HospitalInspections.org

Based on observation and staff interview, it was determined that 1 of 17 patient units on the first floor were not properly protected from fire. Findings include:

During a tour of the Emergency Department (ED) on 1/7/2014 at 3:12 PM, the following was observed:

1. outside of Room 1874
- missing ceiling tile
This finding was confirmed by Mechanical Engineering Manager A at 3:12 PM on 1/7/2014.

2. Super Fast Track area
- Two patient treatment areas were not physically separated from the corridor
This finding was confirmed by Mechanical Engineering Manager A at 3:14 PM on 1/7/2014. Further interview revealed that plans for the Super Fast Track were not submitted to the State Fire Marshal Office for review and approval. The area was immediately closed down and was prohibited from opening up until plans were submitted and approved by the State Fire Marshal Office.

Based on observation and staff interview, it was determined that the facility failed to ensure that corridor doors had properly operating latching devices. Findings include:

During a tour of the facility with Mechanical Engineering Manager A on 1/7/2014 between 11:02 AM and 2:55 PM, the following was observed and acknowledged at the time of discovery:

1. 11:02 AM - Patient Room 2E08
- sliders were not latched properly in the frame

2. 2:55 PM - Patient Room 2460
- door was not latched properly in the frame

Based on observation and staff interview, it was determined that the facility failed to ensure a smoke barrier was maintained for 1 of 20 smoke barriers observed during the survey. Findings include:

During a tour of the facility on 1/7/2014 at 1:15 PM, a ½ inch by ½ inch unsealed penetration was observed in the smoke barrier above the suspended ceiling by Room 2C17. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure smoke barrier doors were maintained for 2 of 20 smoke barrier doors observed during the survey. Findings include:

During a hospital tour on 1/7 and 1/9/2014, the following was observed:

1. 1/7/2014 at 9:45 AM
- double set doors leading to Rooms 4A32-44 had an undercut more than ¾ inch
This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

2. 1/9/2014 at 10:20 AM
- double set of doors leading to the Heart and Vascular Interventional Services Prep & Hold had a gapping more then 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to maintain 2 of 5 hazardous areas in the surgical unit observed during the survey. Findings include:

During a hospital tour with Life Safety Officer A on 1/9/2014 between 9:42 AM and 10:35 AM, the following was observed and acknowledged at the time of discovery:

1. 9:42 AM - door to Room 2633 (soiled utility room) did not have a self-closing or automatic-closing device

2. 10:35 AM - door to Room 2864 (soiled utility room) did not latch properly

Based on observation and staff interview, it was determined that the facility failed to ensure that fire doors were properly maintained. Findings include:

During a hospital tour on 1/6/2014 at 1:05 PM, observation revealed that the fire door label was painted over on the fire doors by Room 5C18. This finding was confirmed by Mechanical Engineering Manager A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure the storage area within 1 of 4 stair enclosures observed during the survey was properly separated. Findings include:

During a tour of the Helen Graham Cancer Center with Mechanical Engineering Manager A on 1/10/2014 at 2:05 PM, the following was observed and acknowledged at the time of discovery:

1. Stairway 3
- wooden outdoor furniture was stored underneath the stairs without proper separation with the stair enclosure

Based on observation and staff interview, it was determined that the hospital failed to ensure that doors in the means of egress (exit access) on 2 of 8 floors were properly maintained. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/7/2014, the following was observed and acknowledged at the time of discovery:

1. 10:00 AM - the 3rd floor stairway door to Stair 19 delayed egress function was not working properly

2. 10:14 AM - the 3rd floor stairway door to Stair 2 had no delayed egress sign and the door did not function properly

3. 10:31 AM - the double doors by Room 3D44 delayed egress function was not working properly

4. 10:45 AM - the 3rd floor door to Stair 22 did not latch properly

5. 3:00 PM - the double doors by Room 2452 had no delayed egress sign and the door did not function properly

Based on observation and staff interview, it was determined that the facility failed to ensure that exit directional signs were displayed with continuous illumination. Findings include:

During a tour of the Comprehensive Center for Behavioral Health on 1/15/2014 at 11:40 AM, it was observed that 1 of 3 exit signs in the parking garage was not illuminated. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain the fire alarm system. Findings include:

During a hospital tour on 1/7/2014 at 9:40 AM, observation above the suspended ceiling by Room 4B00, revealed a fire alarm junction box missing a cover plate. This finding was confirmed by Life Safety Officer A at the time of discovery.

Based on observation and staff interview, it was determined that the facility failed to ensure proper installation, maintenance, and supervision of the sprinkler system. Findings include:

During a tour of Springside Plaza - Christiana Care Rehabilitation Services on 1/10/2014 at 11:30 AM, no sprinkler heads were observed in Room 1114. This finding was confirmed by Life Safety Officer A at time of discovery.

Based on observation and staff interview, it was determined that the automatic sprinkler system was not maintained in compliance with NFPA 13 and NFPA 25. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/13/2014, the following was observed and acknowledged at the time of discovery:

1. 9:40 AM - 8th floor in Stair 5
- a plastic cap was placed over the sprinkler head

2. 9:50 AM - 8th and 9th floor shell spaces
- numerous wiring was lying across/attached to the sprinkler pipes

3. 2:02 PM - hallway by Room 3W91A
- sprinkler was missing an escutcheon plate

Based on observation and staff interview, it was determined that the hospital failed to ensure that exit corridors were maintained free of impediments which would interfere with the safe usage of the corridors during a fire or other emergency. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. beds, not in use, were lined up in corridor by Room 3S97E
This finding was confirmed by Mechanical Engineering Manager A at 2:45 PM on 1/13/2014.

2. chairs, not in use, were lined up in corridor and a storage cabinet was next to an exit door by Room 2W93C
This finding was confirmed by Mechanical Engineering Manager A at 12:52 PM on 1/14/2014.

Based on observation and staff interview, it was determined that for 8 of 12 fire walls observed during the survey, the hospital failed to ensure the fire resistance rating was maintained. Findings include:

During hospital tours on 1/7, 1/8 and 1/9/2014, the following was observed:

1. fire doors by Room 4C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 9:25 AM on 1/7/2014.

2. fire doors by Room 3A44 - did not unlock with 15 pounds of pressure
This finding was confirmed by Mechanical Engineering Manager A at 10:06 AM on 1/7/2014.

3. fire doors by MER#12 3215 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 10:26 AM on 1/7/2014.

4. fire doors by Room 2C35 - latching mechanism did not function properly
This finding was confirmed by Mechanical Engineering Manager A at 1:09 PM on 1/7/2014.

5. fire wall above the suspended ceiling between Rooms 2A12 and 2A23 - approximately a 2 inch round unsealed penetration around a pipe sleeve
This finding was confirmed by Life Safety Officer A at 1:35 PM on 1/7/2014.

6. double set of fire doors leading to the Triangle Restaurant - had a gapping more than 1/8 inch between the double doors
This finding was confirmed by Life Safety Officer A at 2:45 PM on 1/7/2014.

7. fire doors next to Room 1597B - had a gapping more than 1/8 inch between the double doors and the undercut was more than ¾ inch
This finding was confirmed by Life Safety Officer A at 2:47 PM on 1/8/2014.

8. Post Anesthesia Care Unit separation fire doors - latching mechanism did not function properly
This finding was confirmed by Life Safety Officer A at 10:00 AM on 1/9/2014.

Based on observation and staff interview, it was determined that the hospital failed to properly maintain electrical panels, equipment and junction boxes in accordance with NFPA 70, National Electric Code. Findings include:

During hospital tours on 1/13 and 1/14/2014, the following was observed:

1. Stair 5 - an open electrical junction box
This finding was confirmed by Mechanical Engineering Manager A at 9:42 AM on 1/13/2014.

2. Room 5W97 - an air conditioner plugged into an extension cord
This finding was confirmed by Mechanical Engineering Manager A at 1:10 PM on 1/13/2014.

3. Room 3M65 - storage in front of the electrical panels
This finding was confirmed by Life Safety Officer A at 2:03 PM on 1/13/2014.

4. Fire Pump Room, ceiling level - there was an open electrical junction box
This finding was confirmed by Life Safety Officer A at 3:15 PM on 1/13/2014.

5. Materials Distribution Room - an extension cord with a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:23 PM on 1/14/2014.

6. Mail Room - a multi-plug adapter in use
This finding was confirmed by Mechanical Engineering Manager A at 2:25 PM on 1/14/2014.

Based on observation and staff interview, it was determined that Alcohol Based Hand Rub (ABHR) dispensers were installed directly over or adjacent to an ignition source on 1 of 8 floors. Findings include:

During a hospital tour with Mechanical Engineering Manager A on 1/14/2014 at 10:39 AM, the following was observed and acknowledged at the time of discovery:

1. Room 3S30 - an ABHR dispenser was installed directly above an electrical outlet