HospitalInspections.org

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings had a fire resistive rating of at least one hour, specifically in regards to a stairwell door failing to positive latch shut. This had the potential to affect all those utilizing this area and each adjoining floor within the smoke compartments connected to this stairwell. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the basement area this writer observed the door leading to stairwell D failing to close and positive latch shut when tested. This finding was observed by staff members AA and BB during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the first floor, specifically within the lab and front entrance areas this writer observed a lack of exit directional signage at these locations.

Within the dead end corridor at the southwest corner of the lab observation was made while facing east of no exit sign directing flow of egress to the right and out through the southeast exit access. From this vantage point no exit signs were visible at all. This observation was verified by all staff members present during tour of the lab.

Heading west coming out of the radiology department double egress doors and facing the front lobby observation was made by this writer of no visible exit directional signs. Once this writer entered the cross section of the corridor located approximately 26 feet from the radiology double doors observation was made of two exit directional signs to the right facing north and one exit directional sign to the left facing south and no directional sign facing west. Continuing west approximately 35 feet and now within the front lobby area, an exit directional sign was observed above the exit access doors located approximately 100 feet away.
Additionally, when within the cross section corridors facing left down the south corridor, the exit directional sign was measured to be located approximately 150 feet away and directly in front of an exit stairwell which leads to the lower level exit discharge. An additional exit sign was located a little further down the corridor directing flow to an exit discharge at the southwest section of the building. The exit sign in front of this stairwell directed egress flow forward but failed to also direct flow through the stairwell to the lower level exit discharge.

These findings were verified by all staff members present during tour and again with staff member AA during interview on 06/14/12 at approximately 4:15 PM.

Based on observation and staff verification it was determined this facility failed to ensure all smoke barriers were constructed to provide at least a one half hour fire resistive rating specifically in regards to penetrations and doors failing to positive latch shut. This had the potential to affect all those utilizing these areas of this facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the facility observation was made of several penetrations in the smoke barrier above the ceiling tile in the following locations:

First floor:
*Within the south corridor adjacent to the cardiac and nuclear medical department observation was made of two, one inch insulated water lines not sealed around the annular space. These were observed to be a few feet around the corner of the smoke barrier near the double doors leading to the main lobby.
*Heading through the double doors leading to the lobby and to the left a few feet, observation was made of a one inch conduit unsealed around the annular space.
*Continuing around the smoke barrier just around the corner to the left, observation was made of a three inch by two inch opening around two flex conduits.
*Continuing along the smoke barrier and just before the coffee shop observation was made of small sections of drywall not sealed where the edges meet and one unsealed flex conduit around the annular space.
*Along the west side of the gift shop before the double doors of the small closet observation was made of three silver and two insulated lines not sealed around the annular space.
*Continuing on around the smoke barrier and above the corridor double doors observation was made of a three inch water line not sealed around the annular space.
*Continuing around the smoke barrier wall at the south end of the registration area within the electrical closet, observation was made of six penetrations around conduits.
*Within the corridor at the west side of the Jones center being at the outside wall of the restroom observation was made of one water line unsealed around the annular space.
Continuing around the corner at the south door of the women's center, observation was made of two unsealed water lines passing through metal sleeves.
*At the back wall of the PAT office, observation was made of a two inch round hole.
*Within the east corridor adjacent to the medical records office and at the double doors, observation was made of a gap greater than one eights inch between the door leafs when in the closed position.
*Within the medical records room at the southwest corner and above the doors of the stairwell, observation was made of two open end conduits.
*Above the door leading to the file room within the medical records office, observation was made of an approximate three foot long by three inch deep opening through the drywall just above the duct.
*Within zone 13 at the ICU east double doors, observation was made of two open end conduits.
*Facing the same double doors from the corridor side and just to the right of the corner wall, observation was made of one unsealed metal bracket.
*By the vending machines within the surgery waiting area, observation was made of an approximate one inch square penetration and one open end curved conduit with wires passing through.
*Within endo room B at the southeast corner observation was made of an approximate two inch square penetration.
*Within zone eight at the surgery entry doors and between the doors and the chase observation was made of four small round penetrations with wires passing through.
*Above the same double doors observation was made of two water lines not sealed around the annular space.

Second floor:
*At the far north end of the second floor within the med room observation was made of a duct which was not sealed around the annular space.
*Outside the med room at the double doors observation was made of two conduits not sealed around the annular space.
Within the west end of the corridor of the family birthing unit across from the electrical closet near stairwell I, observation was made of a two inch electrical conduit which was not sealed around the annular space.
*Within the charting area of the family birthing unit at the corner of the smoke barrier before reaching the double doors observation was made of an approximate six inch by six inch penetration with wires passing through. Additionally, observation was made of one unsealed silver conduit.
*Within room 272 observation was made of an approximate four inch square penetration with wires passing through.

Third floor:
*Within room 316 observation was made of five penetrations including unsealed wires around the annular space.

These findings were verified by staff BB and CC during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure each exit access was readily available and accessible at all times, specifically regarding the 15 second delay mechanism mounted on doors. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the family birthing unit observation was made of the east end door which was equipped with a 15 second delay mechanism which activated only when the push bar was engaged. The door was tested by this writer after the security department took the appropriate measures to disengage the alarm system prior to testing. The door was tested twice and both times the delay mechanism failed to disengage the door latch at the required 15 seconds. The delay mechanism released the door after 30 seconds on both occasions. This was verified by all staff during the tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition at all times, specifically in regards to dust and debris and missing escutcheon rings. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the facility observation was made of several sprinkler heads which were either dusty, dirty or had missing escutcheon rings and were located in the following locations:

Basement:
*Within the corridor outside the mechanical room and laundry chute room observation was made of two dirty or dusty sprinkler heads.
*Within the housekeeping closet in the corridor north of the kitchen, observation was made of one sprinkler head missing an escutcheon ring.

First floor:
*Missing escutcheon ring from sprinkle head within the file room of the medical records department.
*Four dirty sprinkler heads within the staff locker/lounge room across from the cath lab.
*Dirty sprinkler heads in scan room numbers one and two of the nuclear med department.
*Dirty sprinkler heads between operating rooms five and seven.
*Dirty sprinkler heads within endo room B and in the endo utility room located between endo rooms A and B.
*Dirty sprinkler heads at bay eleven of the ASCU.
*Dirty sprinkler heads within the ICU soiled utility room, nutrition and PAR area and the documentation area.
*Within the west corridor of the histology department, one escutcheon ring was missing.

Second floor:
*Within the rest room of dialysis room number 225, one missing escutcheon ring.

Third floor:
*Dirty sprinkler heads within the atrium balcony area.


These findings were verified by all staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were readily accessible in the event of an emergency. This had the potential to affect all those utilizing this facility. The patient census was 77 at the beginning of the survey.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the surgery department observation was made of one portable fire extinguisher in operating room number three which was mounted on the wall within one inch of a medication return box which was also mounted to the wall. This arrangement could potentially inhibit quick access to the fire extinguisher in the event of an emergency.

Additionally, in the open area located between the endo room and operating rooms one and two, observation was made of a portable fire extinguisher mounted on the wall which was blocked by three large mobile tables with supplies stacked on them.

These findings were verified by staff members BB, EE and FF during tour of these areas of the surgery department.

Based on observation during tour, staff interview and staff verification it was determined this facility failed to ensure the trash receptacles exceeding 32 gallon capacity was stored within a hazardous area. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the west end of the pharmacy department, observation was made of a large mobile trash container filled with cardboard and other materials located in an alcove of an exit egress access corridor. This writer questioned the department manager as to how long this trash bin was located in the alcove. The department manager stated it is kept there all the time and emptied daily. This finding was verified by all staff members during tour.

Based on tour and documentation review and staff verification it was determined this facility failed to ensure the emergency battery operated lights were tested monthly and annually according to the National Fire Protection Association (NFPA) 101 Chapter 7.9.3. This facility failed to ensure quarterly sprinkler tests were performed according to NFPA 25 Chapter 2-1. This facility failed to ensure smoke sensitivity testing of the smoke detectors according to NFPA 72 Chapter 7-3.2.1. This facility failed to ensure the fire extinguishers were inspected monthly according to NFPA 10 Chapter 4-3.4.2. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review of the emergency battery operated lights took place on 06/14/12. During review observation was made of a checklist which included battery operated lights. A check mark was placed in the column which indicated a monthly test was performed but it lacked the duration of the test. This writer questioned the maintenance person in charge of the testing of the emergency lights as to how long he/she performed the monthly tests. The maintenance person was not aware of the required 30 second monthly tests and verified he/she failed to perform the annual 90 minute tests.

Documentation review of the sprinkler test reports took place on 06/14/12. Test reports were available for the third quarter of 2011 and the second quarter of 2012 but no reports were available for the fourth quarter of 2011 and the first quarter of 2012.

Documentation review of the fire alarm test reports took place on 06/14/12. Test reports failed to indicate sensitivity testing of the smoke detectors. Staff CC contacted the professional outside company who performed the fire alarm tests and verification was obtained that they have not performed the necessary sensitivity testing of the smoke detectors.

Tour of the facility took place on 06/14/12 with staff members AA, EE and FF. During tour inspection was made of the portable fire extinguishers and observation was made that each inspection tag lacked the necessary monthly inspection with the initials of the person performing the inspection.

All staff present during this interview and review of the documentation verified these findings.

Based on tour and documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This had the potential to affect all those utilizing this facility. The facility census was 29 at the time of the survey.

Findings include:

Interview with staff AA and BB on 06/14/12 reveals this facility does not have a sprinkler system. Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/14/12. During tour of the furnace room observation was made of a limited sprinkler system. No quarterly sprinkler test reports were available for review.

All staff present verified these findings.

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings had a fire resistive rating of at least one hour, specifically in regards to a stairwell door failing to positive latch shut. This had the potential to affect all those utilizing this area and each adjoining floor within the smoke compartments connected to this stairwell. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the basement area this writer observed the door leading to stairwell D failing to close and positive latch shut when tested. This finding was observed by staff members AA and BB during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure all exit accesses were marked with visible signs in order to provide all occupants a readily available and safe access to exit discharges in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the first floor, specifically within the lab and front entrance areas this writer observed a lack of exit directional signage at these locations.

Within the dead end corridor at the southwest corner of the lab observation was made while facing east of no exit sign directing flow of egress to the right and out through the southeast exit access. From this vantage point no exit signs were visible at all. This observation was verified by all staff members present during tour of the lab.

Heading west coming out of the radiology department double egress doors and facing the front lobby observation was made by this writer of no visible exit directional signs. Once this writer entered the cross section of the corridor located approximately 26 feet from the radiology double doors observation was made of two exit directional signs to the right facing north and one exit directional sign to the left facing south and no directional sign facing west. Continuing west approximately 35 feet and now within the front lobby area, an exit directional sign was observed above the exit access doors located approximately 100 feet away.
Additionally, when within the cross section corridors facing left down the south corridor, the exit directional sign was measured to be located approximately 150 feet away and directly in front of an exit stairwell which leads to the lower level exit discharge. An additional exit sign was located a little further down the corridor directing flow to an exit discharge at the southwest section of the building. The exit sign in front of this stairwell directed egress flow forward but failed to also direct flow through the stairwell to the lower level exit discharge.

These findings were verified by all staff members present during tour and again with staff member AA during interview on 06/14/12 at approximately 4:15 PM.

Based on observation and staff verification it was determined this facility failed to ensure all smoke barriers were constructed to provide at least a one half hour fire resistive rating specifically in regards to penetrations and doors failing to positive latch shut. This had the potential to affect all those utilizing these areas of this facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the facility observation was made of several penetrations in the smoke barrier above the ceiling tile in the following locations:

First floor:
*Within the south corridor adjacent to the cardiac and nuclear medical department observation was made of two, one inch insulated water lines not sealed around the annular space. These were observed to be a few feet around the corner of the smoke barrier near the double doors leading to the main lobby.
*Heading through the double doors leading to the lobby and to the left a few feet, observation was made of a one inch conduit unsealed around the annular space.
*Continuing around the smoke barrier just around the corner to the left, observation was made of a three inch by two inch opening around two flex conduits.
*Continuing along the smoke barrier and just before the coffee shop observation was made of small sections of drywall not sealed where the edges meet and one unsealed flex conduit around the annular space.
*Along the west side of the gift shop before the double doors of the small closet observation was made of three silver and two insulated lines not sealed around the annular space.
*Continuing on around the smoke barrier and above the corridor double doors observation was made of a three inch water line not sealed around the annular space.
*Continuing around the smoke barrier wall at the south end of the registration area within the electrical closet, observation was made of six penetrations around conduits.
*Within the corridor at the west side of the Jones center being at the outside wall of the restroom observation was made of one water line unsealed around the annular space.
Continuing around the corner at the south door of the women's center, observation was made of two unsealed water lines passing through metal sleeves.
*At the back wall of the PAT office, observation was made of a two inch round hole.
*Within the east corridor adjacent to the medical records office and at the double doors, observation was made of a gap greater than one eights inch between the door leafs when in the closed position.
*Within the medical records room at the southwest corner and above the doors of the stairwell, observation was made of two open end conduits.
*Above the door leading to the file room within the medical records office, observation was made of an approximate three foot long by three inch deep opening through the drywall just above the duct.
*Within zone 13 at the ICU east double doors, observation was made of two open end conduits.
*Facing the same double doors from the corridor side and just to the right of the corner wall, observation was made of one unsealed metal bracket.
*By the vending machines within the surgery waiting area, observation was made of an approximate one inch square penetration and one open end curved conduit with wires passing through.
*Within endo room B at the southeast corner observation was made of an approximate two inch square penetration.
*Within zone eight at the surgery entry doors and between the doors and the chase observation was made of four small round penetrations with wires passing through.
*Above the same double doors observation was made of two water lines not sealed around the annular space.

Second floor:
*At the far north end of the second floor within the med room observation was made of a duct which was not sealed around the annular space.
*Outside the med room at the double doors observation was made of two conduits not sealed around the annular space.
Within the west end of the corridor of the family birthing unit across from the electrical closet near stairwell I, observation was made of a two inch electrical conduit which was not sealed around the annular space.
*Within the charting area of the family birthing unit at the corner of the smoke barrier before reaching the double doors observation was made of an approximate six inch by six inch penetration with wires passing through. Additionally, observation was made of one unsealed silver conduit.
*Within room 272 observation was made of an approximate four inch square penetration with wires passing through.

Third floor:
*Within room 316 observation was made of five penetrations including unsealed wires around the annular space.

These findings were verified by staff BB and CC during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure each exit access was readily available and accessible at all times, specifically regarding the 15 second delay mechanism mounted on doors. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the family birthing unit observation was made of the east end door which was equipped with a 15 second delay mechanism which activated only when the push bar was engaged. The door was tested by this writer after the security department took the appropriate measures to disengage the alarm system prior to testing. The door was tested twice and both times the delay mechanism failed to disengage the door latch at the required 15 seconds. The delay mechanism released the door after 30 seconds on both occasions. This was verified by all staff during the tour of this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition at all times, specifically in regards to dust and debris and missing escutcheon rings. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the facility observation was made of several sprinkler heads which were either dusty, dirty or had missing escutcheon rings and were located in the following locations:

Basement:
*Within the corridor outside the mechanical room and laundry chute room observation was made of two dirty or dusty sprinkler heads.
*Within the housekeeping closet in the corridor north of the kitchen, observation was made of one sprinkler head missing an escutcheon ring.

First floor:
*Missing escutcheon ring from sprinkle head within the file room of the medical records department.
*Four dirty sprinkler heads within the staff locker/lounge room across from the cath lab.
*Dirty sprinkler heads in scan room numbers one and two of the nuclear med department.
*Dirty sprinkler heads between operating rooms five and seven.
*Dirty sprinkler heads within endo room B and in the endo utility room located between endo rooms A and B.
*Dirty sprinkler heads at bay eleven of the ASCU.
*Dirty sprinkler heads within the ICU soiled utility room, nutrition and PAR area and the documentation area.
*Within the west corridor of the histology department, one escutcheon ring was missing.

Second floor:
*Within the rest room of dialysis room number 225, one missing escutcheon ring.

Third floor:
*Dirty sprinkler heads within the atrium balcony area.


These findings were verified by all staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure all portable fire extinguishers were readily accessible in the event of an emergency. This had the potential to affect all those utilizing this facility. The patient census was 77 at the beginning of the survey.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the surgery department observation was made of one portable fire extinguisher in operating room number three which was mounted on the wall within one inch of a medication return box which was also mounted to the wall. This arrangement could potentially inhibit quick access to the fire extinguisher in the event of an emergency.

Additionally, in the open area located between the endo room and operating rooms one and two, observation was made of a portable fire extinguisher mounted on the wall which was blocked by three large mobile tables with supplies stacked on them.

These findings were verified by staff members BB, EE and FF during tour of these areas of the surgery department.

Based on observation during tour, staff interview and staff verification it was determined this facility failed to ensure the trash receptacles exceeding 32 gallon capacity was stored within a hazardous area. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 77.

Findings include:

Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/12/12 through 06/14/12. During tour of the west end of the pharmacy department, observation was made of a large mobile trash container filled with cardboard and other materials located in an alcove of an exit egress access corridor. This writer questioned the department manager as to how long this trash bin was located in the alcove. The department manager stated it is kept there all the time and emptied daily. This finding was verified by all staff members during tour.

Based on tour and documentation review and staff verification it was determined this facility failed to ensure the emergency battery operated lights were tested monthly and annually according to the National Fire Protection Association (NFPA) 101 Chapter 7.9.3. This facility failed to ensure quarterly sprinkler tests were performed according to NFPA 25 Chapter 2-1. This facility failed to ensure smoke sensitivity testing of the smoke detectors according to NFPA 72 Chapter 7-3.2.1. This facility failed to ensure the fire extinguishers were inspected monthly according to NFPA 10 Chapter 4-3.4.2. This had the potential to affect all those utilizing this facility. The facility census was zero at the time of the survey.

Findings include:

Documentation review of the emergency battery operated lights took place on 06/14/12. During review observation was made of a checklist which included battery operated lights. A check mark was placed in the column which indicated a monthly test was performed but it lacked the duration of the test. This writer questioned the maintenance person in charge of the testing of the emergency lights as to how long he/she performed the monthly tests. The maintenance person was not aware of the required 30 second monthly tests and verified he/she failed to perform the annual 90 minute tests.

Documentation review of the sprinkler test reports took place on 06/14/12. Test reports were available for the third quarter of 2011 and the second quarter of 2012 but no reports were available for the fourth quarter of 2011 and the first quarter of 2012.

Documentation review of the fire alarm test reports took place on 06/14/12. Test reports failed to indicate sensitivity testing of the smoke detectors. Staff CC contacted the professional outside company who performed the fire alarm tests and verification was obtained that they have not performed the necessary sensitivity testing of the smoke detectors.

Tour of the facility took place on 06/14/12 with staff members AA, EE and FF. During tour inspection was made of the portable fire extinguishers and observation was made that each inspection tag lacked the necessary monthly inspection with the initials of the person performing the inspection.

All staff present during this interview and review of the documentation verified these findings.

Based on tour and documentation review and staff verification it was determined this facility failed to ensure quarterly sprinkler tests according to NFPA 25 Chapter 2-1. This had the potential to affect all those utilizing this facility. The facility census was 29 at the time of the survey.

Findings include:

Interview with staff AA and BB on 06/14/12 reveals this facility does not have a sprinkler system. Facility tour took place with staff members AA, BB, CC, DD, EE and FF on 06/14/12. During tour of the furnace room observation was made of a limited sprinkler system. No quarterly sprinkler test reports were available for review.

All staff present verified these findings.