HospitalInspections.org

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MAC
Based on observation and interview, the facility failed to ensure a two hour separation was in place per requirements of:

2012 NFPA 101, 19.1.3.4, 19.1.6.1 and 8.2.1.3

Findings include:

On 10/03/2017, during a tour of the facility from 8:00 am to 4:15 pm, a two hour separation was not observed between the Medical Building (Hospital) and the Women's Building

A member of the maintenance staff was present when this deficiency was identified.
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DEVIN
Based on observation and interview, the building failed to maintain the minimum fire resistive rating per the requirements of:

2012 NFPA 101, 19.1.6.1 and Table 19.1.6.1

Findings include:

1. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, the steel structural support's protective fire proofing was observed missing from approximately 3 feet by 8 feet area located above the ceiling on the 6th floor in front of elevators O1 and O2.

MAC
2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following was observed:
a. A steel structural I-Beam was missing the two hour fire resistance rating in the utility tunnel next to MRI
b. An unprotected 4x4 section of sheetrock was missing exposing a metal stud frame on the third floor in the Soiled Linen Utility Room across from room 363.
c. An unprotected structural floor member (the backside of the stairwell) supporting the fourth floor was missing the two hour fire resistance rating, this was observed on the third floor south tower hallway ramp above the ceiling.
d. A steel structural I-Beam was missing the two hour fire resistance rating in the Mechanical Room on the third floor interstitial space above surgery.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the corridors per the requirements of:

2012 NFPA 101, 19.2.3.4 (5) (a) and (c)

Findings include:

On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, the facility failed to maintain the Fourth Floor corridors:
1. In the 8'-0" corridors unsecured furniture was observed in the following locations:
a. In the connector wing at room 470
b. At elevator B1
2. The furniture at elevator B1 was observed to be on both sides of the 8'-0" corridor.

A member of the maintenance staff was present when this deficiency was identified.
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MAC
Based on observation and interview, the building failed to ensure the illumination of means of egress per the requirements of:

2012 NFPA 101, 19.2.8 and 7.8

Findings include:

On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the building failed to provide illumination of means of egress for stairwell 16.

A member of the maintenance staff was present when this deficiency was identified.
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DEVIN
Based on observation and interview, the building failed to maintain the fire resistive rating of a stairwell per the requirements of:

2012 NFPA 101, 19.3.1.1

Findings include:

On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, SP/Stairwell #3 on the 6th Floor was observed with an unsealed penetration of a 4.5 inch sprinkler pipe into room 669.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the building failed to maintain the hazardous areas per the requirements of:

2012 NFPA 101, 19.3.2.1.3
2012 NFPA 101, 19.3.2.1.2

Findings include:

1. On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the Employee Shop's (TOGA's) Storage Room was observed to be over 50 sq. ft. with combustibles with the following:
a. Two unsealed penetrations in the wall between the Shop and the Storage Room
b. No self-closing device on the door

DEVIN
2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following rooms located on the first floor were observed to be greater than 50 square feet with an assortment of stored combustibles and without having self-closing devices on their doors:
1. X-ray Room 1
2. X-ray Room 4
3. The room next to office 1128 in Physical Therapy

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the Alcohol Based Hand Rub Dispensers (ABHRs) per the requirements of:

2012 NFPA 101, 19.3.2.6* (8) and (11) (f)

Findings include:

1. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the Alcohol Based Hand Rub Dispensers on the First Floor in the H & V Suite/CDU were observed installed above a light switch (ignition source) at the following locations:
a. Room 1133
b. Room 1134
c. Room 1138
d. Room 1142
e. Room 1147
f. At the Nurses' Station
2. On 10/04/2017, during review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation on policy and procedure on testing in accordance with the manufacturer's care and use instructions each time a new refill is installed.

ROLAND
3. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, an ABHR was observed mounted directly above a Nurses' Call Switch (ignition source) on the 7th Floor near the Nurses' Station.


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4. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, an Alcohol Based Hand Rub Dispenser in the GI Lab Room #1 located in the Basement was observed installed above a light switch (ignition source).

A member of the maintenance staff was present when this deficiency was identified.
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ROLAND
Based on observation and interview, the building failed to maintain the ceiling for the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1 and 9.7.1.1
2010 NFPA 13, 8.5.4.2
2010 NFPA 13, 8.15.7.1

Findings include:

On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm the following was observed:
1. A ceiling tile was found to have an approximately 2" hole in the following locations:
a. Break Area
b. Office Area

MAC
2. The building failed to provide documentation that the canopy located next to stairwell 16 was flame retardant or provide sprinkler coverage for this canopy
3. No automatic sprinkler heads were observed in stairwell 2, that is located between the Doctor Office Building and the Medical Tower (Hospital)

A member of the maintenance staff was present when this deficiency was found.
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Based on review of documentation and interview, the building failed to maintain the automatic sprinkler system riser gauges per the requirements of:

2012 NFPA 101, 19.3.5.1
2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.2.4.2

Findings include:

On 10/05/2017, during the review of documentation from 8:00 am to 12:15 pm, the building failed to provide documentation for the weekly inspection for the gauges on the automatic sprinklers dry system riser.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12
2012 NFPA 101, 9.7.4.1
2010 NFPA 10, 6.1.3.8.1
2010 NFPA 10, 6.1.3.8.3
2010 NFPA 10, 7.2.2
2010 NFPA 10, 5.5.5.3

Findings include:

1. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the following was observed on the First Floor:
a. In the Mechanical Room for Case Management a fire extinguisher was observed on the floor and it had just been inspected the day before.
b. In the Insurance Suite by the water fountain a fire extinguisher was observed mounted over 5'-0" above finished floor and it had just been inspected the day before.

DEVIN
c. A portable fire extinguisher in the Special Procedure's Speech Therapy Office was observed obstructed by three large filing cabinets.


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2. On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the K fire extinguisher at the Service Line Grill area was observed without a placard placed near the extinguisher.

A member of the maintenance staff was present when this deficiency was identified.
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ROLAND
Based on observation and interview, the building failed to maintain the smoke barriers per requirements of:

2012 NFPA 101, 19.3.7.3 and 8.5.2.2

Findings include:

On 10/04/2017, during a tour of the building from 8:00 am to 5:00 pm, the following was observed;
1. An unsealed penetration of a 2" conduit with blue and gray wires was observed in the following smoke barriers:
a. Near room 570
b. Near room 585

MAC
2. An unsealed penetration was observed on the third floor in the following smoke barrier walls:
a. Supply and room 357
b. Near room 356
c. In the Physician Dictation Room
d. In the hallway on Peds next to men's restroom
e. In Applications Analysts IT Room
f. Women's Center hallway near stairwell 11

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the smoke dampers per the requirements of:

2012 NFPA 101, 19.5.2.1
2012 NFPA 101, 9.2.1
2012 NFPA 90A, 5.4.5.4 and 5.4.5.4.2

Findings include:

On 10/05/2017, during a tour of the building from 8:00 am to 12:15 pm, the following smoke dampers failed to close upon activation of the fire alarm system's general alarm:
1. On the 6th Floor at room 685
2. On the 4th Floor at room 485

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the building failed to provide the approved UL listed 1363A or 6060-1 for patient-care-related electrical equipment (PCREE) power strips and UL standard 1363 for non-PCREE power strips per the requirements of:

S&C: 14-46-LSC
2012 NFPA 99, 10.2.4

Findings include:

On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, the facility failed to provide approved UL listed power strips at the PACU Nurses Station. PACU Pumps were observed being plugged into the non-approved power strips.

A member of the maintenance staff was present when this deficiency was identified.
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DEVIN
Based on observation and interview, the building failed to ensure the proper separation of combustible material and stored oxygen tanks per the requirements of:

2012 NFPA 99, 11.3.2.3(2) and (11)

Findings include:

1. On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, combustible materials were observed being stored within 5 feet of filled oxygen storage tank racks located in the sprinkled 4th floor Critical Care Clean Supply Room.


36148


2. On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm, an empty oxygen cylinder was observed unsecured in the Electrical HVAC Shop.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the building failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

Findings include:

On 10/04/2017, during the review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation on the following:
1. The qualifications and training of the building's training personnel on handling oxygen cylinders.
2. Continuing education for their personnel that handle oxygen cylinders
3. Training personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases on the risks associated with their handling and use.
4. A continuing education program for staff that handle oxygen cylinders to include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms." per the requirements of:

2012 NFPA 99, 15.13

Findings include:

On 10/04/2017, during the review of documentation from 8:00 am to 5:00 pm, the building failed to provide documentation of procedures and continuing education the administration provides for "fire loss prevention in operating rooms."

A member of the maintenance staff was present, when this deficiency was identified.