HospitalInspections.org

Based on observation and interview, the facility failed to maintain building construction type and height for all areas of the building.

Findings include:

1. Observation on November 15, 2017, at 2:55 p.m., revealed the building construction type exceeds the height requirements for this type of construction.

Interview with Maintenance Lead on November 15, 2017, at 2:55 p.m., confirmed the building construction type exceeds the height requirements for this type of construction.

Based on observation and interview, the facility failed to maintain exit signs on one of four building levels.

Findings include:

1. Observation on November 15, 2017, at 1:30 p.m., revealed the basement back entrance (near generator room) had an exit sign burned out.

Interview with Maintenance Lead on November 15, 2017, at 1:30 p.m., confirmed the above exit light was burned out.

Based on observation and interview, the facility failed to maintain vertical openings in two of three vertical openings.

Findings include:

1. Observation on November 15, 2017, between 10:00 a.m. and 12:30 p.m., revealed the following stair tower door assemblies did not have label identification to show a fire rating:
A. (10:00 a.m.) Third floor south stair tower near room #308, had door hardware that did not indicate it was "fire exit hardware".
B. (10:20 a.m.) Third floor center stair tower near room #320, had door hardware that did not indicate it was "fire exit hardware".
C. (10:45 a.m.) Second floor center stair tower near Pathologist Room, had door hardware that did not indicate it was "fire exit hardware".
D. (12:30 p.m.) First floor south stair tower near the corridor fire alarm panel, had a door frame that did not indicate the fire rating.

Interview with Maintenance Lead on November 15, 2017, at 12:30 p.m., confirmed the above stair tower components were not correctly labeled.

Based on observation and interview, the facility failed to maintain kitchen appliance regulations for one of one kitchen.

Findings include:

1. Observation on November 15, 2017, at 1:55 p.m., revealed one staff in the basement kitchen did not know the location of the manual pull activation for the hood suppression system.

Interview with Maintenance Lead on November 15, 2017, at 1:55 p.m., confirmed the staff shall be inserviced as to the location of the manual pull activation for the hood suppression system.

Based on observation and interview, it was determined the facility failed to maintain and inspect the the automatic sprinkler system or components used in conjunction with them in two areas within the facility.

Findings include:

1. Observation on November 15, 2017, between 9:35 AM and 10:15 AM, revealed the facility had ceiling tile remove from the the suspended ceiling assembly which may delay the operation of the automatic sprinkler system. This condition was observed at the following locations:
A. The old whirlpool room bathroom (9:35 AM);
B. The IT room behind the reception area (10:15 AM).

Interview with the Maintenance Technician on November 15, 2017, at 10:15 AM, confirmed the ceiling tile was removed from the suspended ceiling at the above listed locations.

Based on observation and interview, the facility failed to maintain portable fire extinguishers on one of four building levels.

Findings include:

1. Observation on November 15, 2017, between 1:45 p.m. and 2:10 p.m., revealed the facility had non-compliant fire extinguishers at the following locations:
A. (1:45 p.m.) Basement Doctor Suite #2, had a fire extinguisher located behind an open door without a visual to indicate the extinguisher's location.
B. (2:10 p.m.) Basement Purchasing Storage room, had a fire extinguisher that was greater than five feet from the floor.

Interview with Maintenance Lead on November 15, 2017, at 2:10 p.m., confirmed the above basement fire extinguishers did not meet regulations.

Based on observation and interview, the facility failed to maintain corridor doors on one of two building levels.

Findings include:

Observation on November 15, 2017, at 10:35 AM, revealed the basement elevator equipment room lacked positive latching with the self-closer.

Interview with the Maintenance Technician on November 15, 2017, at 10:35 AM, confirmed the corridor door lacked positive latching with the self-closer.

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

Findings include:

1. Observation on November 15, 2017, at 11:20 AM, revealed the first floor smoke barrier had an unsealed penetration and had penetrations sealed with an unapproved orange foam, that is only rated for residential use.

Interview with the Maintenance Technician on November 15, 2015, at 11:20 AM, confirmed the unsealed penetration and the use of the unapproved orange foam used to seal other existing penetrations.

Based on document review and interview, the facility failed to maintain a written plan for the protection of all patients in the event of an emergency for one of one fire policy.

Findings include:

1. Observation on November 15, 2017, at 9:00 AM, revealed the fire safety plan did not include an "emergency phone call to the fire department", as one of the steps upon discovery of a fire.

Interview with Maintenance Lead on November 15, 2017, at 9:00 AM, confirmed the fire policy failed to include notifying the fire department by telephone.

Based on observation and interview, the facility failed to prohibit portable electric space heater, which exceed 212 degrees Fahrenheit ( 100 degrees Celsius ), on one of three building levels.

Findings include:

Observation on November 15, 2017, at 10:00 AM, revealed an unapproved portable electric heater in the first floor Program Directors Office.

Interview with the Maintenance Technician on November 15, 2017, at 10:00 AM, confirmed the utilization of an unapproved portable electric heater.

Based on observation and interview, the facility failed to maintain electrical wiring in one of two Operating Room areas.

Findings include:

1. Observation on November 15, 2017, at 1:20 p.m., revealed the first floor Operating Room Recovery area had exposed wiring that was not in a junction box, above the ceiling tile, in the center of the Recovery area.

Interview with Maintenance Lead on November 15, 2017, at 1:20 p.m., confirmed the above wires were not in a junction box.

Based on observation and interview, the facility failed to maintain medical gas storage in one of one main storage room.

Findings include:

1. Observation on November 15, 2017, at 2:15 p.m., revealed the basement main medical gas room (Nitrous Oxide and Oxygen room) did not meet the following regulations:
A. Empty oxygen cylinders were not segregated from full cylinders with signage to indicate full and empty.
B. Door lacked a precautionary sign readable from five feet, "Caution: Oxidizing gas stored within, No Smoking".

Interview with Maintenance Lead on November 15, 2017, at 2:15 p.m., confirmed the above medical gas storage room did not meet regulations.