealed a sprinkler head in room 1W407 with significant accumulation of dust and debris.

During an interview on 9/15/15 at 10:48 am the Facilities Manager confirmed the finding.

Observation on the first floor of the acute hospital in exam room 1 (1E245) on 9/16/15 at 12:30 pm revealed a sprinkler head with significant accumulation of dust and debris.

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Based on observation and interview the facility failed to ensure hood suppression systems were maintained appropriately and free from grease buildup. This failed practiced placed occupants of the building at risk for loss of dietary services and/or a smoke and fire environment. Findings:

Observation of the serve line cooking area on 9/15/15 at 2:10 pm revealed two nozzles of the hood suppression system did not have blow-off caps correctly in place.

Observation of the central kitchen's grill area on 9/15/15 at 2:15 pm revealed sprinkler heads making up the hood suppression system contained a significant about of grease residue. Additional observation revealed the hood system was covered in a thick and consistent layer of grease residue.

Cook #1 and the Kitchen Manager acknowledged the findings at the time of discovery.

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Based on observation the facility failed to ensure privacy curtains were maintained in a manner to allow adequate sprinkler protection coverage. This failed practice placed occupants of the day surgery at risk for a prolonged exposure to a smoke and fire environment. Findings:

Observation on 9/16/15 at 12:51 pm revealed a privacy curtain was mounted flush with the ceiling. The curtain did not provide any mesh to allow sprinkler water discharge to reach all areas of exam room 1E117.

Observation of the day surgery unit on 9/16/15 at 12:52 pm revealed a privacy curtain in exam room 6 contained a mesh size less than 1/2 inch.

The Program Director #1 acknowledged findings at the time of discovery.

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Based on observations and interviews the facility failed to ensure medical gas valves were labeled to reflect the common names of room served by the system. This failed practice had the potential to delay the cessation of medical gases and placed occupants at risk to an accelerated or prolonged exposure to a smoke and fire environment. Findings:

Labor and Delivery:

Observation of the labor and delivery unit on 9/14/15 at 1:20 pm revealed medical shut-off valves that were labeled Isolation Room and Delivery Room (2W437).

During an interview on 9/14/15 at 1:20 pm the Hospital Engineer confirmed the shut-off valves controlled rooms titled PAR 2/PAR 1 and C-Section 1.

Random observations on 9/14/15 revealed door frames were identified by an alphanumeric number. The number was usually located at the top of the door frame on the corridor side. Multiple identification numbers were painted over to match the same color as the door frames.

During an interview on 9/14/15 at 2:30 pm the Hospital Engineer stated most hospital staff were not familiar with the door frame numbers. In addition, he stated these are primarily used by facility maintenance personal as a form of identification.

Cardiology Clinic:

Observation on 9/15/15 at 11:10 am revealed medical gas shut-off valves that served medical gases to E09R, E09S and E09N.

During an interview on 9/15/15 at 11:10 am Nurse Manger #1 was unable to identify which rooms were entitled E09R, E09S and E09N.

Emergency Room:

Observation of the emergency room on 9/15/15 at 1:00 pm revealed medical gas shut-off valves indicating door frame numbers and site locators.

During an interview on 9/15/15 at 1:00 pm Staff #1 was asked to identify the medical gas shut-valves for the individual rooms. The staff was able to only locate and identify Trauma 1 and 2 shut-off valves.

Orthopedic Clinic:

Observation of the orthopedic clinic on 9/16/15 at 12:10 pm revealed medical gas shut-off valves labeled ortho exam rooms 1E208 and 1E223.

During an interview on 9/16/15 at 12:10 pm Staff #5 stated he/she was not familiar with the room numbers indicated on the medical gas shut-off valves.

During an interview on 9/16/15 at 12:13 pm Staff #6 stated it was the responsibility of facility maintenance staff to shut off the medical gas in the event of an emergency.

During an interview on 9/16/15 at 12:15 pm the Hospital Engineer stated it was not the responsibility of the facility maintenance staff and the first staff responders should have a better understanding of who is responsible for shutting off the medical gases during an emergency. In addition, he stated additional training needed to be in place.

During an interview on 9/16/15 at 12:20 pm the Facilities Manager stated medical gas shut-off procedure training needed to occur more frequently in relation to valves and room names matching.

Day Surgery:

Observation on 9/16/15 at 12:55 pm revealed the medical gas shut-off valves were labeled 1E106, 1E109 and 1E124.

During an interview on 9/16/15 at 12:55 pm Staff #7 was asked to identify the rooms listed on the medical gas shut-off valves. Staff #7 reviewed the labels and stated shut-off valves do not match the room names.

During an interview on 9/16/15 at 1:05 pm Nurse Manager #2 stated the medical gas shut-off valves are for exam rooms 1, 2 and 6. In addition, the Nurse Manager stated he or she sees the value of ensuring the medical gas shut-off vales are labeled with the room names as opposed to the door frame numbers. The Nurse Manager continued to state the identifying numbers on the door frame were painted and difficult to see.

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(a) Building Construction:

Based on observation and interview the facility failed to ensure the fire rated construction of the acute care hospital was maintained as designed to resist damage in a fire environment. This placed all occupants of the building at risk for structural instability during a fire emergency. Findings:

Observation of the third floor mechanical area on 9/15/15 at 10:34 am revealed a steal support beam with a significant depletion in the fire resistant coating due to the travel path of facility maintenance staff. The construction design caused facility maintenance staff to walk over beam. The coating was depleted to the point of bare metal exposure.

During an interview on 9/15/15 at 10:34 am the Hospital Engineer and Facilities Manager confirmed staff walk over the area causing the fire resistant coating to be worn down exposing bare metal.

(b) Generator Room:

Based on observation and interview the facility failed to ensure the emergency lighting units in the generator room were functioning. As a result, this deficient practice had the potential to provide inadequate lightning and delay the facility staff to evaluate the generators during an emergency generator failure. This failed practice placed occupants of the facility at risk for loss or delay of electrical services during a power outage. Findings:

Observation on 9/16/15 at 1:55 pm revealed a emergency light mounted on the wall with a note that stated the test switch was broken since 6/9/15 and "failed 6-10-15."

During an observation on 6/19/15 at 1:56 pm the emergency light failed when the Facilities Manager tested it for functionality.
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Based on observations and interviews the facility failed to ensure: 1) electronic devices were provided electricity in a safe manner; 2) power strips were used in a safe manner; 3) electrical panels were labeled and/or free from obstruction; 4) electrical equipment was maintained free from dust and debris; and 5) outlets near a water source were ground fault interrupter protected. This failed practice placed occupants of the facilities at risk for exposure to a smoke and fire environment or loss of electrical services. Findings:

Main Hospital:

Observation of the critical care unit on 9/14/15 at 12:50 pm revealed a mobile computer cart plugged into an outlet. Further observation revealed a significant amount of tension was being applied to the plug-in and outlet causing it to partially pull plug-in device out of the outlet.

Observation of the labor and delivery unit on 9/14/15 at 2:05 pm revealed electrical panels FACP#06, DA21, and TCV21 were located in an electrical room and blocked by three bi-fold ladders.

Observation on the fifth floor on 9/15/15 at 8:44 am revealed 4 active power strips with an excessive accumulation of dust and debris located at the 5-west nurse's station. The power strips were located through an opening in the wall construction of the desks.

Observation on the fifth floor on 9/15/15 at 9:07 am revealed 1 active power strip with an excessive accumulation of dust and debris located at the 5-east nurse's station. The power strip was located through an opening in the wall construction of a desk.

Observation on the fourth floor on 9/15/15 at 9:28 am revealed 2 active power strips with an excessive accumulation of dust and debris located at the 4-west nurse's station. The power strips were located through an opening in the wall construction of the desks.

Observation in the cardiology/surgical center on 9/15/15 at 11:03 am revealed an unlabeled electrical panel.

Observation of the mammogram room on 9/15/15 at 11:32 am revealed a refrigerator plugged directly into a power strip.

Observation of the teleradiology room (1E421) on 9/15/15 at 11:39 am revealed a computer tower air intake panel with significant accumulation of dust and debris. Additional observation revealed the tower was very warm to the touch. Further observation revealed an active power strip with excessive accumulations of dust and debris.

Observation of the oncology department on 9/15/15 at 1:17 pm revealed an active power strip suspended in air supported only by the plugged in cords.

Observation of the admitting department on 9/15/15 at 2:45 pm revealed a coffee pot, hot plate water warmer, microwave and refrigerator plugged directly into a power strip.

During an interview on 9/15/15 at 2:45 pm Staff #3 stated the staff often trip the breaker when they attempt to use two of the items at once.

Observation of the Ears, Nose and Throat (ENT) Clinic on 9/16/15 at 12:32 pm revealed a power strip plugged directly into another power strip.

Observation of ENT room (1E278) on 9/16/15 at 12:33 pm revealed a refrigerator plugged into a powers strip.

Observation on 9/16/15 at 12:51 pm revealed an active power strip suspended in air supported only by the plugged in cords in exam room 1E117.

Observation of the paint shop on 9/16/15 at 2:10 pm revealed a water cooler was plugged into a power strip.


Primary Care Center (PCC):

Observation of 3-West Pod C on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 2-West Pod A on 9/16/15 revealed an active power strip suspended in air supported only by the plugged in cords. Additional observation revealed a microwave ,plugged into the power strip, had a white and black cord spliced together.

Observation of 2-West Pod C on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 3-East Pod C on 9/16/15 revealed a refrigerator, coffee pot and microwave plugged into a power strip.

Observation of 2-East Pod A on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 1-East Reception Waiting Area on 9/16/15 revealed an active power strip suspended in air, supported only by the plugged in cords.

Observation of 1-West Pod A on 9/16/15 revealed a refrigerator, microwave, toaster and coffee pot plugged into a power strip.

Observation of 1-West Pod B on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of 1-West Pod C on 9/16/15 revealed a power strip plugged into another power strip which was supplying electricity to a refrigerator.

During an interview on 9/16/15 Staff #4 stated staff are not able to run more than one device because the breaker will trip every time.

Observation of the southeast corner of obstetrics office on 9/16/15 revealed a refrigerator plugged into a power strip.

Observation of the north center pod of the obstetrics office on 9/16/15 revealed an active power strip suspended in air, supported only by the plugged in cords. Additional observation revealed a refrigerator plugged into the suspended power strip.

Observation of the southwest corner of the obstetric office on 9/16/15 revealed a refrigerator plugged into a power strip.


ANMC ENT, Audiology, and Ophthalmology Clinic:

Observation of the waiting area on 9/16/15 at 3:15 pm revealed a water cooler plugged into a non ground fault interrupter protected outlet.

The Institute Environmental Health Manager acknowledged the finding at the time of discover
.