HospitalInspections.org

Based on observation and interview it was determined the facility failed to maintain one two-hour common wall affecting one of five floors in this component.

Findings include:

1. Observation on November 28, 2016, at 2:56 PM, revealed the double set of common wall doors, located in the basement (facility ground floor) dietary department did not provide positive latching when tested.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the dietary common wall doors did not latch when tested.

Based on observation and interview it was determined the facility failed to maintain building construction requirements affecting one of twenty five smoke compartments in this component.

Findings include:

1. Observation on November 28, 2016, at 10:39 AM, revealed combustible paper-backed insulation on heating, ventilation and air conditioning (HVAC) ducts, located above the fifth floor corridor ceiling near the IT Project Manager office.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the paper-backed insulation on the fifth floor.

Based on observation and interview it was determined the facility failed to maintain two exit stair towers affecting five of five floors in this component.

Findings include:

1. Observation on November 28, 2016, between 1:39 PM and 2:47 PM, revealed the following exit stair tower deficiencies:

a. 1:39 PM - First floor, old chapel, converted into a hazardous area used to store supplies in combustible packaging, opened directly into the exit stair tower.
b. 2:47 PM - Basement, (facility ground floor), trash can stored on the lower landing of the exit stair tower nearest the security office.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed these exit stair tower deficiencies.

Based on observation and interview it was determined the facility failed to maintain required exit components affecting two of five floors in this component.

Findings include:

1. Observation on November 28, 2016, between 12:15 PM and 1:20 PM, revealed the following exit deficiencies:

a. 12:15 PM - Third floor Hospice unit, two large reclining chairs were obstructing the exit corridor near the Hospice Family Room.
b. 1:20 PM - First floor Cancer Infusion suite, a wooden easel and poster was obstructing the exit door.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed these exiting deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit corridor walls affecting 5 of 5 floors within the component.

Findings include:

1. Observation on November 28, 2016, between 8:15 AM and 3:45 PM revealed the following elevator shaft enclosures had unprotected structural steel:

a. D-Elevator, located in the west wing had unprotected structural steel embedded in the enclosure walls on all floors.
b. Dietary Elevator, had unprotected structural steel embedded in the enclosure walls on all floors.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the elevator enclosures had unprotected structural steel.

2. Observation on November 28, 2016, at 2:15 PM, revealed an unprotected penetration around a sprinkler pipe on the ground floor landing of the OR exit stair tower.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the unprotected penetration in the OR exit stair tower.

Based on observation and interview it was determined the facility failed to maintain smoke detectors in two instances on two of five floors in this component.

Findings include:

1. Observation on November 28, 2016, between 12:43 PM and 1:26 PM, revealed the following smoke detector deficiencies:

a. 12:43 PM - Second floor, corridor by room 215, smoke detector placed within three feet of HVAC diffuser.
b. 1:26 PM - First floor, The Work Center exam area, smoke detector placed within three feet of HVAC diffuser.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed these smoke detector deficiencies.

Based on observation and interview it was determined the facility failed to maintain one fire extinguisher affecting one of twenty five smoke compartments in this component.

Findings include:

1. Observation on November 28, 2016, at 2:52 PM, revealed the K-type fire extinguisher, installed in the dietary department lacked the required signage.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the K-type fire extinguisher installed in the kitchen did not have the required signage.

Based on observation and interview, it was determined the facility failed to maintain exit corridor walls in fifteen of twenty five smoke compartments in this component.

Findings include:

1. Observation on November 28, 2016, between 8:15 AM and 3:45 PM revealed numerous unprotected penetrations in exit corridor walls on all levels, caused by the heating, ventilation and air conditioning (HVAC) system.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the unprotected penetrations in exit corridor walls on all levels caused by HVAC "open return plenums" used extensively throughout the construction of the original building.

Based on observation and interview it was determined the facility failed to maintain one of over 27 corridor doors on the first floor in this component.

Findings include:

1. Observation on November 28, 2016, at 1:22 PM, revealed first floor room C1156, Clinical Trials office, had a wooden wedge holding the door open. The wedge was removed by staff and the door was closed. Observation on November 28, 2016, at 1:41 PM revealed the wedge was in use on room C1156 corridor door.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the unauthorized use of a wedge on a corridor door.

Based on observation and interview it was determined the facility failed to maintain the installed electrical distribution system affecting one of twenty five smoke compartments in this component.

Findings include:

1. Observation on November 28, 2016, at 2:10 PM, revealed improperly terminated electrical wiring embedded in the first floor smoke barrier wall near the cancer infusion pharmacy.

Exit interview with facility administrative officer and maintenance representative #1, on November 29, 2016, between 8:30 AM and 8:45 AM confirmed the improperly terminated wiring on the first floor.