HospitalInspections.org

Based on observation and interview it was determined that the facility failed to ensure that structural steel components maintain a fire resistance rating on one of two levels within this component.

Findings include:

Observation made on September 14, 2015, at 7:58 am, revealed that above the ceiling of the second floor west corridor by the stair tower, there was a steel beam that was missing spray on fire proofing material in two locations where the clamp hangers were attached .

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the missing spray on fire proofing on the steel beam.

Based on observation and interview it was determined that the facility failed to ensure that corridor doors were maintained free of impediments to closing and positively latching on one of two levels within this component.

Findings include:

Observation made on September 14, 2015, at 7:41 am, revealed that on the first floor, the corridor door to the Radiology X ray room was being held open by a rubber wedge.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the door was wedged open by a rubber wedge.

Based on observation and interview it was determined that the facility failed to ensure that elevator shaft walls were maintained free of unsealed penetrations on one of two levels within this component.

Findings include:

Observation made on September 14, 2015, at 10:22 am, revealed that on the first floor above the ceiling of the service elevator, there was an unsealed penetration of the shaft wall that is near the staff lounge door.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the unsealed penetration of the elevator wall.

Based on observation and interview it was determined that the facility failed to ensure that smoke barrier walls were maintained free of openings and unsealed penetrations on one of two levels within this component.

Findings include:

1. Observations made on September 14, 2015, between 9:28 am and 11:58 am, revealed unsealed penetrations and openings in the smoke barrier partitions at the following locations:

a. 9:28 am, first floor above the ceiling of office #1, rectangular openings and a hole.
b. 10:34 am, first floor above the ceiling by the main elevator, an unsealed penetration by a sprinkler pipe.
c. 10:40 am, first floor above the ceiling of the smoke barrier doors by the OR's and the Dining room, a red fire alarm cable.
d. 11:50 am, first floor above the ceiling by the double smoke barrier doors by the Recovery unit, four unsealed penetrations and openings, one with a bundle of data cables.
e. 11:58 am, first floor above the ceiling of the recovery by the single door, an opening and a hole with data cables.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the unsealed penetrations and openings of the smoke barrier walls in the above named locations.

Based on observation and interview it was determined that the facility failed to ensure that hazardous areas were maintained with self closing devices and were free of impediments to closing on one of two levels within this component.

Findings include:

1. Observation made on September 14, 2015, at 7:40 am, revealed that on the first floor, the door to the Receiving storage room was propped open by a rubber wedge.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the door to the storage room was propped open by a rubber wedge.


2. Observation made on September 14, 2015, at 9:24 am, revealed that first floor office #2 is being used for long term storage of over 28 cardboard boxes that contain paper files. The door to the room lacks a self closer and the room is greater that fifty square feet.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the storage of the files in the room and that the door lacks a self closer.


3. Observation made on September 14, 2015, at 9:46 am, revealed that inside the first floor Admissions area, room K is being used for the storage of paper files housed inside open filing cabinets. The room is greater than fifty square feet and the door lacks a self closer.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the room is being used for storage of paper files and that the door lacks a self closer.

Based on observation and interview it was determined that the facility failed to ensure that stair tower walls were maintained free of unsealed penetrations in one of two stair towers within this component.

Findings include:

Observation made on September 14, 2015, at 9:41 am, revealed that on the first floor above the ceiling of the East stair tower exit access door, there was an unsealed penetration of the stair tower wall by a sprinkler pipe that had only mineral wool used to seal the hole and lacked fire stopping.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the unsealed sprinkler pipe penetration of the stair tower wall.

Based on observation and interview it was determined that the facility failed to ensure that stair tower illumination was maintained with continuous illumination in one of two stair towers within this component.

Findings include:

Observation made on September 14, 2015, at 8:35 am, revealed that inside the second floor landing of the East stair tower, the light fixture had a burnt out bulb and was not illuminated.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the burnt out light fixture inside the stairtower.

Based on observation, interview and document review it was determined that the facility failed to ensure that battery back up lights were maintained in operable condition and tested at required intervals on one of two levels within this component.

Findings include:

1. Observation made on September 14, 2015, at 11:40 am, revealed that inside the first floor OR # 1, the wall mounted battery back up light failed to illuminate when tested. The OR also has ceiling mounted bodine battery back up lights which had a test button and red indication light bulb. The red indicator bulb was not illuminated which could indicate there was no power to the battery pack.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the battery back lighting was not fully operable.


2. Document review made on September 14, 2015, between 12:00 pm and 1:40 pm, revealed that the facility could not produce documentation of the annual ninety minute testing of the battery back up lights inside the OR's.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the lack of documentation for the battery back up lighting.

Based on observation and interview it was determined that the facility failed to ensure that the sprinkler system components were maintained free of obstructions, external loads and the ceiling assemblies maintain smoke tight resistance on two of two levels within this component.

Findings include:

1. Observations made on September 14, 2015, between 7:47 am and 10:54 am, revealed wires and external loads laying and zip tied to sprinkler piping and hangers in the following locations:

a. 7:47 second floor above the ceiling by the smoke barrier by the nurse station of 2 west, Armor cables zip tied to pipe hanger.
b. 7:57 am, second floor above the ceiling by the West stair tower, metal race way in contact with the sprinkler pipe.
c. 8:18 am, second floor West above the ceiling between the chairs and room # 212, Armor cables zip tied to pipe hanger.
d. 10:54 am, first floor mechanical room next to the air Handler by the door, Armor cables zip tied to sprinkler pipe.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the wires and external loads on sprinkler piping and hangers in the above named locations.


2. Observations made on September 14, 2015, between 7:51 am and 8:07 am, revealed missing sprinkler head escutcheon plates in the following locations:

a. 7:51 am, second floor West wing patient room # 201 window side sprinkler head.
b. 8:07 am, second floor West wing patient room # 205 anti room.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the missing sprinkler head escutcheon plates in the above named locations.


3. Observation made on September 14, 2015 at 8:55 am, revealed that the second floor telephone room has data wires which were improperly run through the ceiling tile assembly causing the ceiling tile assembly not to resist the passage of smoke.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the openings in the ceiling assembly.


4. Observation made on September 14, 2015, at 9:32 am, revealed that inside the first floor Woman's restroom, the sprinkler head had a build up of dirt and debris.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the build up of dirt and debris on the sprinkler head.

Based on observation and interview it was determined that the facility failed to ensure that portable oxygen cylinders were maintained in a secured position on one of two levels within this component.

Findings include:

Observation made on September 14, 2015, at 11:51 am, revealed that inside the first floor Recovery room, there was an "E" class oxygen cylinder placed in a metallic holder assembly. The cylinder was laying on the floor.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the oxygen cylinder was laying on the floor.

Based on observation, interview and document review it was determined that the facility failed to ensure that medical gas manifold systems were maintained in operable condition and properly cylinders were secured within this component.

Findings include:

1. Observation made on September 14, 2015, at 11:03 am, revealed that the first floor Medical gas manifold room there was a mini cylinder in one of the corners of the room which was unsecured and free standing.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the cylinder was unsecured.


2. Document review made on September 14, 2015, between 12:00 pm and 1:50 pm, revealed that the Annual Med gas inspection report dated February 24, 2015, indicated several leaks in Oxygen and Vacuum outlets, and other deficiencies. The facility could not provide documentation verifying the deficiencies were repaired.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the lack of documentation of repairs of deficient conditions.

28 Pa. Code § 103.4(3). FUNCTIONS

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.

(a) 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:

Observations made on September 14, 2015, between 9:15 am and 9:23 am, revealed that on the roof top, there were several exhaust fan hood assemblies that were mounted to the sides of the walls of the attic spaces during exterior roof work. The facility could not produce documentation that proposed plans for the renovation work had been received by the Department.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed that the facility failed to obtain Department-approved plans prior to initiating alterations and renovations.

28 Pa Code § 51.3. Notification (d)

Based on document review and interview it was determined that the facility failed to ensure emergency generator components were maintained in operable condition within this component.

Findings include:

1. Document review made on September 14, 2015, between 12:00 pm, and 1:40 pm, revealed that the generator service report dated August 8, 2015, revealed the following deficiencies:

a. Coolant dirty and becoming Acidic.
b. Coolant bypass hoses need replacement Critical, ends are dry rotted and starting to split.
c. Hoses are in poor condition and hard to touch.
d. Notice head gasket weeping.
e. Head gaskets upper and lower and valve cover gaskets are leaking oil, total 4 heads.
f. Engine start batteries due to be changed aged 3 years.

The facility could not produce documentation of repairs to the above named deficiencies.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed documentation was unavailable verifying deficiency repairs for the emergency generator.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment were secured and maintained in operable condition, and to prevent the improper and unauthorized use of extension cords and outlet multipliers on two of two levels within this component.

Findings include:

1. Observations made on September 14, 2015, between 9:34 am and 11:09 am, revealed the improper and unauthorized use of extension cords and outlet multipliers in the following locations:

a. 9:34 am, first floor Conference room under the table, a blue extension cord powering a power strip and a black extension cord powering another power strip.
b. 10:11 am, first floor Telecom room, black extension cord powering IT equipment.
c. 11:09 am, first floor maintenance shop.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the improper and unauthorized uses of extension cords and outlet multipliers in the above named locations.


2. Observation made on September 14, 2015, at 8:48 am, revealed that inside the second floor electrical room, the panel labeled PP2A was missing two circuit breaker blank switch covers.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the missing circuit breaker blank covers inside the electrical panels.


3. Observations made on September 14, 2015, between 9:15 am and 11:42 am, revealed open junction boxes, outlet boxes and damaged telecom junction boxes with exposed inner wiring in the following locations:

a. 9:15 am, Attic space accessible from the janitor's closet, open junction box that is located along the wall next to a exhaust fan half at the ninety degree turn in the wall.
b. 9:49 am, first floor Pre Admin testing group desk area, under the desk, one telecom junction box had a loose face plate and another was disconnected from the conduit pipe and had exposed inner wiring.
c. 11:42 am, first floor OR Decontamination room, above the ceiling next to the sterilizer, open duplex box with exposed inner wiring.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the open junction boxes and telecom boxes in the above named locations.


4. Observation made on September 14, 2015, at 10:14 am, revealed that inside the first floor OR staff lounge, there was a quad electrical outlet that had a broken face plate.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the broken face plate on the quad electrical outlet.


5. Observation made on September 14, 2015, at 10:33 am, revealed that on the first floor corridor above the ceiling by the main elevator, the light fixture had two Armor cables that were not connected to the light fixture and had exposed inner wiring.

Interview with the President and the Maintenance Representative during the exit conference on September 14, at 1:45 pm, confirmed the Armor cables were not properly connected to the light fixture.