HospitalInspections.org

Based upon observation and interview, the facility failed to maintain corridor walls to meet the requirements of the regulations on one of seven building levels.

Findings include:

Observation on August 13, 2014 at 9:35 am revealed first floor corridor wall above clean utility door (across from room 110) has an unplugged conduit.

Interview with Engineering and Security Manager (ESM) and General Maintenance II (GMII) on August 13, 2014 at 9:35 am confirmed the above corridor wall has an unplugged conduit.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on one of seven building levels.

Findings include:

Observation on August 12, 2014 between 10:15 am and 10:27 am revealed the following corridor doors do not meet code requirements:
A. Third floor O. R. women's locker room door lacks positive latching with a self-closure (10:15 am).
B. Third floor O. R. break room has an unauthorized hold-open, wedge (10:20 am).
C. Third floor doors to O. R. #2, #3, and #4 lack positive latching (10:25 am).
D. Third floor door to O. R. #2 has unsealed holes (10:27 am).

Interview with ESM and GMII on August 12, 2014 at 10:27 am confirmed the above corridor doors do not meet code requirements.

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

Findings include:

1. Observation on August 12, 2014 between 9:15 am and 10:00 am revealed the following smoke barriers have unsealed penetrations:
A. Fourth floor O. B. smoke barrier, open conduit with blue data wires (9:15 am).
B. Fourth floor 4FD#7 smoke barrier, data conduit (9:45 am).
C. Fourth floor I. C. U. smoke barrier, data conduit (10:00 am).

Interview with ESM and GMII on August 12, 2014 at 10:00 am confirmed the above smoke barriers have unsealed penetrations.

2. Observation on August 13, 2014 at 9:40 am revealed first floor smoke barrier between patient room 110 and 112 has unsealed penetrations (nurse call and fire alarm).

Interview with ESM and GMII on August 13, 2014 at 9:40 am confirmed the unsealed smoke barrier penetrations.

Based upon observation and interview, the facility failed to maintain smoke barrier door assemblies to comply with regulations on one of seven building levels.

Findings include:

Observation on August 12, 2014 at 11:35 am revealed the following deficiencies with the recently installed second floor behavioral health smoke barrier doors:
A. Doors have a gap greater than 1/8" wide between the doors.
B. Doors lack vision panels with wired glass, or fire rated glazing.

Interview with ESM and GMII on August 12, 2014 at 11:35 am confirmed the above deficient items in the smoke barrier doors.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of seven building levels.

Findings include:

Observation on August 13, 2014 between 10:25 am and 11:15 am revealed the following hazardous area doors are not in accordance with regulations:
A. First floor cottage gift shop storage room door hardware lacks a fire rated hardware label (10:25 am).
B. Ground floor E. R. dirty utility room door (far side) lacks positive latching with the closure due to a condition where if the door is pushed open too far, the handle hangs up on the cabinet behind the door (11:15 am).

Interview with ESM and GMII on August 13, 2014 at 11:15 am confirmed the above hazardous area doors to not meet regulations.

Based upon observation and interview, the facility failed to maintain exit egress components to have a fire resistive rating of at least one hour, or arranged to provide a continuous path of egress as per regulations on three of seven building levels.

Findings include:

1. Observation on August 12, 2014 at 10:35 am revealed eight plastic totes filled with medical supplies stored in the third floor corridor in front of exit stair tower door 3FD#13.

Interview with ESM and GMII on August 12, 2014 at 10:35 am confirmed the totes stored in the corridor, and the subsequent correction of this item during the time of the survey.

2. Observation on August 13, 2014 between 9:20 am and 9:25 am revealed the following locations do not provide a continuous path of egress:
A. First floor office door 100 does not easily open once in the latched position (9:20 am).
B. First floor outside exit discharge at stairtower #6 has a trip hazard (hose) across the sidewalk (9:25 am).

Interview with ESM and GMII on August 13, 2014 at 9:25 am confirmed the above exits are not readily continuous.

3. Observation on August 14, 2014 at 10:10 am revealed the old sub-basement exit door to the outside, above stairs, does not easily open once in the latched position.

Interview with ESM and GMII on August 14, 2014 at 10:10 am confirmed the above exit is not readily continuous.

Based upon observation and interview, the facility failed to maintain illumination of the means of egress in accordance with regulations on one of seven floors.

Findings include:

Observation on August 14, 2014 at 9:45 am revealed basement stair tower #5 behind central stores has lighting burned out.

Interview with ESM and GMII on August 14, 2014 at 9:45 am confirmed the stair tower lighting is not illuminated.

Based upon documentation review and interview, it was determined the facility failed to maintain required smoke detectors in accordance with regulations in all areas of the building.

Findings include:

Document review on August 12, 2014 at 1:15 pm revealed smoke detectors lack the following documentation:
A. Semi-annual visual inspection of electrically tied-in smoke detectors within 6 months of their annual functional testing.
B. Weekly functional test of the battery operated smoke detectors.
C. Semi-annual battery change of the battery operated smoke detectors.

Interview with ESM and GMII on August 12, 2014 at 1:15 pm confirmed the lack of smoke detector documentation.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in all areas of the building.

Findings include:

Document review on August 12, 2014 at 1:15 pm revealed facility lacks documentation that required testing is performed on the fire sprinkler hoses throughout the building, such as but not limited to:
A. Annual cabinet and nozzle inspection in accordance with NFPA 25.
B. Hose shall be removed and service tested in accordance with NFPA 1962 at intervals not exceeding five (5) years after installation and every three (3) years thereafter.
C. In-service hose shall be unracked and physically inspected in accordance with NFPA 1962 at least annually.

Interview with ESM and GMII on August 12, 2014 at 1:15 pm confirmed the facility lacks documented inspections of the fire sprinkler hoses.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers are installed, inspected and maintained in accordance with regulations on one of seven building levels.

Findings include:

Observation on August 13, 2014 at 10:20 am revealed first floor east corridor in administration suite has a fire extinguisher that was not visually inspected for the month of July 2014.

Interview with ESM and GMII on August 13, 2014 at 10:20 am confirmed the above fire extinguisher lacks a monthly inspection for the month of July 2014.

Based upon observation and interview, it was determined that facility failed to store medical gas in accordance with regulations on one of seven building levels.

Findings include:

Observation on August 14, 2014 at 9:00 am revealed basement respiratory therapy oxygen cylinder storage is not segregated and labeled for full and empty.

Interview with ESM and GMII on August 14, 2014 at 9:00 am confirmed the oxygen storage is not separated by full and empty.

Based upon observation and interview, oxygen transfilling locations and/or procedures failed to meet regulations on one of seven building levels.

Findings include:

Observation on August 14, 2014 at 8:35 am revealed basement main oxygen storage location is also being used as a liquid oxygen transfilling location, and lacks a posted sign indicating that transferring is occurring.

Interview with ESM and GMII on August 14, 2014 at 8:35 am confirmed the oxygen transfilling location lacks a "transferring in progress" sign.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of seven building levels.

Findings include:

Observation on August 13, 2014 at 11:25 am revealed ground floor security office is utilizing an extension cord for radios.

Interview with ESM and GMII on August 13, 2014 at 11:25 am confirmed the use of an extension cord in the security office.