HospitalInspections.org

During tour of the facility on 3/27/13 and 3/28/13 it was observed that the facility failed to maintain smoke/fire barriers for several areas within the hospital.

Findings include:

During tour of the facility with Staff I (Director of Facilities) and Staff R (Assistant Director of Facilities) it was found that several areas throughout the facility had failed smoke/fire barriers. The facility provided a facility floor plan that showed the smoke/fire barriers and theirlocation. These areas were inspected by surveyor on 3/27/13 and 3/28/13 at which time all observations made were documented by Staff R and written as follows:

"1) 3rd floor west
Right hallway by fire door open chase

2) 3rd floor west
Right hallway sidewall ventilation pipe by fire door gap

3) 3rd floor west
Left hallway communication chase pushed out of wall and not sealed, also 2 holes in wall for electrical not patched and sealed

4) 3rd floor east oncology smoke walls
Entrance to oncology wire chase not patched and sealed

5) 3rd east hallway bath oncology break room
No sheet rock on walls not sealed and patched reconfigured fire and smoke partition

6) 3rd east hallway, bath, break room oncology side...
3 doors need to be rated for extend fire wall (bathroom hall) (break room inside door) (office manager) all need door closures, also office manager needs magnet

7) 3rd east oncology hallway
Patch and seal holes over back door to oncology and in corner. (wire chase) (electrical box) (corner gap)

8) Oncology
Re-map [relocated] wall for new smoke area

9) Spaulding/GPU[geriatric physiatric unit] hallway
a. Over GPU doors several wires thru wall not sealed
b. Bath by elevators wall outside door holes around ducts not sealed to ceiling
c. Fire door 2E12 holes above frame and on side top right

10) Spaulding
a. IT (communication closet) DF 20 holes above strobe
b. Fire door 2E14 holes above frame in sheetrock
c. Fire door 2E20 sheet rock missing fill gaps to top of wall

11) Spaulding work room
a. Work room fill hole top of wall over printer
b. Fire door 2E19 holes replace sheetrock right side of frame

12) Spaulding nurse mangers office
Towel used in hole in ceiling

13) CCU left hallway
Fill hole in corner of firewall above fire curtain

14) CCU right hallway
Wrap stud that is exposed right side of fire curtain access from bathroom #252

15) Cardiac testing 1st floor west
Hole above glass fire rated door

16) Lobby first floor west
Door into lobby hoes above frame

17) Hallway main street
Multiple holes system need to be re-evaluated at this point"

At this time the smoke/fire barrier inspection stopped as sufficient sampling of smoke/fire barriers had been established for non compliance. During interview Staff I stated there is a system to check these walls and place tags on them to show that they had been inspected and passed. It was observed that some of the walls had tags on them that were placed by facility staff from two days prior to the inspection performed by surveyor, and no findings were found by the facility as confirmed through interview with Staff I.

Cross refer to tag A700

Based on tour of the facility on 3/27/13 with staff it was found that the facility failed to have proper Signage for exit access.

Findings include:

During tour of the facility on 3/27/13 with Staff I (Director of Facilities) it was observed that an illuminating exit sign located on the third floor east wing by oncology was over a door which was unable to be opened. This door was shown to Staff I who stated that the door is not an exit door any more, and was used as a temporary exit door during the construction in 2008. Staff I stated that they failed to remove the exit sign since the completion of the construction.

Based on record review and interview with Staff it was found that the facility failed to conduct fire drills at least quarterly on each shift.

Findings include:

During review of the facility's yearly fire drills it was found that the second quarter for the months of April, May, and June, second shift failed to have a fire drill. This information was shown to Staff I (Director of Facilities) who confirmed by reviewing the fire drills that the facility failed to perform a drill for that quarter during that shift.

During tour of the facility on 3/27/13 and 3/28/13 it was observed that the facility failed to maintain smoke/fire barriers for several areas within the hospital.

Findings include:

During tour of the facility with Staff I (Director of Facilities) and Staff R (Assistant Director of Facilities) it was found that several areas throughout the facility had failed smoke/fire barriers. The facility provided a facility floor plan that showed the smoke/fire barriers and theirlocation. These areas were inspected by surveyor on 3/27/13 and 3/28/13 at which time all observations made were documented by Staff R and written as follows:

"1) 3rd floor west
Right hallway by fire door open chase

2) 3rd floor west
Right hallway sidewall ventilation pipe by fire door gap

3) 3rd floor west
Left hallway communication chase pushed out of wall and not sealed, also 2 holes in wall for electrical not patched and sealed

4) 3rd floor east oncology smoke walls
Entrance to oncology wire chase not patched and sealed

5) 3rd east hallway bath oncology break room
No sheet rock on walls not sealed and patched reconfigured fire and smoke partition

6) 3rd east hallway, bath, break room oncology side...
3 doors need to be rated for extend fire wall (bathroom hall) (break room inside door) (office manager) all need door closures, also office manager needs magnet

7) 3rd east oncology hallway
Patch and seal holes over back door to oncology and in corner. (wire chase) (electrical box) (corner gap)

8) Oncology
Re-map [relocated] wall for new smoke area

9) Spaulding/GPU[geriatric physiatric unit] hallway
a. Over GPU doors several wires thru wall not sealed
b. Bath by elevators wall outside door holes around ducts not sealed to ceiling
c. Fire door 2E12 holes above frame and on side top right

10) Spaulding
a. IT (communication closet) DF 20 holes above strobe
b. Fire door 2E14 holes above frame in sheetrock
c. Fire door 2E20 sheet rock missing fill gaps to top of wall

11) Spaulding work room
a. Work room fill hole top of wall over printer
b. Fire door 2E19 holes replace sheetrock right side of frame

12) Spaulding nurse mangers office
Towel used in hole in ceiling

13) CCU left hallway
Fill hole in corner of firewall above fire curtain

14) CCU right hallway
Wrap stud that is exposed right side of fire curtain access from bathroom #252

15) Cardiac testing 1st floor west
Hole above glass fire rated door

16) Lobby first floor west
Door into lobby hoes above frame

17) Hallway main street
Multiple holes system need to be re-evaluated at this point"

At this time the smoke/fire barrier inspection stopped as sufficient sampling of smoke/fire barriers had been established for non compliance. During interview Staff I stated there is a system to check these walls and place tags on them to show that they had been inspected and passed. It was observed that some of the walls had tags on them that were placed by facility staff from two days prior to the inspection performed by surveyor, and no findings were found by the facility as confirmed through interview with Staff I.

Cross refer to tag A700

Based on tour of the facility on 3/27/13 with staff it was found that the facility failed to have proper Signage for exit access.

Findings include:

During tour of the facility on 3/27/13 with Staff I (Director of Facilities) it was observed that an illuminating exit sign located on the third floor east wing by oncology was over a door which was unable to be opened. This door was shown to Staff I who stated that the door is not an exit door any more, and was used as a temporary exit door during the construction in 2008. Staff I stated that they failed to remove the exit sign since the completion of the construction.

Based on record review and interview with Staff it was found that the facility failed to conduct fire drills at least quarterly on each shift.

Findings include:

During review of the facility's yearly fire drills it was found that the second quarter for the months of April, May, and June, second shift failed to have a fire drill. This information was shown to Staff I (Director of Facilities) who confirmed by reviewing the fire drills that the facility failed to perform a drill for that quarter during that shift.