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Based on observation, record review and interview the facility failed to ensure fire resistance coating was maintained on the steel structure supports in accordance with NFPA 101-2012 Edition, Section 18.1.6.1. This has the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 at 1:15 P.M., during tour of the facility, noted the integrity of the building construction and protected steel support beams.

1. Examination of the OR (Operating Room) corridor, near the OR Equipment Room, located in above ceiling space, observed from the corridor, revealed two sections of missing fire resistant proofing off the steal support beams. The sections measured 15 inches in diameter and eight inches in diameter.

Interview with Safety Corridor #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure exit doors were unlocked in accordance with NFPA 101-2012 Edition, Sections 7.2.1.5.10.2; 7.2.1.5.3. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/24/19 at 8:40 A.M., during tour of the facility, noted the accessibility of the emergency exit doors throughout the facility. Examination of the thumb turn style dead bolt locks on the egress doors, at the east front lobby exit, and the rear north exit, revealed the doors were locked and not immediately accessible. When tested, the exit doors required two motions to open by unlocking the dead bolt and activating the door handle.

Interview with Safety Coordinator #11 verified the two doors were marked with illuminated exit signs and the locks required two motions for the exit doors to open.

Based on observation, record and interview the facility failed to ensure the two hour rated stairwell enclosures were maintained in accordance with NFPA 101-2012 Edition, Sections 18.2.2.3; 7.2. This has the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Finding include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the two hour rated stairwells located throughout the facility.

1. Observation at 2:11 P.M. of the second floor stairwell, located inside the OR (Operating Room) corridor, across from OR#4, in the above ceiling space, revealed a four inch sprinkler pipe installed through the wall was unsealed around the angular space. In addition, a three inch section of missing concrete block was discovered around electrical conduit, fire alarm wire and low voltage communication wire.

2. Observation at 9:10 A.M. of the second floor stairwell, next to the employee breakroom, discovered the concrete wall failed to seal at the top of the ceiling above. The open void space was packed with wool material and not sealed at the metal ceiling assembly.

Record review on 04/22/19 at 8:30 A.M., during review of the provided life safety schematics confirmed the stairwells were noted as rated as a two hour enclosure.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure one exit discharge was provided with an all weather travel surface to the public way in accordance with NFPA 101-2012 Edition, Sections 18.2.7; 7.7. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the exit discharges to the public way throughout the facility. Examination at 3:30 P.M. of the stairwell exit across from the in-patient nurses station, noted the exit sign and exit access to the stairwell from the second floor to the ground floor. The exit discharge was discovered to terminate at the grass landscape, approximately 12 feet from the public parking lot.

Interview with Maintenance Director #12 verified the exit discharge was not a hard packed, all weather surface to the public way.

Based on observation and interview the facility failed to provide emergency lighting in accordance with NFPA 101-2012 Edition, Sections 19.2.9.1; 7.9.3.1.1. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/24/19 at 8:45 A.M., during tour of the facility, noted the integrity of the battery operated emergency lights located in the Therapy Gym. Further examination revealed the battery operated light on the wall, next to the examination room, failed to function when tested.

Interview with Safety Coordinator #11 verified the findings at the time of discovery.

Based on observation, record and interview the facility failed to ensure two hour rated vertical shaft enclosures were maintained in accordance with NFPA 101-2012 Edition, Section 18.3.1. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the two hour rated vertical shafts between the ground floor and the third floor.

1. Observation at 3:45 P.M. of the first floor vertical chute, near Suite A, revealed the door failed to latch, after three attempts. In addition, three open voids of the outer membrane were discovered, which measured three inches in diameter.

2. Observation at 3:40 P.M. of the first floor vertical chute, at the first floor pain center, discovered a six inch by six inch square section of missing gypsum board of the outer membrane.

3. Observation at 3:10 P.M. of the second floor fertile chute, inside Patient Room #1, revealed a six inch diameter open void section.

4. Observation at 3:20 P.M. of the second floor vertical chute, near the physician sleeping room noted the rated fire door failed to latch, after three attempts.

Record review on 04/22/19 at 8:30 A.M., during review of the provided life safety schematics confirmed the noted vertical shafts were noted was rated as a two hour enclosure and connected from the ground floor to the third floor of the facility.

Interview with Safety Corridor #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation, record review and interview the facility failed to ensure hazardous areas were maintained in accordance with NFPA 101-2012 Edition, Section 18.3.2.1. This has the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the application of hazardous areas separations throughout the facility with the following deficiencies:

1. Observation at 2:35 P.M. of the Janitors Closet, near Patient Room #2, discovered a 20 cubic feet plastic dumpster used for trash and refuse inside the room, which measured greater than 50 square feet. Examination of the door revealed the door lacked a fire label to validate a one hour separation.

2. Observation at 2:45 P.M. of the corridor, outside Patient Room #12, revealed a covered clean linen cart and two soft soiled linen bags stored in the corridor and not stored in an approved hazardous area enclosure.

3. Observation at 2:10 P.M. of the OR (Operating Room) Storage Room, from the corridor revealed a series of pin holes in the labeled 3/4 hour fire rated door, located around the door handle.

4. Observation at 2:15 P.M. from the OR corridor, in the above ceiling space of the OR Storage Room, revealed two penetrations around the one inch electrical conduit. In addition, a four inch by four inch section of the outer fire barrier membrane was missing.

5. Observation at 2:17 P.M. from inside the OR electrical room, across from OR #4, looking back into the corridor, revealed a series of penetrations to include a six inch diameter raceways open void, a four inch penetration around the angular space around electrical conduit.

6. Observation at 2:45 P.M. of the second floor in-patient corridor equipment storage room, near the DON (Director of Nursing) Office, revealed the door failed to latch, after three attempts.

Record review on 04/22/19 at 8:30 A.M., during review of the provided life safety schematics confirmed the Janitors Closet, near Patient Room #2, was not a one hour rated enclosure and the OR Storage Room, OR Electrical Room and the Equipment Storage by the Director of Nursing (DON) Office were noted as rated as a one hour enclosure.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on record review and interview the facility failed to ensure two duct detectors were tested in accordance with NFPA 101-2012 Edition, Section 9.6.1.5; NFPA 72-2010 Edition, Sections 14.3.2; 14.3.3. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Record review on 04/22/19 at 9:35 A.M. of the fire alarm inspection and test records dated 07/2/18 to 8/17/18 noted the annual functional test of the initiation devices located throughout the facility. Further review revealed two duct detectors #22 and #35, located inside the Pre Operation Area, was noted as inaccessible and not tested. No additional documentation was provided to validate the duct detectors were tested.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the duct detectors were not tested in the past 18 months.

Based on review of the fire alarm inspection documentation and staff interview, the facility failed to ensure smoke detectors were tested and functional to ensure they were capable of detecting smoke within the manufacturer's recommended limits in accordance with NFPA 101-2012 Edition, Section 9.6.1.5*; NFPA 72-2010 Edition, Sections 14.4.5.3.2, 14.4.5.3.4, 14.4.5.3.5 and 14.4.5.3.6. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

On 04/22/19 at 9:35 A.M., review of the fire alarm smoke detector sensitivity inspection documentation dated 07/2/18 to 8/17/18 , identified 52 smoke detectors installed throughout the facility. All of the 52 smoke detectors were listed with a passing value. However, the 52 detectors were noted without a manufacturer's range on the provided report to validate the passing range.

Interview with Safety Coordinator #11 and Maintenance Director #12, during review of fire alarm inspection documentation, revealed he was unaware of the inspection results being listed as passed and verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure sprinkler protection was provided in accordance with NFPA 101-2012 Edition, Section 18.3.5.1. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the sprinkler system protection throughout the facility.

1. Observation on 2:37 P.M. of the OR (Operating Room) corridor equipment storage room, near the OR stairwell, revealed the storage room lacked sprinkler protection inside the storage room.

2. Observation on 2:10 P.M. of the Post Operation area, near the corner refrigerator, at the double set of entrance doors, revealed the area lacked sprinkler protection. Further examination of the above ceiling space, discovered a concealed sprinkler head improperly installed above the cieling grid.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure sprinkler heads were free from foreign materials in accordance with NFPA 101-2012 Edition, Section 9.7.5; NFPA 25-2011 Edition, Section 5.2.1.1.1*. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the concealed sprinkler heads located inside the operating rooms (OR). The noted sprinkler head caps were noted to be stamped "do not paint."

1. Observation at 2:37 P.M., inside OR #4 revealed one concealed sprinkler head painted and one sprinkler cap missing.

2. Observation at 2:39 P.M., inside OR #3 revealed three concealed sprinkler heads painted and one sprinkler cap missing.

3. Observation at 2:41 P.M., inside OR # 1 revealed one concealed sprinkler cap was missing.

4. Observation at 2:43 P.M., inside the Decontamination Room, off of OR #1, revealed one concealed sprinkler cap painted.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified thr findings at the time of survey.

Based on observations, record review and interview, the facility failed to ensure corridor walls could resist the passage of smoke in accordance with NFPA 101-2012 Edition, Section 19.3.6.2.3*. This has the potential to affect all patients receiving services in this facility. The facility performed 61 procedures in the last 30 days.

Findings include:

Observations on 04/24/19 between 9:00 A.M. and 11:00 A.M., during tour of the facility, noted the integrity of the corridor walls inside the Imaging corridor smoke compartment. The above ceiling space was observed with an open plenum ventilation return and the corridor walls were constructed to exterminate at the concrete deck above with a series of penetrations.

1. Observation at 9:05 A.M. in the above ceiling space from the corridor outside the Imaging Manager Office, revealed a one inch penetration at top of round five inch ductwork.

2. Observation at 9:10 A.M. in the above ceiling space above Dressing Room #2 revealed a one inch penetration around two inch electrical conduit.

3. Observation at 9:20 A.M. in the above ceiling space from the corridor outside the Magnetic Resonance Imaging (MRI) Room, looking at the waiting room entrance door above the exit sign, was a one inch penetration inside the smoke barrier.

4. Observation at 9:45 A.M. in the above ceiling space from the corridor to the Staff Room, was a series of four penetrations with a four inch raceway open void.

Record review on 04/22/19 at 8:30 A.M., during review of the provided life safety schematics confirmed the Imaging Corridor smoke compartment was rated for one hour.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure patient room doors could close and latch in accordance with NFPA 101-2012 Edition, Section 18.3.6.3. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the corridor doors throughout the facility. Examination of Patient Room #12 revealed the door failed to latch, after three attempts.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation, record review and interview the facility failed to ensure smoke barrier assemblies could resist the passage of smoke in accordance with NFPA 101-2012 Edition, Section 18.3.7.3. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the smoke barriers throughout the facility.

1. Observation at 10:10 A.M. noted inside the Post Operation Area, above the refrigerator, in the above ceiling space, at the double set of entrance doors, revealed a 18 inch by five inch square section of missing drywall. In addition, a one inch section of missing drywall was discovered around the angular space of electrical conduit.

2. Observation on 2:18 P.M. from the corridor, in the above ceiling space, across from Patient Room #1, discovered a one inch section of missing drywall around the angular space of fire alarm wire.

3. Observation on 2:05 P.M. from the corridor cross from Operating Room (OR) #4, in the above ceiling space, revealed an eight inch by 12 inch square raceway with an open void through the smoke barrier.

4. Observation on 1:37 P.M. from the corridor, outside the OR Manager Office, discovered a two inch section open void.

5. Observation on 1:40 P.M. from the corridor, above the Decontamination Room, discovered a one inch open void space around electrical conduit.. In addition, the five inch chiller line was noted with a three inch open void space with a blue low voltage wire, which penetrated through the smoke barrier.

6. Observation on 1:42 P.M. from the corridor, outside OR #5, in the above ceiling space, revealed a five inch diameter open void space. In addition, a one inch penetration was discovered around electrical conduit and four inch square open void and a two round diameter section of missing drywall.

7. Observation on 1:45 P.M., from the corridor, outside the OR Equipment Storage Room, near the disconnected elevators, revealed a two inch open void space.

Record review on 04/22/19 at 8:30 A.M., during review of the provided life safety schematics confirmed the listed smoke detectors were noted as rated as a one hour separation.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure electrical receptacles within six feet of a sink were ground fault circuit interrupter protected (GFCI) in accordance with NFPA 101-2012 Section 9.1.2; NFPA 70-2011 Edition, Section 210.8. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation on 04/24/19 at 8:45 A.M.., during tour of the facility, noted the application of electrical receptacles, next to the employee kitchen sink. Further examination revealed the room contained an electrical outlet, within six feet of the sink, without GFCI protection.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified thr findings at the time of discovery.

Based on record review and interview the facility failed to ensure patient room hospital grade electrical receptacles were initially tested after installation in accordance with NFPA 99-2012 Edition, Section 6.3.4. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Record review on 04/22/19 at 8:30 A.M. of the facility maintenance and test records for the hospital grade electrical outlets from the past 12 months revealed the documentation lacked a retension test of the patient room electrical outlets installed inside patient rooms #1 to #12. No additional documentation was provided to validate the tension tests were completed.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the hospital grade electrical outlets were not tested after installation.

Based on observation and interview the facility failed to provide a battery operated emergency lighting for the generator transfer switch equipment in accordance with NFPA 101-2012 Edition, Section 7.9.2.4; NFPA 110-2010 Edition, Sections 7.3.1; 7.3.2. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observation beginning on 04/23/19 and and ending on 04/24/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility, noted the integrity of the emergency illumination throughout the facility.

1. Examination at 11:15 A.M. of the ground floor main electrical room, located inside the boiler room, revealed the room was equipped with emergency generator transfer switches; however the room was not provided with battery operated emergency lights, in the event of generator failure.

2. Observation at 2:37 P.M. of the second floor electrical room, near the Physicians Sleeping Room, revealed the electrical panel labeled CBC2 was missing breaker with an open void space.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observation and interview, the facility failed to ensure extension cords were not used for permanent wiring in accordance with NFPA 101-2012 Edition, Section 9.1.2; NFPA 70-2011 Edition, Section Article 4008. This had the potential to affect all patients receiving services in this facility. The facility performed 61 procedures in the last 30 days.

Findings include:

Observation on 04/24/19 between 9:00 A.M. and 11:00 A.M., during tour of the facility revealed the application of flexible electrical cords throughout the facility. Examination of the Magnetic Resonance Imaging (MRI) Data Equipment Room revealed an orange extension cord plugged into a power strip, which served computer data equipment.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on observations and staff interview, the facility failed to maintain oxygen cylinders in accordance NFPA 99-2012 Edition, Section 11.3.4.1; 11.3.4.2; 11.3.2.3. This had the potential to affect all patients receiving services in this facility. The facility received 20 patients from in the past 30 days.

Findings include:

Observations on 04/23/19 between 9:00 A.M. and 4:00 P.M., during tour of the facility noted the storage of E type oxygen cylinders throughout the facility.

1. Observation at 2:35 P.M. of the Operating Room Storage Room revealed three H size cylinders, secured on wheeled carts, within 20 feet of combustible storage. In addition, the room lacked a caution signs to alert others of the oxygen storage.

2. Observation at 2:40 P.M. of the Sterile Storage Room entrances discovered three E size cylinders, secured on wheeled stands, without caution signs to alert other of the oxygen storage.

3. Observation at 2:44 P.M. of the Post Operation Room, revealed 19 E size oxygen cylinders, stored in racks in the corner, next to patient hospital beds and combustible privacy curtains, lacked caution signs and not stored in a hazardous area enclosure.

4. Observation at 3:40 P.M. of the second floor in-patient corridor equipment storage room, located outside the Director of Nursing Office, discovered six E size oxygen cylinders stored in racks, without proper caution signs.

Interview with Safety Coordinator #11 and Maintenance Director #12 verified the findings at the time of discovery.

Based on medical record review and staff interview the facility failed to ensure dry times for flammable germicide preps are documented in the medical record. This has the potential to affect 21 of 21 all who received surgical services at the facility.

Findings include:

Review of 21 patient medical records on 04/22/19 at 9:15 A.M. revealed no documentation of the dry time for flammable germicidal preps. It was noted that the facility used the following flammable chloraprep swabs with a dry time of 3 minutes on hairless skin. There was a total of 21 out of 21 patients whom did not have documented evidence that the chloraprep swabs were removed from the operating room (OR), or that the dry time for the chloraprep (flammable product) was greater than three minutes.

Interview with Director of Nursing #13 completed on 04/22/19 at 8:30 AM revealed the facility does not document the dry times or the removal after application of flammable germicides in the patient medical records.