HospitalInspections.org

Based on observation and interview, the facility failed to ensure the division of building construction types on one of four building levels.
Findings include:
Observation on May 11, 2021, at 1:21 p.m., revealed the first floor, above the emergency room fire rated doors, had an unsealed penetration, around a section of conduit.
Interview with the maintenance supervisor and risk manager on May 11, 2021, at 1:21 p.m., confirmed the unsealed penetration existed.

Based on observation and interview, it was determined the facility failed to maintain building construction in one of three floors.

Findings include:

Observation on May 11, 2021, at 12:45 p.m. revealed the following:

The ceiling floor rated assembly has been modified by removing the florescent lights and the five sided bonnets, and replacing them with LED lights all throughout the ground floor level. The facility could not confirm if the new lights meet the UL design of the structural steel protection.

Interview with maintenance representative #1 on May 11, 2021, at 12:45 p.m. confirmed the existence of this condition.

Based on observation and interview it was determined that the facility failed to maintain the means of egress free of obstructions, on one of four levels.

Findings include:

Observation on May 11, 2021, at 1:41 p.m., revealed the first floor kitchen, freezers and coolers, had holes drilled into the door handles to insert and secure with "Master Lock" padlocks.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 1:41 p.m., confirmed the above locks were used to secure the freezers and coolers and could unintentionally trap personnel inside.

Based on observation and interview, it was determined the facility failed to maintain stairways and smokeproof towers on one of three levels.

Findings include:

Observation on May 11, 2021, revealed the following:

A. At 12:30 p.m., the back stairwell door in the OR area, near the clean work room, did not close and latch.

B. At 12:50 p.m., fire exit 10, ground floor, the coordinator did not let doors latch in its frame.

Interview with maintenance representative #1 on May 11,2021, confirmed that the above stated existence of the stairtower doors not latching or coordinators not working at the above times.

Based on document review and interview, the facility failed to maintain cooking facilities in one of one, main kitchen.

Findings include:

1. Observation and document review on May 11, 2021, at 10:21 a.m., revealed the monthly kitchen suppression system visual inspections were not being documented.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 10:21 a.m., confirmed the monthly inspections for the kitchen suppression system were not being documented.

2. Interview on May 11, 2021, at 1:34 p.m., revealed that two kitchen staff members were unaware of the location for the manual pull activation for the hood suppression system.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 1:34 p.m., confirmed that two kitchen staff member was unaware of the location of the kitchen hood suppression system manual pull activation.

Based on document review and interview, the facility failed to maintain fire alarm systems for one of one system affecting the entire building.

Findings include:

Document review on May 11, 2021, at 10:05 a.m., revealed there was no documentation to confirm that one of the two semi-annual visual inspections were being completed, at the time of the survey.

Interview with maintenance supervisor on May 11, 2021, at 10:05 a.m., confirmed the above fire alarm documentation was not available, at the time of the survey.

Based on observation and interview it was determined that the facility failed to maintain the sprinkler system on one of five levels.

Findings include:

1. Observation on May 11, 2021, between 11:21 a.m. and 11:32 a.m., revealed the following sprinkler system deficiencies.

A. (11:21 a.m.) fourth floor, nurses' lounge, electrical equipment closet, had a loose sprinkler escutcheon plate creating a gap in the ceiling, potentially causing a delay in the activation;
B. (11:32 a.m.) fourth floor, rated fire doors, above the lay-in ceiling, had data cables laying on the sprinkler pipe.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 11:32 a.m., confirmed the above sprinkler deficiencies existed.

Based on observation and interview, it was determined the facility failed to maintain corridor walls on one of three levels.

Findings include:

Observation on May 11, 2021, at 12:57 p.m., revealed the following:

1. There is a hole in the corridor wall, above the ceiling tile, located near the smoke wall separation, going into the camel hall, above the speaker.

Interview with maintenance representative #1 on May 11, 2021, at 12:58 p.m., confirmed the hole in the wall.

Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke, and positively latch on one of three levels

Findings include:

On May 11, 2021, at 11:05 a.m., the door on patient room 1105, was hard to pull close and latch in its frame.

Interview with maintenance representative #1 on May 11, 2021, at 11:05 a.m., confirmed the door did not latch and was hard to shut.

Based on observation and interview, it was determined the facility failed to provide smoking regulations in one of three levels.

Findings include:

Observation on May 11, 2021, at 1:20 p.m., revealed the following:

1. The smoke extinguishing area, near the time clock door, had combustible materials inside the ashtray device.

Interview with maintenance representative #1 on May 11, 2021, at 1:21 p.m., confirmed there were combustible materials in the bottom of the ashtray.

Based on observation and interview, the facility failed to maintain rated doors on one of 20 rated doors.

Findings include:

Observation on May 11, 2021, at 12:31 p.m., revealed the third floor, soiled utility room 3330, door frame, lacked a readily legible UL approved label, due to the label being painted over.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 12:31 p.m., confirmed the above door frame was painted over.

Based on document review and interview, the facility failed to maintain piped-in medical gas systems in all areas of the building that supply piped-in medical gas.
Findings include:
Document review on May 11, 2021, at 10:43 a.m., revealed the last annual medical inspection (October 1, 2020) noted deficiencies in the Central Supply - Vacuum pumps, Central Supply - Manifolds, and the Outlets and Inlets section of the report.
Interview with the maintenance supervisor on May 11, 2021, at 10:43 a.m., confirmed the above medical gas inspection report noted deficiencies.

Based on document review and interview, the facility failed to maintain piped-in medical gas systems in all areas of the building that supply piped-in medical gas.
Findings include:
Document review on May 11, 2021, at 10:43 a.m., revealed the last annual medical inspection (October 1, 2020) noted deficiencies in the Central Supply - Vacuum pumps, Central Supply - Manifolds, and the Outlets and Inlets sections of the report.
Interview with the maintenance supervisor on May 11, 2021, at 10:43 a.m., confirmed the above medical gas inspection report noted deficiencies.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements per NFPA 70 and NFPA 99, on four of five levels.

Findings include:

1. Observation on May 11, 2021, between 11:21 a.m. and 12:54 p.m., revealed the following electrical deficiencies:
A. (11:21 a.m.) fourth floor, nurses' lounge, electrical equipment closet, had an electrical control panel with a missing cover;
B. (12:54 p.m.) second floor, mechanical room, had a junction box that was missing the cover.

Reference: NFPA 70-314.28(C)

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 12:54 p.m., confirmed the electrical system deficiencies listed above existed.

2. Observation on May 12, 2021, between 9:05 a.m. and 9:37 a.m., revealed the following electrical deficiencies:
A. (9:05 a.m.) first floor, storeroom, had a junction box located above the door, that was missing the cover;
B. (9:22 a.m.) ground floor, main entrance fire doors, had a section of NM cable/temporary wiring, above the ceiling;
C. (9:37 a.m.) ground floor, registration desk, had cord insulation that was separating from a plug end located under the desk.

Reference: NFPA 70-314(C), NFPA 70 517(C), and NFPA 70 400.2

Interview with the maintenance supervisor and risk manager on May 12, 2021, at 9:37 a.m., confirmed the electrical system deficiencies listed above existed.

Based on observation and interview, the facility failed to maintain electrical receptacles on two of five levels.

Findings include:

1. Observation on May 11, 2021, at 1:42 p.m., revealed the first floor, kitchen dishwashing area, had a receptacle that was not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 1:42 p.m., confirmed the above receptacle deficiency existed.

2. Observation on May 11, 2021, at 9:33 a.m., revealed the ground floor, staff lounge restroom, had a receptacle located above the sink that was not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 9:33 a.m., confirmed the above receptacle deficiency existed.

Based on observation and interview it was determined that the facility failed to install and maintain the emergency generator per NFPA 110-5.6.5.6, on two of two emergency generators.

Findings include:

Observation on May 12, 2021, between 10:03 a.m. and 10:09 a.m., revealed the following emergency generators lacked a remote emergency shut off buttons, located on the exterior of the emergency generator room:
A. (10:03 a.m.) generator #1, located in the sub-basement, mechanical room;
B. (10:09 a.m.) generator #2, located in the detached garage.

Interview with the maintenance supervisor and risk manager on May 12, 2021, at 10:09 a.m., confirmed the emergency generators lacked a remote emergency shut off button, located on the exterior of the emergency generator room.

Based on observation and interview, the facility failed to maintain electrical power cords on two of five levels.

Findings include:

1. Observation on May 11, 2021, at 12:54 p.m., revealed the second floor, mechanical room had an extension cord being used to power a box fan.

Interview with the maintenance supervisor and risk manager on May 11, 2021, at 12:54 p.m., confirmed the above power cord deficiency existed.

2. Observation on May 12, 2021, at 9:47 a.m., revealed the ground floor, communication room 0216, located in the mechanical room, had an extension cord plugged into a surge protector and other extension cords being used to power IT equipment.

Interview with the maintenance supervisor and risk manager on May 12, 2021, at 9:47 a.m., confirmed the above power cord deficiency existed.

Based on observation and interview, the facility failed to remain in accordance with gas equipment storage requirements on one of five levels.

Findings include:

1. Observation on May 12, 2021, at 9:10 a.m., revealed the gas storage area, located on the outside loading dock, had seven unsecured carbon dioxide cylinders.

Interview with maintenance supervisor and risk manager on May 12, 2021, at 9:10 a.m., confirmed the above location had unsecured carbon dioxide cylinders.