HospitalInspections.org

Based on observation the facility failed to provide acceptable fireproofing of the building structure.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) structural column in the tower penthouse by the PRVs that had damaged fireproofing, and 2) a penetration in the floor assembly in I.S. closet 3021 that was not fireproofed.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following issues with penetrations in smoke barriers: 1) the 6th floor north corridor at the cross corridor doors, 2) the 6th floor south corridor at the cross corridor doors, 3) the 6th floor south corridor at the cross corridor doors, 4) the 4th floor near room 4000 the smoke barrier had no gypsum board on the wall above the ceiling, 5) on the 4th floor near door 4TS12 which was at the 4th floor bed tower to the N.E. corridor, 6) the 4th floor at door 4NE2, 7) the 4th floor at door 4SE10, 8) the 3rd floor at the south entry to the heart cent from the CCU, 9) the 3rd floor at the north entry to the heart center from the CCU, 10) the 3rd floor at the cross corridor door, 3P211, and 11) the 3rd floor at the antepartum entry door 3SB1.

Based on observation the facility failed to provide acceptable enclosures at hazardous areas.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) the 8th floor soiled utility, door 8TE4, the closer requires adjustment, 2) the 4th floor soiled utility, door 4NE6, the closer requires adjustment, 3) in the 3rd floor pavilion the door to the storage in the sterile core did not latch, 4) the 3rd floor soiled utility and clean utility in the echo cardio area the closers require adjustment, 5) there was a missing closer on the 3rd floor for the door for storage between two cath labs, 6) on the 3rd floor at the equipment room storage the door did not latch, 7) ) the 3rd floor soiled utility in the ICU the closer requires adjustment, 8) the 3rd floor storage, door 3ICU2, the closer requires adjustment, 9) on the 2nd floor the diagnostic work area closet had 2 doors without closers, 10) the 2nd floor micro lab storage room did not have a closer, 11) at the 2nd floor service building catering there was a storage room that had been an office and did not have a closer, 12) the 2nd floor outpatient suite the soiled utility requires the closer to be adjusted, 13) the kitchen dishwasher closet did not have a closer, and 14) the environmental services storage requires the closer to be adjusted.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) on the 4th floor there was not a smoke detector in the south waiting room, 2) on the 3rd floor at the labor and delivery waiting room there was not a smoke detector, and 3) at the lobby for the Hitt auditorium there was not a smoke detector.

Based on observation the facility failed to provide an acceptable fire sprinkler installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) there was a large bundle of data wires bearing on the sprinkler pipe at the 10th floor south corridor by the equipment room, 2) there was an unsupported sprinkler arm outside of room 4171, 3) at the 3rd floor vending area there was not a sprinkler head, and 4) the housekeeping room in the decontamination of the 1st floor did not have a sprinkler head.

Based on observation the facility failed to provide an acceptable fire extinguisher.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) an out of date fire extinguisher on the 4th floor between dialysis and the N.E. corridor, and 2) a missing tag on the extinguisher in the elevator machine room on the 1st floor.

Based on observation the facility failed to provide acceptable corridor egress.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) on the 3rd floor there were storage shelves in the egress corridor to day surgery by the lockers, and 2) there was a bench in the corridor on the 3rd floor at east elevator #2, pavilion #2.

Based on observation the facility failed to provide acceptable medical gas installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) in the 3rd floor anesthetizing work room the tanks were not adequately secured, 2) in the 2nd floor core lab medical gas closet the tanks were not adequately secured, 3) there were leaves present in the bulk oxygen yard that must be cleaned out, 4) on the 3rd floor LND by the c-section entry there were medical gas lines that were not labeled, there was steel/copper contact in this area, and there was also a green/blue colored substance deposited on the copper lines that should be cleaned off and this area must be monitored to determine if the deposits return.

Mechanical equipment rooms, boiler rooms, furnace rooms, and similar spaces shall be arranged to limit common path of travel to a distance not exceeding 50 ft , unless otherwise permitted by the following: (2) In an existing building, a common path of travel not exceeding 150 ft shall be permitted if all of the following criteria are met: (a) The building is protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7, (b) No fuel-fired equipment is within the space, (c) The egress path is readily identifiable. - NFPA 101, 2000, 7.12.1.

Based on observation the facility failed to provide acceptable exit signage from the roof penthouse level.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were multiple roof top penthouses with only one penthouse having an exit stairway. There was not an exit sign on the exterior of the penthouse that contained the stair. Therefore the egress was not readily identifiable.

Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that the facility did not have preferred customer status for emergency fuel or water.

Based on observation the facility failed to provide an acceptable electrical installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following problems: 1) there was a transfer switch in the E. Tower Penthouse that was not labeled " Equipment " , and 2) also on the third floor there was another ATS not identified as to which branch it served, 3) the 4th floor electrical room panel LGN that was a critical panel did not have a directory, 4) on the third floor electrical room, panel EC3HB there was no directory, 5) in the 4th floor CCU the critical outlets were not labeled re. the panel/breaker that supplies power, 6) in the 3rd floor Cath Lab PACU, O.R.s and ICU the critical outlets were not labeled re. the panel/breaker that supplies power, 7) on the 2nd floor E.D. Trama the critical outlets were not labeled re. the panel/breaker that supplies power, and 8) in the PBX the FACP did not have a panel/breaker label that cross referenced it ' s power source.

Based on observation the facility failed to provide acceptable fireproofing of the building structure.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) structural column in the tower penthouse by the PRVs that had damaged fireproofing, and 2) a penetration in the floor assembly in I.S. closet 3021 that was not fireproofed.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following issues with penetrations in smoke barriers: 1) the 6th floor north corridor at the cross corridor doors, 2) the 6th floor south corridor at the cross corridor doors, 3) the 6th floor south corridor at the cross corridor doors, 4) the 4th floor near room 4000 the smoke barrier had no gypsum board on the wall above the ceiling, 5) on the 4th floor near door 4TS12 which was at the 4th floor bed tower to the N.E. corridor, 6) the 4th floor at door 4NE2, 7) the 4th floor at door 4SE10, 8) the 3rd floor at the south entry to the heart cent from the CCU, 9) the 3rd floor at the north entry to the heart center from the CCU, 10) the 3rd floor at the cross corridor door, 3P211, and 11) the 3rd floor at the antepartum entry door 3SB1.

Based on observation the facility failed to provide acceptable enclosures at hazardous areas.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) the 8th floor soiled utility, door 8TE4, the closer requires adjustment, 2) the 4th floor soiled utility, door 4NE6, the closer requires adjustment, 3) in the 3rd floor pavilion the door to the storage in the sterile core did not latch, 4) the 3rd floor soiled utility and clean utility in the echo cardio area the closers require adjustment, 5) there was a missing closer on the 3rd floor for the door for storage between two cath labs, 6) on the 3rd floor at the equipment room storage the door did not latch, 7) ) the 3rd floor soiled utility in the ICU the closer requires adjustment, 8) the 3rd floor storage, door 3ICU2, the closer requires adjustment, 9) on the 2nd floor the diagnostic work area closet had 2 doors without closers, 10) the 2nd floor micro lab storage room did not have a closer, 11) at the 2nd floor service building catering there was a storage room that had been an office and did not have a closer, 12) the 2nd floor outpatient suite the soiled utility requires the closer to be adjusted, 13) the kitchen dishwasher closet did not have a closer, and 14) the environmental services storage requires the closer to be adjusted.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) on the 4th floor there was not a smoke detector in the south waiting room, 2) on the 3rd floor at the labor and delivery waiting room there was not a smoke detector, and 3) at the lobby for the Hitt auditorium there was not a smoke detector.

Based on observation the facility failed to provide an acceptable fire sprinkler installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) there was a large bundle of data wires bearing on the sprinkler pipe at the 10th floor south corridor by the equipment room, 2) there was an unsupported sprinkler arm outside of room 4171, 3) at the 3rd floor vending area there was not a sprinkler head, and 4) the housekeeping room in the decontamination of the 1st floor did not have a sprinkler head.

Based on observation the facility failed to provide an acceptable fire extinguisher.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) an out of date fire extinguisher on the 4th floor between dialysis and the N.E. corridor, and 2) a missing tag on the extinguisher in the elevator machine room on the 1st floor.

Based on observation the facility failed to provide acceptable corridor egress.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there was: 1) on the 3rd floor there were storage shelves in the egress corridor to day surgery by the lockers, and 2) there was a bench in the corridor on the 3rd floor at east elevator #2, pavilion #2.

Based on observation the facility failed to provide acceptable medical gas installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following observations: 1) in the 3rd floor anesthetizing work room the tanks were not adequately secured, 2) in the 2nd floor core lab medical gas closet the tanks were not adequately secured, 3) there were leaves present in the bulk oxygen yard that must be cleaned out, 4) on the 3rd floor LND by the c-section entry there were medical gas lines that were not labeled, there was steel/copper contact in this area, and there was also a green/blue colored substance deposited on the copper lines that should be cleaned off and this area must be monitored to determine if the deposits return.

Mechanical equipment rooms, boiler rooms, furnace rooms, and similar spaces shall be arranged to limit common path of travel to a distance not exceeding 50 ft , unless otherwise permitted by the following: (2) In an existing building, a common path of travel not exceeding 150 ft shall be permitted if all of the following criteria are met: (a) The building is protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7, (b) No fuel-fired equipment is within the space, (c) The egress path is readily identifiable. - NFPA 101, 2000, 7.12.1.

Based on observation the facility failed to provide acceptable exit signage from the roof penthouse level.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were multiple roof top penthouses with only one penthouse having an exit stairway. There was not an exit sign on the exterior of the penthouse that contained the stair. Therefore the egress was not readily identifiable.

Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that the facility did not have preferred customer status for emergency fuel or water.

Based on observation the facility failed to provide an acceptable electrical installation.

The inspector observed while accompanied by the Vice President of Operations, the Director of Plant Operations, the Engineering Supervisor, the Project Coordinator, and the Director of Clinical Processes during the hours of the inspection from 8:00 am to 7:00 pm that there were the following problems: 1) there was a transfer switch in the E. Tower Penthouse that was not labeled " Equipment " , and 2) also on the third floor there was another ATS not identified as to which branch it served, 3) the 4th floor electrical room panel LGN that was a critical panel did not have a directory, 4) on the third floor electrical room, panel EC3HB there was no directory, 5) in the 4th floor CCU the critical outlets were not labeled re. the panel/breaker that supplies power, 6) in the 3rd floor Cath Lab PACU, O.R.s and ICU the critical outlets were not labeled re. the panel/breaker that supplies power, 7) on the 2nd floor E.D. Trama the critical outlets were not labeled re. the panel/breaker that supplies power, and 8) in the PBX the FACP did not have a panel/breaker label that cross referenced it ' s power source.