HospitalInspections.org

K 012

Based on observation and interview, the facility failed to maintain proper building construction type in one instance throughout the facility on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:50 pm revealed zero floor elevator equipment room 0209 has a section of structural steel beam that lacks fire proof spray to maintain the 2-hour fire rated ceiling assembly.

Interview with Maintenance Manager on April 26, 2012 at 1:50 pm confirmed the structural steel beam lacks sufficient fire proof spray coverage.

K 018

Based upon observation and interview, it was determined the facility failed to provide doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations in two of six building levels.

Findings include:

Observation on April 26, 2012 between 9:30 am and 1:15 pm revealed the following corridor doors lack positive latching in the frame:
A. Fourth floor I. C. U. clean utility room door 4433 would not close due to a cart placed in a location to block the door closure (9:30 am).
B. Fourth floor patient room 4413 door would not close due to a monitor and computer on wheels placed in a location to block door closure (9:20 am).
C. Zero floor Communication Central door is blocked open with a trash can (1:15 pm).

Interview with Maintenance Manager on April 26, 2012 at 1:15 pm confirmed the above corridor doors would not close in the frame, and the subsequent correction of these items during the time of the survey.

K 025

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

Findings include:

Observation on April 26, 2012 between 9:45 am and 11:00 am revealed the following smoke barrier walls have unsealed penetrations:
A. Third floor smoke barrier above soiled utility room door 3330 has multiple unsealed conduits (9:45 am).
B. Third floor smoke barrier above East Senior Transitions Unit doors has unsealed P. T. S. Network cable conduit (10:00 am).
C. Second floor smoke barrier above E. R. entrance (near elevator #4) has unsealed P. T. S. Network cable conduit (11:00 am).

Interview with Maintenance Manager on April 26, 2012 at 11:00 am confirmed the above smoke barrier walls have unsealed penetrations.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of four building levels.

Findings include:

Observation on April 27, 2012 at 10:50 am revealed zero floor storage room (next to elevator #3) door lacks positive latching with the self-closure.

Interview with Maintenance Manager on April 27, 2012 at 10:50 am confirmed the storage room door lacks positive latching with the self-closure.

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 on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:35 pm revealed zero floor main entrance is part of a 2-hour fire rated stair tower. Facility has storage of two chairs, a table and artificial tree inside the stair tower, main entrance.

Interview with Maintenance Manager on April 26, 2012 at 1:35 pm confirmed the storage of items within the stair tower.

K 046

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1 1/2 hours duration annually, and 30 seconds monthly in accordance with regulations in all areas of the entire building.

Findings include:

Document review on April 27, 2012 at 8:00 am revealed facility lacks documentation that the battery back-up emergency lighting is tested in accordance with regulations with the following:
A. Battery pack lighting in the operating rooms shall have an annual drain - 1 1/2 hour test.
B. Battery pack lighting in the emergency generator locations shall have an annual drain - 1 1/2 hour test, and a 30 second function test monthly.

Interview with Maintenance Manager on April 27, 2012 at 8:00 am confirmed the facility lacks documentation that the battery pack emergency lighting is tested in accordance with regulations.

K 056

Based upon observation and interview, it was determined the facility failed to install the automatic fire sprinkler system as per NFPA 13 on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:50 pm revealed zero floor switchgear room 0214 lacks fire sprinkler coverage. For this condition to be acceptable, facility shall verify this room is rated for 2-hour fire rated construction, including the following:
A. Fusible link fire dampers present in the duct penetrating the room walls.
B. 1-1/2 hour fire rated doors with fire rated hardware.

Interview with Maintenance Manager on April 26, 2012 at 1:50 pm confirmed the facility shall verify 2-hour construction of the switchgear room, or add sprinkler coverage.

K 062

Based on document review and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in all areas of the building.

Findings include:

Document review on April 27, 2012 at 8:30 am revealed the following sprinkler system inspection deficiencies:
1. Quarterly flow test on January 13, 2012 stated approximately 2 1/2" of 1/2" pipe is rusted and leaks when alarm line is activated on system in boiler room in basement.
2. Annual back-flow preventer test on July 22, 2011 stated check valve #2 leaked and failed, suggest rebuilding or replacement.

Interview with Maintenance Manager on April 27, 2012 at 8:30 am confirmed the sprinkler system concerns shall be addressed.

K 076

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of six building levels.

Findings include:

Observation on April 26, 2012 between 10:30 am and 1:00 pm revealed the following unsecured medical gas cylinders:
A. Second floor fan room, one E-type oxygen cylinder laying on the floor (10:30 am).
B. First floor dock cylinder storage area, eleven H-type medical gas cylinders unchained (1:00 pm).

Interview with Maintenance Manager on April 26, 2012 at 1:00 pm confirmed the above medical gas cylinders are unsecured, and the subsequent correction of these items during the time of the survey.

K 078

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

Findings include:

Document review on April 27, 2012 at 9:00 am revealed facility lacks documentation that relative humidity was maintained equal to or greater than 35% in three operating rooms during the months of February and March 2012.

Interview with Maintenance Manager on April 27, 2012 at 9:00 am confirmed the facility lacks documentation that the relative humidity was maintained during the months of February and March 2012 in the operating rooms.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of four building levels.

Findings include:

Observation on April 27, 2012 between 10:00 am and 11:15 am revealed the following electrical issues:
A. First floor Hane Cancer Center office is utilizing a hubble multiple cord strip (10:00 am).
B. Zero floor Campbell wing boiler room has a surge protector plugged into an extension cord (10:30 am).
C. Zero floor O. R. has a refrigerator plugged into a hubble "extension cord" mounted to wheeled cart across from fire exit door #8 (11:15 am).

Interview with Maintenance Manager on April 27, 2012 at 11:15 am confirmed the above electrical deficiencies, and the subsequent correction of these items during the time of the survey.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of six building levels.

Findings include:

Observation on April 26, 2012 between 9:50 am and 2:00 pm revealed the following electrical issues:
A. Fourth floor I. C. U. room one (1) doctor office has a refrigerator plugged into a surge protector (9:50 am).
B. Zero floor housekeeping office has a microwave and toaster plugged into a surge protector (2:00 pm).

Interview with Maintenance Manager on April 26, 2012 at 2:00 pm confirmed the above items were not plugged directly into wall receptacles, and the subsequent correction of these items during the time of the survey.

K 012

Based on observation and interview, the facility failed to maintain proper building construction type in one instance throughout the facility on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:50 pm revealed zero floor elevator equipment room 0209 has a section of structural steel beam that lacks fire proof spray to maintain the 2-hour fire rated ceiling assembly.

Interview with Maintenance Manager on April 26, 2012 at 1:50 pm confirmed the structural steel beam lacks sufficient fire proof spray coverage.

K 018

Based upon observation and interview, it was determined the facility failed to provide doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations in two of six building levels.

Findings include:

Observation on April 26, 2012 between 9:30 am and 1:15 pm revealed the following corridor doors lack positive latching in the frame:
A. Fourth floor I. C. U. clean utility room door 4433 would not close due to a cart placed in a location to block the door closure (9:30 am).
B. Fourth floor patient room 4413 door would not close due to a monitor and computer on wheels placed in a location to block door closure (9:20 am).
C. Zero floor Communication Central door is blocked open with a trash can (1:15 pm).

Interview with Maintenance Manager on April 26, 2012 at 1:15 pm confirmed the above corridor doors would not close in the frame, and the subsequent correction of these items during the time of the survey.

K 025

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

Findings include:

Observation on April 26, 2012 between 9:45 am and 11:00 am revealed the following smoke barrier walls have unsealed penetrations:
A. Third floor smoke barrier above soiled utility room door 3330 has multiple unsealed conduits (9:45 am).
B. Third floor smoke barrier above East Senior Transitions Unit doors has unsealed P. T. S. Network cable conduit (10:00 am).
C. Second floor smoke barrier above E. R. entrance (near elevator #4) has unsealed P. T. S. Network cable conduit (11:00 am).

Interview with Maintenance Manager on April 26, 2012 at 11:00 am confirmed the above smoke barrier walls have unsealed penetrations.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of four building levels.

Findings include:

Observation on April 27, 2012 at 10:50 am revealed zero floor storage room (next to elevator #3) door lacks positive latching with the self-closure.

Interview with Maintenance Manager on April 27, 2012 at 10:50 am confirmed the storage room door lacks positive latching with the self-closure.

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 on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:35 pm revealed zero floor main entrance is part of a 2-hour fire rated stair tower. Facility has storage of two chairs, a table and artificial tree inside the stair tower, main entrance.

Interview with Maintenance Manager on April 26, 2012 at 1:35 pm confirmed the storage of items within the stair tower.

K 046

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1 1/2 hours duration annually, and 30 seconds monthly in accordance with regulations in all areas of the entire building.

Findings include:

Document review on April 27, 2012 at 8:00 am revealed facility lacks documentation that the battery back-up emergency lighting is tested in accordance with regulations with the following:
A. Battery pack lighting in the operating rooms shall have an annual drain - 1 1/2 hour test.
B. Battery pack lighting in the emergency generator locations shall have an annual drain - 1 1/2 hour test, and a 30 second function test monthly.

Interview with Maintenance Manager on April 27, 2012 at 8:00 am confirmed the facility lacks documentation that the battery pack emergency lighting is tested in accordance with regulations.

K 056

Based upon observation and interview, it was determined the facility failed to install the automatic fire sprinkler system as per NFPA 13 on one of six building levels.

Findings include:

Observation on April 26, 2012 at 1:50 pm revealed zero floor switchgear room 0214 lacks fire sprinkler coverage. For this condition to be acceptable, facility shall verify this room is rated for 2-hour fire rated construction, including the following:
A. Fusible link fire dampers present in the duct penetrating the room walls.
B. 1-1/2 hour fire rated doors with fire rated hardware.

Interview with Maintenance Manager on April 26, 2012 at 1:50 pm confirmed the facility shall verify 2-hour construction of the switchgear room, or add sprinkler coverage.

K 062

Based on document review and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in all areas of the building.

Findings include:

Document review on April 27, 2012 at 8:30 am revealed the following sprinkler system inspection deficiencies:
1. Quarterly flow test on January 13, 2012 stated approximately 2 1/2" of 1/2" pipe is rusted and leaks when alarm line is activated on system in boiler room in basement.
2. Annual back-flow preventer test on July 22, 2011 stated check valve #2 leaked and failed, suggest rebuilding or replacement.

Interview with Maintenance Manager on April 27, 2012 at 8:30 am confirmed the sprinkler system concerns shall be addressed.

K 076

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of six building levels.

Findings include:

Observation on April 26, 2012 between 10:30 am and 1:00 pm revealed the following unsecured medical gas cylinders:
A. Second floor fan room, one E-type oxygen cylinder laying on the floor (10:30 am).
B. First floor dock cylinder storage area, eleven H-type medical gas cylinders unchained (1:00 pm).

Interview with Maintenance Manager on April 26, 2012 at 1:00 pm confirmed the above medical gas cylinders are unsecured, and the subsequent correction of these items during the time of the survey.

K 078

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

Findings include:

Document review on April 27, 2012 at 9:00 am revealed facility lacks documentation that relative humidity was maintained equal to or greater than 35% in three operating rooms during the months of February and March 2012.

Interview with Maintenance Manager on April 27, 2012 at 9:00 am confirmed the facility lacks documentation that the relative humidity was maintained during the months of February and March 2012 in the operating rooms.

K 144

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

Findings include:

Document review on April 27, 2012 at 8:15 am revealed facility lacks documentation that the weekly specific gravity test is performed on the two emergency generators' batteries (facility performs this test monthly).

Interview with Maintenance Manager on April 27, 2012 at 8:15 am confirmed the facility lacks documentation that the weekly specific gravity test of the emergency generators' batteries is performed in accordance with regulations.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of four building levels.

Findings include:

Observation on April 27, 2012 between 10:00 am and 11:15 am revealed the following electrical issues:
A. First floor Hane Cancer Center office is utilizing a hubble multiple cord strip (10:00 am).
B. Zero floor Campbell wing boiler room has a surge protector plugged into an extension cord (10:30 am).
C. Zero floor O. R. has a refrigerator plugged into a hubble "extension cord" mounted to wheeled cart across from fire exit door #8 (11:15 am).

Interview with Maintenance Manager on April 27, 2012 at 11:15 am confirmed the above electrical deficiencies, and the subsequent correction of these items during the time of the survey.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of six building levels.

Findings include:

Observation on April 26, 2012 between 9:50 am and 2:00 pm revealed the following electrical issues:
A. Fourth floor I. C. U. room one (1) doctor office has a refrigerator plugged into a surge protector (9:50 am).
B. Zero floor housekeeping office has a microwave and toaster plugged into a surge protector (2:00 pm).

Interview with Maintenance Manager on April 26, 2012 at 2:00 pm confirmed the above items were not plugged directly into wall receptacles, and the subsequent correction of these items during the time of the survey.