HospitalInspections.org

Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating between the corridors and patient rooms in a non-sprinkled section of the building where walls extend to the roof deck, potentially affecting visitors, staff and the 180 patient census in the 511 bed facility.

Findings included:

1. Observation of 3-west on 4/26/10 at 8:50 A.M. showed an 18 inch wide by 18 inch high section of drywall missing from the corridor wall above the suspended ceiling of 6 West corridor outside of room 6110, exposing unprotected interior portions of the corridor wall.

Observation of 4-north on 4/27/10 at 4:00 P.M. revealed a one half inch hole penetrated the wall next to a four inch pipe located at the south end of the four north corridor. On the west side of the corridor, the exterior wall of an electrical closet had a one half inch wide open area below a conduit that penetrated the wall and a one half inch wide gap around a four inch metal sleeve around a wire bundle.

Observation of the corridor walls of an electrical room near #4057 at 4:55 P.M. showed an unsealed 10 inch diameter hole with wire runs through it, and a one inch hole around a metal conduit.

Observation of the 3-north corridor on 4/28/10 at 2:00 P.M. showed three open places above the suspended ceiling in a corridor wall where wire and flex conduit penetrated, the largest hole measured approximately two inches in diameter.

Observation of the 3-north corridor on 4/28/10 at 2:30 P.M. showed a one half inch square hole below a sprinkler pipe, where it penetrated the wall above an electrical room.

During interviews on 4/26/10 through 4/29/10, the Plant Operations Manager said he had made calls and was having any breaches or penetrations of walls sealed immediately. He said the information obtained from surveys was useful in helping them to eliminate any deficient practice that might jeopardize their attempt at becoming certified as a "zero smoke" facility (meaning the facility has quick response sprinkler systems and smoke control systems are so efficient that no smoke from a potential fire could be generated and none would negatively affect patients or patient caregivers.) He said a recent survey by Joint Commission identified several deficiencies related to the facility's physical plant, environment and fire safety. He said they generated a tickler list and contracted several companies to identify, assess, record deficiencies throughout the entire structure so they could be repaired or upgraded. He said the crewmen and contractors making repairs were down to level 2, (2nd floor) above ground and had not yet reached A-level (1st floor), or B-level, (basement).

Based on observation, the facility failed to ensure doors to all patient rooms closed and stay latched securely to resist the passage of smoke into patient rooms, potentially affecting visitors, facility staff, and 29 of 122 patient rooms, adjoining corridors, common areas, on the 4th floor of a facility with a census of 180 patients at the time of the survey.

Findings included:

1. Observation on 4/27/10 at 3:00 P.M. doors to the following patient rooms failed to latch securely into the door frame:
Room # 's 4002, 4003, 4004, 4006, 4007, 4009, 4018, 4020, 4021, 4022, 4023, 4024, 4027, 4029, 4030, 4036, 4038, 4039, 4040, 4041, 4043, 4046, 4047, 4049, 4050, 4051, 4052, 4053, 4055.

During an interview on 4/27/10 at 4:00 P.M., the Plant Operations Manager said the area had recently been renovated and everything checked off the punch list for a QA. He said it was probably due to subtle differences in moisture content of the wood doors. He said the problem could be remedied easily with some adjustments to the latches and they would get right on it.

On 4/28/10 at 9:00 A.M., he reported the doors had been corrected. Observation at the time showed all doors could be closed tightly into the jamb, positively latched to provide the best possible seal for smoke containment. He said he also had maintenance check the rest of the doors on the remaining floors to ensure they closed and latched securely, to prevent any recurrent problems.

Based on observation and interview, the facility failed to ensure trash chutes are in compliance with NFPA 82, paragraph 9.5, and do not present an unusual hazard to the housekeepers, staff or patients. This deficient practice could potentially create an air supply to a smoldering fire and cause ignition of flame on more than one level throughout the seven story, 511 bed hospital affecting staff, visitors and the 180 patient census at the time of the survey.

Findings included:

1. Observation of a third floor utility closet on 4/28/10 at 2:15 P.M. showed a broken cable prevented the refuse chute from closing unassisted. The metal door to the chute stopped in a half-open position and would not close until assisted by hand. Normal operation involved use of a spring loaded foot pedal that caused the door to close once pressure is removed from the foot pedal. The refuse chute and soiled linen chutes are served by automatic sprinklers interconnected to the facility fire alarm systems.

During an interview on 4/28/10 at 2:30 P.M., the Plant Operations Manager tried the operation, said the cable appeared broken and told staff to turn in a work order on it. He said all the soiled linen chutes, refuse chutes and dumb waiter shafts were completely enclosed. He said the dumb waiters were no longer used but since the chute was completely enclosed and protected, the shaft is now used for electrical and communication cable runs.

2. Observation of the B-level (basement) soiled utility closet on 4/30/10 at 10:30 A.M. showed a trash bag containing trash, stuck halfway in and out of the bottom of a refuse chute. Designed to be held open by a fusible link as required and tied to a metal brace near the ceiling with a spring, the metal door of the chute pinched the trash bag against the open chute, creating a breach of the vertical shaft that could allow oxygen to aid or fuel a potential ignition of flame. The spring tension was questionable and not enough to hold the door completely open so bags of trash coming down the chute would fall clear, not be impeded, and fall into the appropriately positioned container or hopper. A quick check of at least three other service points showed the same issue affected all soiled linen and refuse chutes at their exit points. The metal springs, attached between the brace near the ceiling with the other end attached to the door via the fusible link, had all weakened over time and were no longer fulfilling their intended purpose of holding the doors open. Soiled linen and refuse doors are designed to be held open or locked shut, and if held open, the intent of the regulation is they are to be held completely open via the required fusible (solder) link, which will melt and disengage in a fire event.

During an interview on 5/4/10 at 11:00 A.M., the Plant Operations Manager said he is having the doors to all trash and linen chutes reworked to eliminate any opportunity for the door to impede the travel of any bags of refuse or soiled linen that are coming down the chute. He said maintenance will install and eyebolt in the monolithic ceiling and attach the door with fusible link to it via a short link piece of chain, to ensure the door stays open and no longer impedes the descent of the bags.

Based on observation and interview, the facility failed to ensure separation between extended smoke compartments of patient sleeping rooms in accordance with 18.3.7.8, which requires smoke doors in newly constructed areas to be equipped with rabbets, bevels or astragals at the meeting edges. This deficient practice potentially affects staff, visitors and patients in 64 beds of the east and west wings of 6th and 5th floor. The patient census was 180 patients.

Findings included:

1. Observation of 6 East corridors on 4/27/10 at 9:30 A.M. showed no astragal on two sets of 20 minute composite construction smoke doors to cover the one eighth inch gap. The double doors were located in midsection of the north and south corridors, just east of the east elevator towers, in the vicinity of room #6243 and a patient nourishment room.

Other observations from 4/27/10 at 2:30 P.M., through 4/29/10 at 2:00 P.M. showed no astragals to cover the crack between double doors at smoke separations in corridor near room #5260, near the first floor main elevator bank, at a set of corridor doors near the Gamma Knife, and outside of the cardiology department in the west corridor.

During an interview on the 4/27/10 at 2:30 P.M., the Plant Operations Manager said the doors near room #6243 were part of new construction modifications that had been made since 2003. He said there were several smoke doors in the facility that were new or had been replaced during renovations to a floor. He said they would just do a 100% check of all smoke and fire doors in the facility and put astragals on the ones that were not so equipped, because the hospital had undergone so many changes over the years and the separation between doors varied. He said they wanted to ensure they provided the safest possible environment for the care of patients. He said the seven story facility had been in operation since the early 1900's and had undergone numerous major construction revisions, upgrades for codes compliance departmental expansions, and structural additions. He said a recent survey by Joint Commission identified several deficiencies related to the facility's physical plant, environment and fire safety. He said they generated a tickler list and contracted several companies to identify, assess, record deficiencies throughout the entire structure so they could be repaired or upgraded. He said the crewmen and contractors making repairs were down to level 2, (2nd floor) above ground and had not yet reached A-level (1st floor), or B-level, (basement). He produced documentation of a point by point survey of all walls, doors, electrical systems, fire alarm and sprinkler systems on all floors. He said the objective was to raise the facility's fire safety compliance and be granted a "zero smoke" certification, which would allow them more latitude in division of their departments and med-surg floors. He said the process was already ongoing, new prints were being drawn up to reflect current and upgraded areas and funds had already been allocated for the upgrades. He said they are also working with Department of Health administrative officials and architects for compliance with state regulations and final approval of projects. He said any information acquired from all state, federal and local survey deficiencies will be added into their current drive and justification for repair, renovation and upgrades on the three remaining levels.

Based on observation and interview, the facility failed to provide complete sprinkler coverage in accordance with NFPA 101, 19.3.5.1 to protect an enclosed electrical closet space located off of the southeast corner of the 3-north wing. This deficient practice potentially affects all staff, visitors and patients of the 59 bed wing, in a 511 bed hospital with a census of 180 patients at the time of the survey.

Findings included:

Observations on 4/28/10 at 2:30 P.M. revealed no automatic sprinkler service in an electrical closet located on 3-north. The closet was located across from room #3056. Several housekeeping supplies were in the room, including mops, mop buckets, blower, and a service cart with buffing pads and wiping towels piled on it. The closet measured approximately five feet wide by eight feet deep, or 40 square feet and equipped with a non-rated door.

During an interview on 4/28/10 at 2:30 P.M., the Plant Operations Manager agreed there was no sprinkler or smoke detector in the room. He made a phone call and reported the sprinkler company would be out to place pipe immediately. He also contacted Environmental Services and ordered the housekeeping supplies removed. A short while later he reported he received confirmation from the vendor that the missing sprinkler would be installed the next morning. On 4/29/10 at 11:00 A.M., he reported the sprinkler had been installed in the room. Observation on the same date and time showed the sprinkler head and pipe service completed.

Based on observation and interview, the facility failed to provide a minimum one half hour fire resistance rating between the corridors and patient rooms in a non-sprinkled section of the building where walls extend to the roof deck, potentially affecting visitors, staff and the 180 patient census in the 511 bed facility.

Findings included:

1. Observation of 3-west on 4/26/10 at 8:50 A.M. showed an 18 inch wide by 18 inch high section of drywall missing from the corridor wall above the suspended ceiling of 6 West corridor outside of room 6110, exposing unprotected interior portions of the corridor wall.

Observation of 4-north on 4/27/10 at 4:00 P.M. revealed a one half inch hole penetrated the wall next to a four inch pipe located at the south end of the four north corridor. On the west side of the corridor, the exterior wall of an electrical closet had a one half inch wide open area below a conduit that penetrated the wall and a one half inch wide gap around a four inch metal sleeve around a wire bundle.

Observation of the corridor walls of an electrical room near #4057 at 4:55 P.M. showed an unsealed 10 inch diameter hole with wire runs through it, and a one inch hole around a metal conduit.

Observation of the 3-north corridor on 4/28/10 at 2:00 P.M. showed three open places above the suspended ceiling in a corridor wall where wire and flex conduit penetrated, the largest hole measured approximately two inches in diameter.

Observation of the 3-north corridor on 4/28/10 at 2:30 P.M. showed a one half inch square hole below a sprinkler pipe, where it penetrated the wall above an electrical room.

During interviews on 4/26/10 through 4/29/10, the Plant Operations Manager said he had made calls and was having any breaches or penetrations of walls sealed immediately. He said the information obtained from surveys was useful in helping them to eliminate any deficient practice that might jeopardize their attempt at becoming certified as a "zero smoke" facility (meaning the facility has quick response sprinkler systems and smoke control systems are so efficient that no smoke from a potential fire could be generated and none would negatively affect patients or patient caregivers.) He said a recent survey by Joint Commission identified several deficiencies related to the facility's physical plant, environment and fire safety. He said they generated a tickler list and contracted several companies to identify, assess, record deficiencies throughout the entire structure so they could be repaired or upgraded. He said the crewmen and contractors making repairs were down to level 2, (2nd floor) above ground and had not yet reached A-level (1st floor), or B-level, (basement).

Based on observation, the facility failed to ensure doors to all patient rooms closed and stay latched securely to resist the passage of smoke into patient rooms, potentially affecting visitors, facility staff, and 29 of 122 patient rooms, adjoining corridors, common areas, on the 4th floor of a facility with a census of 180 patients at the time of the survey.

Findings included:

1. Observation on 4/27/10 at 3:00 P.M. doors to the following patient rooms failed to latch securely into the door frame:
Room # 's 4002, 4003, 4004, 4006, 4007, 4009, 4018, 4020, 4021, 4022, 4023, 4024, 4027, 4029, 4030, 4036, 4038, 4039, 4040, 4041, 4043, 4046, 4047, 4049, 4050, 4051, 4052, 4053, 4055.

During an interview on 4/27/10 at 4:00 P.M., the Plant Operations Manager said the area had recently been renovated and everything checked off the punch list for a QA. He said it was probably due to subtle differences in moisture content of the wood doors. He said the problem could be remedied easily with some adjustments to the latches and they would get right on it.

On 4/28/10 at 9:00 A.M., he reported the doors had been corrected. Observation at the time showed all doors could be closed tightly into the jamb, positively latched to provide the best possible seal for smoke containment. He said he also had maintenance check the rest of the doors on the remaining floors to ensure they closed and latched securely, to prevent any recurrent problems.

Based on observation and interview, the facility failed to ensure trash chutes are in compliance with NFPA 82, paragraph 9.5, and do not present an unusual hazard to the housekeepers, staff or patients. This deficient practice could potentially create an air supply to a smoldering fire and cause ignition of flame on more than one level throughout the seven story, 511 bed hospital affecting staff, visitors and the 180 patient census at the time of the survey.

Findings included:

1. Observation of a third floor utility closet on 4/28/10 at 2:15 P.M. showed a broken cable prevented the refuse chute from closing unassisted. The metal door to the chute stopped in a half-open position and would not close until assisted by hand. Normal operation involved use of a spring loaded foot pedal that caused the door to close once pressure is removed from the foot pedal. The refuse chute and soiled linen chutes are served by automatic sprinklers interconnected to the facility fire alarm systems.

During an interview on 4/28/10 at 2:30 P.M., the Plant Operations Manager tried the operation, said the cable appeared broken and told staff to turn in a work order on it. He said all the soiled linen chutes, refuse chutes and dumb waiter shafts were completely enclosed. He said the dumb waiters were no longer used but since the chute was completely enclosed and protected, the shaft is now used for electrical and communication cable runs.

2. Observation of the B-level (basement) soiled utility closet on 4/30/10 at 10:30 A.M. showed a trash bag containing trash, stuck halfway in and out of the bottom of a refuse chute. Designed to be held open by a fusible link as required and tied to a metal brace near the ceiling with a spring, the metal door of the chute pinched the trash bag against the open chute, creating a breach of the vertical shaft that could allow oxygen to aid or fuel a potential ignition of flame. The spring tension was questionable and not enough to hold the door completely open so bags of trash coming down the chute would fall clear, not be impeded, and fall into the appropriately positioned container or hopper. A quick check of at least three other service points showed the same issue affected all soiled linen and refuse chutes at their exit points. The metal springs, attached between the brace near the ceiling with the other end attached to the door via the fusible link, had all weakened over time and were no longer fulfilling their intended purpose of holding the doors open. Soiled linen and refuse doors are designed to be held open or locked shut, and if held open, the intent of the regulation is they are to be held completely open via the required fusible (solder) link, which will melt and disengage in a fire event.

During an interview on 5/4/10 at 11:00 A.M., the Plant Operations Manager said he is having the doors to all trash and linen chutes reworked to eliminate any opportunity for the door to impede the travel of any bags of refuse or soiled linen that are coming down the chute. He said maintenance will install and eyebolt in the monolithic ceiling and attach the door with fusible link to it via a short link piece of chain, to ensure the door stays open and no longer impedes the descent of the bags.

Based on observation and interview, the facility failed to ensure separation between extended smoke compartments of patient sleeping rooms in accordance with 18.3.7.8, which requires smoke doors in newly constructed areas to be equipped with rabbets, bevels or astragals at the meeting edges. This deficient practice potentially affects staff, visitors and patients in 64 beds of the east and west wings of 6th and 5th floor. The patient census was 180 patients.

Findings included:

1. Observation of 6 East corridors on 4/27/10 at 9:30 A.M. showed no astragal on two sets of 20 minute composite construction smoke doors to cover the one eighth inch gap. The double doors were located in midsection of the north and south corridors, just east of the east elevator towers, in the vicinity of room #6243 and a patient nourishment room.

Other observations from 4/27/10 at 2:30 P.M., through 4/29/10 at 2:00 P.M. showed no astragals to cover the crack between double doors at smoke separations in corridor near room #5260, near the first floor main elevator bank, at a set of corridor doors near the Gamma Knife, and outside of the cardiology department in the west corridor.

During an interview on the 4/27/10 at 2:30 P.M., the Plant Operations Manager said the doors near room #6243 were part of new construction modifications that had been made since 2003. He said there were several smoke doors in the facility that were new or had been replaced during renovations to a floor. He said they would just do a 100% check of all smoke and fire doors in the facility and put astragals on the ones that were not so equipped, because the hospital had undergone so many changes over the years and the separation between doors varied. He said they wanted to ensure they provided the safest possible environment for the care of patients. He said the seven story facility had been in operation since the early 1900's and had undergone numerous major construction revisions, upgrades for codes compliance departmental expansions, and structural additions. He said a recent survey by Joint Commission identified several deficiencies related to the facility's physical plant, environment and fire safety. He said they generated a tickler list and contracted several companies to identify, assess, record deficiencies throughout the entire structure so they could be repaired or upgraded. He said the crewmen and contractors making repairs were down to level 2, (2nd floor) above ground and had not yet reached A-level (1st floor), or B-level, (basement). He produced documentation of a point by point survey of all walls, doors, electrical systems, fire alarm and sprinkler systems on all floors. He said the objective was to raise the facility's fire safety compliance and be granted a "zero smoke" certification, which would allow them more latitude in division of their departments and med-surg floors. He said the process was already ongoing, new prints were being drawn up to reflect current and upgraded areas and funds had already been allocated for the upgrades. He said they are also working with Department of Health administrative officials and architects for compliance with state regulations and final approval of projects. He said any information acquired from all state, federal and local survey deficiencies will be added into their current drive and justification for repair, renovation and upgrades on the three remaining levels.

Based on observation and interview, the facility failed to provide complete sprinkler coverage in accordance with NFPA 101, 19.3.5.1 to protect an enclosed electrical closet space located off of the southeast corner of the 3-north wing. This deficient practice potentially affects all staff, visitors and patients of the 59 bed wing, in a 511 bed hospital with a census of 180 patients at the time of the survey.

Findings included:

Observations on 4/28/10 at 2:30 P.M. revealed no automatic sprinkler service in an electrical closet located on 3-north. The closet was located across from room #3056. Several housekeeping supplies were in the room, including mops, mop buckets, blower, and a service cart with buffing pads and wiping towels piled on it. The closet measured approximately five feet wide by eight feet deep, or 40 square feet and equipped with a non-rated door.

During an interview on 4/28/10 at 2:30 P.M., the Plant Operations Manager agreed there was no sprinkler or smoke detector in the room. He made a phone call and reported the sprinkler company would be out to place pipe immediately. He also contacted Environmental Services and ordered the housekeeping supplies removed. A short while later he reported he received confirmation from the vendor that the missing sprinkler would be installed the next morning. On 4/29/10 at 11:00 A.M., he reported the sprinkler had been installed in the room. Observation on the same date and time showed the sprinkler head and pipe service completed.