HospitalInspections.org

Based on observation and interview, it was determined the facility failed to provide a smoke tight separation between use rooms and corridors on two of nine levels.

Findings include:

1. Observation on April 20, 2011, at 10:00 am, revealed a hole in the ceiling tile in front of the electrical closet in front of the elevators.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the ceiling tile was not smoke tight.

2. Observation on April 20, 2011, at 9:55 am, revealed that the smoke tight corridor wall in the basement at the janitors closet had an unsealed penetration (empty) in the corridor wall backing to the janitors closet.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the basement corridor wall was not smoke tight.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors were substantial, 1 ? inch solid-bonded core wood, capable of resisting the passage of smoke with no impediment to closing in three of nine levels.

Findings include:

1. Observation on April 20, 2011, between 10:15 am and , revealed the corridor doors were blocked or impeded from closing at the following locations:

a. 10:15 am, fifth floor, old long term care space, room 501 Lounge/Dining room, the door was held open with a wooden ottoman.
b. 11:35 am, fourth floor, Triumph Administratio Suite, Day Room door was held open with a chair.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the doors were impeded from being closed.


2. Observation on April 20, 2011, between 11:10 am and , revealed doors that did not stay latched in the frames when pressure was applied, in the following locations:

a. 11:10 am, fourth floor, room 458.
b. 11:15 am, fourth floor, room 459.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the doors did not stay latched.


3. Observation on April 20, 2011, between 11:30 am and 1:15 pm, revealed doors were not capable of resisting the passage of smoke in the following locations:

a. 11:30 am, fourth floor, Triumph Administration Suite, room 464 CEO's office, had a gap at the top greater than half an inch.
b. 1:15 pm, third floor, room 364, had a gap at the top greater than half an inch.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the doors had gaps in excess of half an inch.

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors with a minimum two hour fire resistive rated construction on four of nine levels.

Findings include:

1. Observation on April 20, 2011, at 2:15 pm, on the first floor Main building revealed an unsealed conduit penetration of the freight elevator shaft wall. Penetration was located in the corridor at the elevator doors, above the suspended ceiling.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the elevator shaft penetration.

2. Observation made on April 20, 2011, at 10:15 am, revealed that the sub basement stat room ceiling assembly had an unsealed penetration around orange fiber optic wiring and orange armored cables.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference, confirmed the vertical penetrations.

3. Observation on April 20, 2011, at 11:50 am, revealed a penetration of cables, through a sleeve, in the ceiling of the janitor's closet by room 353, on the third floor.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed there was a vertical penetration.

4. Observation on April 20, 2011, at 10:00 am, revealed that in the basement pipe chase across from elevators, two unsealed penetrations through the floor slab bottom of the shaft and left side large unsealed penetration for electrical wiring.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the penetrations within the above pipe chase shaft.

Based upon observation and interview, it was determined the facility failed to maintain the one half hour fire resistance rating of the smoke barrier walls on five of nine levels of the facility.

Findings include:

1. Observations on April 20, 2011, between 10:30 am and 1:20 pm, revealed the following unsealed penetrations in the smoke barrier walls:

a. 10:35 am, ground floor, Main building within lab G-13 had an unsealed through penetration of the smoke barrier wall.
b. 10:45 am, fourth floor, Main building at room 470, electrical conduit and BX cable.
c. 11:50 am, third floor, Main building at room 371, electrical conduit.
d. 1:00 pm, second floor, at the entrance to Marion building from the Main building, above the cross corridor double doors, medical air pipe penetration.
e. 1:10 pm, second floor, above the cross corridor doors at the entrance to the "active" ICU, BX cable penetration. The doors are located near the separation wall for Marion and Main building.
f. 1:20 pm, ground floor, Main building above the smoke barrier doors at x-ray, one around blue data wiring.
g. 2:00 pm, second floor, between the old SPU and burn unit, on the demolition side of the wall, there is a penetration above the doors.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed smoke barrier penetrations.

Based upon observation and interview, it was determined the facility failed to ensure the doors in the smoke barrier walls, when closed, maintained smoke tight resistance on two of nine levels.

Findings include:

1. Observations on April 20, 2011, between 10:45 am and 11:05 am, revealed when the smoke barrier doors were closed the gap between the meeting edges of the doors was greater than an 1/8 of an inch in the following locations:

a. 10:40 am, fourth floor, smoke barrier doors located at room 431.
b. 10:45 am, fourth floor Main building, smoke barrier doors located at room 470.
c. 11:05 am, fourth floor Main building, smoke barrier doors located at room 459.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed excessive gap between the meeting edges of the smoke barrier doors.


2. Observation made on April 20, 2011, at 1:05 pm, revealed the ground floor smoke doors outside the old emergency room failed to fully close.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the smoke barrier doors require adjustment.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas separated from other spaces by smoke resisting partitions in sprinklered locations on three of nine levels.

Findings include:

1. Observations made on April 20, 2011, at 9:45 am, revealed that sub-basement electrical vault equipment room doors would not properly close and latch in place and had hasp installed.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference, confirmed that the doors failed to positively latch in the frame.


2. Observation on April 20, 2011, at 11:00 am, revealed the door would not self close and three penetrations in the electrical room on the fourth floor across from the elevators.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the electrical closet was not smoke tight.

3. Observation on April 20, 2011, at 11:55 am, revealed penetrations of the electrical room on the third floor across from the elevators.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the electrical closet was not smoke tight.

4. Observation on April 20, 2011, at 10:30 am, revealed penetrations inside storage room B-14 into the HVAC room, and the door separating the storage room from the HVAC room failed to fully close or latch.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the storage room above failed to maintain its fire rating.

Based upon observation and interview, it was determined that the facility failed to maintain exit egress components with a fire resistive rating for a minimum of two hours on two of nine levels.

Findings include:

1. Observation made on April 20, 2011, at 12:00 pm, revealed that within the ground floor Marion Pavilion building mechanical room stair tower" L" door failed to close and latch properly.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference, confirmed that the the stair tower door requires adjustment.


2. Observation on April 20, 2011, at 2:30 pm, revealed the right side leaf of the exit egress doors from the protected exit way at Stair Tower C did not latch into the frame.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the door did not latch.

Based upon observation and interview, it was determined the facility failed to maintain the exit access to be accessible at all times and clear of obstructions on four of nine levels.

Findings include:

1. Observation made on April 20, 2011, between 9:40 am and 9:50 am, revealed the following locations that had locks in place that would prevent exit from the egress side of the door:

a. 9:40 am, sub-basement room SB-22, hasp and combination lock on the corridor side of the door.
b. 9:42 am, sub-basement room SB-24, hasp and combination lock on the corridor side of the door.
c. 9:50 am, basement level carpenters shop, hasp and padlock on the corridor side of the door.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed there were locks in place obstructing access to the means of egress when engaged.


2. Observation Made on April 20, 2011, between 1:30 pm and 2:15 pm, revealed the following locations exit stairtowers had trash and debris in the path of egress.

a. 1:30 pm, ground floor, north building inside stairtower #1, there was trash and debris in the path of egress in the stairtower.
b. 2:15 pm, first floor, north building inside stairtower #1, there was trash and debris in the path of egress in the stairtower.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed there was debris in the exit stairtowers listed above.

Based on observation, document review, and interview, it was determined the facility failed to ensure smoke detection devices were installed, inspected, and tested within the facility.

Findings include:

1. Document review and interview on April 20, 2011, between 8:30 am and 10:00 am, revealed sixteen smoke detectors had failed sensitivity testing. Documentation was unavailable verifying the deficiencies were corrected.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference, confirmed fire alarm system components were not maintained in operable condition.


2. Observation on April 20, 2011, at 10:30 am, on the fourth floor Main building, in the corridor at the entrance to the North building, revealed there was a smoke detector detector was attached to a board laying on top of the suspended ceiling. The red power light on the detector indicated the detector was active.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the smoke detector was not installed properly.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler piping free of external loads on one of nine levels.

Findings include:

Observation made on April 20, 2011, at 11:59 am, revealed in the Marion pavilion mechanical room corridor there was wiring ziptied to the sprinkler piping.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the above location sprinkler piping was used to support non-system components.

Based on documentation review and interview, it was determined the facility failed to ensure portable fire extinguishers remain accessible at all times on one of nine levels.

Findings include:

Observation made on April 20, 2011, at 11:50 am, revealed on the ground floor Marion Pavilion mechanical room, the fire extinguisher near the shaft door was blocked by a pallet with ceiling tiles and a rolling cart.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the above fire extinguisher was not accessible.

Based on observation and interview, it was determined the facility failed to maintain the chute service opening room enclosure with a minimum two hour fire resistive rating on one of nine levels.

Findings include:

Observation on April 20, 2011, at 11:30 am, revealed on the third floor Main building above the suspended ceiling at the alcove across from room 353, there were pipe and cable penetrations of the laundry chute room corridor wall.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed penetrations of the linen chute room.

Based upon observation and interview, it was determined that the facility failed to maintain the medical gas storage room with a minimum one hour enclosure in one instance within this component .

Findings include:

Observation made on April 20, 2011, at 2:15 pm, revealed that the first floor North building oxygen storage room corridor door failed to close and latch into corresponding door frame.


Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference, confirmed the cylinder storage room door requires adjustment.

Based on observation and interview, it was determined the facility failed to ensure medical gas system pipes and pipe hangers are free of external loads on one of nine levels.

Findings include:

Observation on April 20, 2011, at 10:00 am, revealed above the suspended ceiling on the fifth floor of the North building inside the lounge dining room, there was a large piece of flexible duct work and several cables resting on, and attached to the medical gas system pipes.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the medical gas piping was used to support non-system components.

28 PA Code ? 103.4(3). Responsibility of the Licensee

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(b) Standards - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item did not conform to applicable Federal, State and local laws and regulations.

Findings include:

Observation on April 20, 2011, at 11:45 am, revealed a portion of the old rehabilitation gym was under renovation at the time of survey. The ceiling tiles had been removed, exposing wiring, ductwork, etc. The staff lunch room is located adjacent to this space and is separated only by a laminated cloth accordian style door. This accordian style door does not provide adequate separation from the occupied area.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the area under renovation was not separated from the occupied space.

Based upon documentation review and interview, it was determined that the facility failed to inspect and maintain the emergency generators in one instance within this facility.

Findings include:

Observation on April 20, 2011, at 9:10 am, made during document review, revealed documentation was unavailable verifying the following inspections had been conducted for the main building emergency generator:

a. Annual load bank testing
b. Monthly load testing under a minimum of 30% of the name plate

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of exit conference confirmed required testing of the emergency generator has not been conducted.

Based upon observation and interview, it was determined the facility failed to maintain the electrical elements in working order, protective covers and plates in place and prevent use of unauthorized electrical equipment in five of nine levels, Department of Health message board, message dated October 30, 2009, and NFPA 70.

Findings include:

1. Observation on April 20, 2011, between 10:05 am and 11:20 am, revealed broken or unlatchable locks on the electrical panels in the corridors at the following locations:

a. 10:05 am, fifth floor, by the elevators, electrical panel had a broken lock.
b. 11:20 am, fourth floor, electrical panel RP4A, across from room 462, was missing the bolt and would not stay latched.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the electrical panels were not latched and locked.


2. Observation on April 20, 2011, at 10:30 am, revealed a missing electrical outlet cover by room 512, at the stair tower, on the fifth floor.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the outlet cover was missing.


3. Observation on April 20, 2011, at 10:50 am, revealed IV stands were plugged into a surge protector in the fourth floor Pyxis Machine room.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the improper use of a surge protector.


4. Observation on April 20, 2011, at 10:55 am, revealed the cover of the electrical panel had been removed in the electrical closet on the fourth floor, across from the elevators.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the electrical panel was not covered.


5. Observation made on April 20, 2011, between 9:45 am and 11:20 am, revealed the following locations had unauthorized electrical devices in use:

a. 9:45 am, inside sub-basement, room SB40 storage room, there were two hardwired flexible extension cords ending in a 1900 box with a single receptacle.
b. 10:20 am, basement, room B-20 MIS office, had a powerstrip attached to the bottom of the desk, back right side desk, that was powered by another powerstrip (daisy-chained).
c. 11:20 am, sub-basement, clean linen room, there was an orange extension cord in use powering a radio.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the above locations had unauthorized electrical devices in use.


6. Observation made on April 20, 2011, at 1:10 pm, in the broad street building, ground floor transformer vault, revealed numerous unsealed penetrations for old toggle bolt holes and conduit (2), through the corridor wall.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the above location had unsealed penetrations in the wall of the transformer vault.


7. Observation made on April 20, 2011, at 2:00 pm, ground floor, north building generator room, inside electrical panel marked EQ-B, revealed a protective circuit breaker blank missing.

Interview with the Director of Safety, Director of Quality Management, and the Maintenance Director on April 20, 2011, at 2:20 pm, at the time of the exit conference confirmed the above location had protective circuit breaker blank missing.