HospitalInspections.org

The Edith Sanford Breast Center at 1309 W. 17th Street was found not in compliance due to the following:

Observation at 9:00 a.m. on 10/31/17 revealed a storage room over 100 square feet in area with large amounts of combustibles (cardboard, paper, plastic, and latex gloves). The corridor door was not equipped with a self-closing device.

Interview with the construction project manager at the time of the observation confirmed that finding. He stated the room was a result of a construction separation of a larger room into two creating that storage area approximately two years ago.

Based on observation and interview, the provider failed to maintain self-closing doors and hazardous room penetrations as required (PT Solutions, Family Medicine/Children's/Acute Care, Brandon Family Medicine Clinic, Outpatient Therapy at Family Wellness, and Power Physical Therapy). Findings include:

PT Solutions located at 1721 S. Cleveland Ave. Suite 200 was found not in compliance due to the following:
*Observation on 10/31/17 from 8:50 a.m. to 9:30 a.m. revealed an unapproved device (wedge) was used to hold open the self-closing corridor door to treatment room 3. Interview with the infection control manager at the time of the observation confirmed that finding. She stated the clinics were aware doors could not be propped open.

Family Medicine/Children's/Acute Care located at 4405 E. 26th Street was found not in compliance due to the following:
*Observation on 10/31/17 from 9:40 a.m. to 10:45 a.m. revealed:
-An unapproved device (wedge) was used to hold open the self-closing corridor door to the radiology department. Interview with the radiology technician at the time of the observation confirmed that finding. She stated she "wedged" that door open so they could move patients through in a wheel chair. She was not aware that door could not be propped open.
-The conduit for the fire alarm panel in electrical room 160 had not been sealed with fire caulk. Interview with the engineer at the time of the observation confirmed that finding. He stated a new panel had been installed approximately a year ago. He was not aware the conduit had not been sealed after installation of the new panel.

Brandon Family Medicine Clinic located at 1105 E. Holly Blvd., Brandon, was found not in compliance due to the following:
*Observation on 10/31/17 from 3:55 p.m. to 4:20 p.m. revealed approximately twelve metal conduit penetrations in electrical room 109 A were not sealed with fire caulking. Interview with the engineer at the time of the observation confirmed that finding. He stated he was not aware those penetrations had not been sealed.

Outpatient Therapy at Family Wellness located at 8701 W. 32nd Street, was found not in compliance due to the following:
*Observation on 10/31/17 from 1:30 p.m. to 2:30 p.m. revealed:
-An unapproved device (kick down) was used to hold open the self-closing corridor door of room 107 and 126. Interview with the engineer and maintenance manager at the time of the observation confirmed that finding. The maintenance manager stated he was not aware kick downs could not be used to hold open corridor doors.
-A self-closer was not installed on the door to the soiled laundry room, 125 A, in the maintenance area. That room was approximately 200 square feet and held rolling bins of soiled towels. Interview with the engineer and maintenance manager at the time of the observation confirmed that finding. Neither the maintenance manager nor engineer were aware a door to a soiled laundry room must be self-closing.

Power Physical Therapy located at 2215 W. Pentagon Place, was found not in compliance due to the following:
*Observation on 10/31/17 from 2:45 p.m. to 3:30 p.m. revealed a self-closer had been removed from a cross corridor door by treatment room 130. Interview with the engineer at the time of the observation confirmed that finding. He stated he was not aware that closer had been removed. Interview with a physical therapist at that same time stated the closer had been removed as it was not a rated fire door. When questioned how she knew it was not a fire door she stated "that's what they said." She did not know who "they" was.

Based on observation and interview, the provider failed to provide a two-hour fire-rated construction between the healthcare occupancy and the basement level business occupancy. Findings Include:

1. Inspection in the north east corner of mechanical room (L501) on 11/01/17 at 12:45 p.m. revealed two steel beams supporting the floor above. Those steel beams were not covered with fire proofing. Unprotected floor beams are not allowed in a two-hour fire rated floor construction. The mechanical room was on a floor level that was classified as a business occupancy and the floor level above the mechanical room was classified as a healthcare occupancy. Those occupancies must be separated by two-hour fire-rated construction.

Interview with the facilities director at the time of the observation confirmed that finding.

This deficiency had the potential to affect the smoke compartment located above the mechanical room.

Based on observation and interview, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC).The 5000 level ceiling system and roof assembly were wood framed construction (Type III). Findings include:

1. Observation at 9:00 a.m. on 10/31/17 revealed the 5000 level ceiling system and roof assembly was wood framed construction (Type III) that was not permitted in a five story building. Interview with the senior director of construction services at the time of observation revealed that was the original construction of the building.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified in K000.

Based on observation, measurement, and interview, the provider failed to maintain the correct exit height in corridors. Randomly observed corridors revealed ceiling heights were not conforming to the exit height required by the Life Safety Code. Findings include:

1. Observation on at 10:30 a.m. 10/31/17 revealed the ceiling height in Corridor- GC2 and CG6 were low. Measurement at the time of observation revealed those ceilings ranged in height from 6 feet 6 inches to 6 feet 8 inches. Interview at the time of observation with the senior director of construction services confirmed those heights. He that condition had existed for a number of years and the ceiling could not be raised because of other obstructions.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified in K000.

A. Based on observation, testing, and interview, the provider failed to ensure exit egress doors equipped with special locking arrangements were properly installed in one of many randomly observed doors (00-07.1245 door assembly for stair enclosure 4800-S02). Findings include:

1. Observation at 8:30 a.m. on 10/31/17 revealed door assembly #00-07.1245 was marked as an exit and was equipped with a magnetic lock, motion sensor, and side release button indicating it was an access-controlled door. Testing of the motion sensor at the time of the observation revealed the light on the sensor was active, but the magnetic lock did not release. Testing of the side release button after testing the motion sensor revealed the side release button did release the magnetic lock.

Interview with the construction project manager at the time of the observation revealed he was unaware both the motion sensor and the side release button were required to release the door magnet.

The special locking arrangement would classify as an access-controlled egress locking and should have been installed in accordance with section 7.2.1.6.2 of NFPA 101 Life Safety Code.

B. Based on observation, testing, and interview, the provider failed to ensure exit egress doors equipped with special locking arrangements were properly installed in two of many randomly observed doors (4800 C14A and the exit from the Heart Hospital to the East Patient Building). Findings include:

1. Observation at 9:15 a.m. on 10/31/17 revealed a magnetically locked door 4800 C14A. Testing of the door at the time of the observation revealed the magnetic lock released at almost thirty seconds delay time. There was not a sign mounted to indicate the magnetic lock was delayed egress (and to note a fifteen second release delay).

2. Observation at 10:30 a.m. on 10/31/17 revealed a magnetically locked door at the exit from the Heart Hospital to the East Patient Building with signage indicating it was a delayed egress lock with a thirty second delayed release. Testing of the door at the time of the observation revealed the magnetic lock did release at the thirty second delay time indicated. The magnetic delayed egress door lock time delay can not be longer than fifteen seconds without a waiver from the Department of Health, Office of Licensure and Certification.

Interview with the construction project manager at the time of the above observations confirmed those conditions. He indicated he was unaware the delayed egress time could not be longer than fifteen seconds and issued a work order to reset the delays and have the correct signage mounted to indicate the correct delay time.

Based on observation and interview, the provider failed to ensure exit egress doors equipped with special locking arrangements were properly installed in one of many randomly observed cross-corridor egress door (east exit from 1700 level post operation suite). Findings include:

1. Observation at 1:35 p.m. on 10/31/17 revealed a set of cross-corridor doors on the east end of the post-operative suite leading to elevator lobby 17EL02 on the 1700 level. Those doors were equipped with magnetic locks. Those magnetic locks were inactivate at the time of observation. Interview with the director of safety at the time of observation revealed those magnetic locks would activate during the evening hours to provide added security into the post-operative suite. The special locking arrangement would classify as an access-controlled egress locking and should have been installed in accordance with section 7.2.1.6.2 of NFPA 101 Life Safety Code. A manual lock release device was not provided on the egress side of the door. The release device shall be installed in the event the motion sensor that was provided above the door fails to operate properly.

Interview with the post-operation clinical manager and director of safety at the time of the above observation confirmed that condition. They indicated they were unaware the manual release device was required on the access control egress door assembly.

Based on observation, measurement, and interview, the provider failed to maintain conforming exit stairs. Two randomly observed stair enclosures did not have adequate width at the landings. Findings include:

1. Observation and measurement at 9:45 a.m. on 10/31/17 revealed the ground floor landing in the south stair enclosures intermediate landing was reduced down to 34 inches in width. Interview with the director of facilities revealed that condition had existed since the stair enclosure was constructed.

2. Observation at 10:00 a.m. on 10/31/17 revealed the north stair enclosure door on the mezzanine level encroached into the required width of the stair landing. Measurement at the time of observation reviewed that door reduced the required width of the stair landing to 16 inches. Interview with the director of facilities confirmed that condition and indicated it had existed since the stairs were constructed.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain the ninty minute fire resistive rating of horizontal exit doors. One randomly observed fire door (door #00-70.0155) would not latch into the frame. Findings include:

1. Observation at 11:15 a.m. on 10/31/17 revealed the north leaf of the pair of ninty minute fire rated separation door on the 5000 level would not latch into the frame. Interview with the senior director of construction services at the time of the observation confirmed the door would not latch. Following the observation it was revealed the door was connected to the fire alarm system, so latching only occurred during fire alarm activation. Observation at 8:50 a.m. on 11/01/17 revealed during the simulated fire drill conducted in the east patient building the door leaf would not latch while the fire alarm was active. Interview with the senior director of construction services at the time of that observation confirmed the latching mechanism was not operating correctly.

This deficiency could affect patients within the adjacent smoke compartment on the east patient building and staff within the adjacent smoke compartment of the heart center.

Based on observation and interview, the provider failed to install exit signs for one randomly observed location in the lower level (elevator lobby - 1836 guest area). Findings include:

1. Observation at 10:00 a.m. on 10/31/17 revealed one exit sign located in the lower level elevator lobby for the west door. The north door to the 1836 guest area from the elevator lobby was not marked to identify the second required path of egress.

Interview with the construction project manager at the time of the observation confirmed that finding.

The deficiency affected one location required to be provided with a marked and identifiable path of egress.

Based on observation, document review, and interview, the provider failed to ensure proper testing and maintenance were maintained on the commercial kitchen hood fire suppression systems installed in three separate kitchen hoods located on the ground level food service area. Findings include:

1. Observation at 3:40 p.m. on 10/31/17 revealed a food service area located on the ground level. Further observation revealed maintenance and testing documentation located on the side of the kitchen hood. Review of the inspection documentation prepared by Sigler Fire Equipment Company dated 7/25/17 revealed a comment stating the tank, cartridge, and chemical agent due for 12 year hydrostatic testing.

Interview with the safety director at the time of the above observation confirmed that condition. She indicated she was unaware those fire suppression systems were overdue for the 12 year hydrostatic testing.

Based on observation and interview, the provider failed to ensure spaces open to exit egress corridors were provided in three randomly observed locations (vending areas on 1000, 2000, and 3000 levels) Findings include:

1. Observation 9:15 a.m. on 10/31/17 revealed a vending area on the 3000 level. Further observation revealed that area was open to the corridor and was not provided with smoke detection. Further observation revealed similar conditions on the 2000 and 1000 level.

Interview with the safety director at the time of the above observations confirmed those conditions. She indicated she was not aware smoke detection should have been provided in those vending areas.

Based on observation and interview, the provider failed to conspicuously mark the locations for four randomly observed fire extinguishers (adjacent to patient rooms 5103, 5156, 5166, and 5215). Findings include:

1. Observations beginning at 8:55 a.m. on 11/1/17 during the fire drill revealed four fire extinguishers located adjacent to patients' rooms 5103, 5156, 5166, and 5215 in the corridors were in recessed cabinets with only a one inch lip protruding from the wall. The cabinets were identified with a decal sign on the front of the cabinet that could not be seen from the side of the cabinet a distance down the corridor. Fire extinguishers shall be conspicuously marked.

Interview with the construction project manager at the time of the observations confirmed those conditions.

The deficiency affected one of numerous requirements for installing and maintaining fire extinguishers.

Based on observation, testing, and interview, the provider failed to ensure one randomly observed corridor door (4814 - Staff Lounge) would resist the passage of smoke. Findings include:

1. Observation and testing at 8:55 a.m. on 10/31/17 revealed the corridor door for room 4814 - staff lounge would not latch into the frame. The striker was recessed into the door and would not extend outward to engage the strike plate in the side of the frame.

Interview with the construction project manager at the time of the observation confirmed that finding.

The deficiency could affect one of the four smoke compartments on that floor.

Based on observation, testing, and interview, the provider failed to ensure one randomly observed corridor door (storage 3155) would resist the passage of smoke. Findings include:

1. Observation at 2:35 p.m. on 11/01/17 revealed the door for room 3155 had a piece of flat metal screwed into the door frame near the latch. That piece of metal was used as a door stop to prevent the door from swinging into the corridor. Further observation revealed that door was a dual swing pivot door. The metal door frame was built for a door that swung only in one direction. A gap of approximately one quarter of an inch existed between the door and the frame on the hinge side of the door and also on the latching side of the door. A gap also existed between the top of the door and the door frame. Testing of the door revealed the door would close and latch but did not provide a smoke tight fit between the door and frame on three sides of the door.

Interview with the facilities director at the time of the observation confirmed that finding. He indicated that door had been that way for many years. He indicated it appeared a door had been modified at one time to fit into that existing door frame.

The deficiency could affect one of the five smoke compartments on that floor.

Based on observation and interview, the provider failed to ensure electrical service equipment was appropriately provided in one randomly observed location (lower level food service area). Findings include:

1. Observation at 10:45 a.m. on 10/31/17 revealed power strips in-use in the food service area used to supply power to miscellaneous devices. The use of the power strips was not justified as the availability of a power supply to provide permanent power was readily available for the select few items using the power strips.

Interview with the dietary manager at the time of the above observation confirmed that condition. She indicated the power strips were not a temporary use device and used a permanent power supply. Further interview with the maintenance manager at the time of the above observation revealed the electrical service tray the power strips were plugged into could be utilized to add permanent outlets.