HospitalInspections.org

K 012

Based upon observation and interview, it was determined the building construction type and height does not meet regulations in two of six floors.

Findings include:

1. Observation on August 11, 2010 at 10:30 am revealed facility recently completed an I. T. computer project throughout facility. This project created an unsealed penetration in the second floor data closet beside P. T. (ceiling and floor).

Interview with Director of Environmental Services (DES) on August 12, 2010 at 1:55 pm confirmed unsealed penetration and the subsequent correction of the above item at the time of survey.

2. Observation on August 12, 2010 at 11:10 am revealed new sub-basement 72 wing has sections of two structural steel beams that lack fire protective coating above 7-8 pump and old compressor.

Interview with DES on August 12, 2010 at 1:57 pm confirmed structural steel beams lack fire protection.

K 018

Based upon observation and interview, it was determined the doors protecting corridor openings in other than hazardous areas are not substantial, nor smoke resistant as per regulations in two of six floors.

Findings include:

Observation on August 11, 2010 between 10:05 am and 1:35 pm revealed facility has corridor doors blocked open with items that prevent door closure at the following locations:
1. Second floor doors to nourishment center - trash containers (10:05 am).
2. First floor patient room 121 - bed (1:35 pm).

Interview with DES on August 12, 2010 at 2:00 pm confirmed staff blocking of corridor door closure and the subsequent correction of the above items at the time of survey.

K-025

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls in two of six floors.

Findings include:

1. Observation between August 10, 2010 and August 11, 2010 revealed facility recently completed an I. T. computer project throughout facility. This project created the following unsealed penetrations:
A. Third floor ICU smoke barrier (August 10, 2010 at 11:55 am).
B. Second floor smoke barrier near room 208 (August 11, 2010 at 10:00 am).

Interview with DES on August 12, 2010 at 1:40 pm confirmed unsealed penetrations and the subsequent correction of the above items at the time of survey.

2. Observation on August 11, 2010 at 9:50 am revealed smoke barrier door near room 208 lacks closure due to the bottom sweep rubbing against the floor.

Interview with DES on August 12, 1010 at 1:45 pm confirmed smoke barrier door would not close in frame.

K 033

Based upon observation and interview, the exit egress components do not have a fire resistive rating of at least one hour or are not arranged to provide a continuous path of egress as per regulations for three of six stair tower locations.

Findings include:

1. Observation on August 10, 2010 at 12:05 pm revealed facility recently completed an I. T. computer project throughout facility. This project created unsealed penetrations at the third floor stair tower, opposite corridor from ICU suite.

Interview with DES on August 12, 2010 at 1:40 pm confirmed unsealed penetrations and the subsequent correction of the above item at the time of survey.

2. Observation on August 12, 2010 between 10:20 am and 11:00 am revealed facility is using stair towers to store the following items:
A. Ground floor stair tower before Medical Arts, large container of salt (10:20 am).
B. Basement stair tower behind main central storage room, large linen cart with plastic bins (11:00 am).

Interview with DES on August 12, 2010 at 1:45 pm confirmed items were stored in stair towers.

K 062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of one six floors.

Findings include:

Observation on August 11, 2010 at 10:50 am revealed second floor behavioral health laundry room had clothes washing items stored within 18 " of the fire sprinkler head.

Interview with DES on August 12, 2010 at 1:25 pm confirmed items were stored within 18" of the sprinkler head and the subsequent correction of the above items at the time of survey.

K 069

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations in two of two cooking locations.

Findings include:

1. Interview with kitchen staff on August 12, 2010 at 11:30 am revealed that three staff were unfamiliar with procedures for manual activation of the extinguishing system over the cooking surface.

Interview with DES on August 12, 2010 at 1:20 pm confirmed staff was unaware of shut-off location for hood suppression system.

2. Observation on August 11, 2010 at 11:30 am revealed cafeteria location hood system has filters that were not placed properly within the hood system, creating an open void into the duct system above.

Interview with DES on August 12, 2010 at 1:15 pm confirmed hood filters were not placed properly within the hood system.

K 077

Based upon observation and interview, the piped in medical gas system does not comply with regulations for one of one system.

Findings include:

Observation on August 12, 2010 at 11:35 am revealed main piped-in nitrogen system inside main oxygen storage room has incorrect label colors on the piping above tanks.

Interview with DES on August 12, 2010 at 1:20 pm confirmed nitrogen labels are not color-coded according to regulations.

K 078

Based document review and interview, it was determined that the facility failed to comply with regulations for five of five anesthetizing locations.

Findings include:

Document review on August 12, 2010 at 12:35 pm revealed humidity logs indicated multiple days where the relative humidity in anesthetizing locations is below the required 35% at the following times:
1. O. B. - February 2010.
2. Four operating rooms - April 2009 through present.

Interview with DES on August 12, 2010 at 1:35 pm confirmed relative humidity in anesthetizing locations is below the required 35 %.

K 144

Based upon documentation review and interview, it was determined that the facility failed to comply with regulations for one of one generators.

Findings include:

Document review on August 10, 2010 at 12:30 pm revealed last generator inspection (3/10/10) did not include a notation that the inspector checked for evidence of wet-stacking.

Interview with DES on August 12, 2010 at 1:30 pm confirmed future generator inspection documentation shall include wet-stacking information.