HospitalInspections.org

Based on observation and interview, the facility failed to ensure two hour barriers separating buildings had rated doors and were free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

On 05/17/16 at 11:55 AM a tour was conducted of Level A with Staff Q and R.

1.On 05/17/16 at 2:15 PM observation of the two hour barrier separating the north pavilion from the west pavilion (a business occupancy wing) revealed door A246 was unrated.

On 05/17/16 at 2:15 PM in an interview, Staff Q confirmed the finding.

On 05/18/16 at 11:00 AM a tour was conducted of the first floor with Staff Q and R.

2. On 05/18/16 at 11:05 AM observation above the drop down ceiling over the most easterly double doors in the two hour barrier between the north and west pavilion revealed an open junction box with conduits traveling through the barrier.

On 05/18/16 at 11:05 AM in an interview, Staff Q confirmed the finding.

3. On 05/18/16 at 11:11 AM observation above the drop down ceiling of the two hour barrier between the north and west pavilion as seen from within medication room 1112 revealed a three inch by six inch penetration with a green corrugated conduit traveling through it.

On 05/18/16 at 11:11 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each corridor door with self-closing hardware self-closed the doors. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.



Findings include:

1. On 05/16/16 at 1:42 PM a tour was conducted of the fifth floor with Staff Q and R.

On 05/16/16 at 2:45 PM observation of the five north women ' s restroom revealed it had a self-closer that did not close and latch the door.

On 05/16/16 at 2:45 PM in an interview, Staff Q confirmed the finding.


2. On 05/16/16 at 3:07 PM a tour was conducted of the fourth floor with Staff Q and R.

On 05/16/16 at 3:22 PM the corridor door to the four north galley was observed to have self-closing and latching hardware that when tested did not self-close and latch the door.

On 05/16/16 at 3:22 PM in an interview, Staff Q confirmed the finding.


3. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

On 05/17/16 at 9:50 AM the corridor door to room N320 was observed to have self-closing and latching hardware that when tested did not self-close and latch the door.

On 05/17/16 at 9:50 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure construction protecting shafts and other vertical openings are free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/16/16 at 3:07 PM a tour was conducted of the fourth floor with Staff Q and R.

On 05/16/16 at 4:07 PM observation above the drop down ceiling of the two hour barrier on the west side of the north pavilion ' s east exit stair revealed, as seen from within the computer alcove opposite room N401, blue wires traveling through a penetration.

On 05/16/16 at 4:07 PM in an interview, Staff Q confirmed the finding.

2. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

On 05/17/16 at 11:03 AM observation above the drop down ceiling of the two hour barrier protecting a shaft in room S349 revealed a strut with an annular space around it.

On 05/17/16 at 11:03 AM in an interview, Staff Q confirmed the finding.

3. On 05/17/16 at 11:55 AM a tour was conducted of Level A with Staff Q and R.

On 05/17/16 at 4:06 PM observation above the drop down ceiling of the two hour barrier that protects a vertical shaft perpendicular to conference room A219, as seen from within A219, revealed a six inch open conduit holding blue wires.

On 05/17/16 at 4:06 PM in an interview, Staff Q confirmed the finding.

4. On 05/18/16 at 11:00 AM a tour was conducted of the first floor with Staff Q and R.

On 05/18/16 at 11:48 AM observation above the drop down ceiling in physician office 1118 of the two hour barrier protecting a shaft revealed a one inch by five inch penetration with blue wiring traveling through it.

On 05/18/16 at 11:48 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each path of egress was appropriately marked with an exit sign. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/17/16 at 11:55 AM a tour was conducted of Level A with Staff Q and R.

a. On 05/17/16 at 3:00 PM observation of the fire evacuation plan, hung in the corridor running north/south in the southeast pavilions, and near the portrait of a woman sitting by a piano, revealed paths of egress which did not match the exit signs as hung. Specifically, exit signs lacked chevrons indicating a path of egress to a nearby stairway and to and through a northern corridor as directed by the plan.

On 05/17/16 at 3:00 PM in an interview, Staff Q and R confirmed the observation.

b. On 05/18/16 at 11:59 AM the path of egress in stairwell three was traced to the outside with Staff Q and R. Upon reaching level A the occupant is faced with a door directly in front, or to take a hairpin turn to reach the continuance of the stairs on the other side of the stairwell. At the door facing the landing, a sign was observed to read "exit down to level B." However there wasn't an illuminated EXIT sign to direct occupants to take the hairpin to the continuation of the stairs to continue down to the exit on level B.

On 05/19/16 at 11:59 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each smoke tight barrier was smoke tight and free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

On 05/17/16 at 9:44 AM observation above the drop down ceiling of the east side of the smoke barrier over the double doors between N315 and N318 revealed on the east side a one inch conduit open on both sides with white wires traveling through it.

On 05/17/16 at 9:44 AM in an interview, Staff Q confirmed the finding.

2. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

a. On 05/17/16 at 10:12 AM observation above the drop down ceiling of the smoke barrier perpendicular to room S332 and over door 3061 revealed a one inch conduit holding grey wires open on both sides of the barrier and wrapped in a label that read " gas annunciator " .

On 05/17/16 at 10:12 AM in an interview, Staff Q confirmed the finding.

b. On 05/17/16 at 10:52 AM observation above the drop down ceiling of the smoke tight barrier in respiratory care room 346 revealed an open two inch conduit holding a candy stripe colored line and open on both sides of the barrier. The opening in the respiratory care room can be seen two tiles north of the barrier.

On 05/17/16 at 10:52 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each rated barrier was free of penetrations. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/16/16 at 1:42 PM a tour was conducted of the fifth floor with Staff Q and R.

On 05/16/16 at 2:48 PM observation above the drop down ceiling of the two hour barrier in room N5023A revealed two sleeves holding pipes with an annular space between the pipes and the sleeves.

On 05/16/16 at 2:48 PM in an interview, Staff R confirmed the finding.

2. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

a. On 05/17/16 at 9:55 AM observation above the drop down ceiling of the two hour barrier above the door opposite room S324 revealed an open conduit holding grey and white wires.

On 05/17/16 at 9:55 AM in an interview, Staff Q confirmed the finding.

b. On 05/17/16 at 11:07 AM observation above the drop down ceiling of the one hour barrier in room 349 revealed two green corrugated conduits with annular spaces.

On 05/17/16 at 11:07 AM in an interview, Staff Q confirmed the finding.

3. On 05/17/16 at 11:55 AM a tour was conducted of Level A with Staff Q and R.

a. On 05/17/16 at 3:20 PM observation above the drop down ceiling of the two hour rated barrier in rooms A104A and A104B revealed three green corrugated conduits with annular spaces.

On 05/17/16 at 3:20 PM in an interview, Staff Q confirmed the finding.

b. On 05/17/16 at 3:45 PM observation of the corridor just south of the CT scanner revealed no one hour barrier with a door traveling from a vertical shaft to the outside wall, although the drawing showed one there with a door.

On 05/17/16 at 3:45 PM in an interview Staff Q and R confirmed the observation and could not explain the discrepancy between the real construction and the construction depicted on the schematic.

4. On 05/17/16 at 4:35 PM a tour was conducted of Level B with Staff Q and R.

a. On 05/17/16 at 4:39 PM observation of the double doors to the electrical room and in a two hour barrier revealed they did not have a coordinator to prevent the astragal from stopping one of the doors to close.

On 05/17/16 at 4:39 PM in an interview, Staff Q and R confirmed the finding.

b. On 05/17/16 at 4:40 PM observation of another set of double doors to the electrical room and in a one hour barrier revealed they did not have coordinator to prevent the astragal from stopping one of the doors to close.

On 05/17/16 at 4:40 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the rating of the construction around each hazardous area, and failed to ensure the door to each hazardous self-closed. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/16/16 at 1:42 PM a tour was conducted of the fifth floor with Staff Q and R.

On 05/16/16 at 2:05 PM observation of the linen room next to room 514 revealed it had self-closing and latching hardware that when tested did not self-close and latch the door.

On 05/16/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

2. On 05/17/16 at 4:35 PM a tour was conducted of Level B with Staff Q and R.

On 05/17/16 at 4:35 PM observation above the drop down ceiling of the one hour barrier over the door to the trash room revealed a one inch penetration holding a grey wire.

On 05/17/16 at 4:35 PM in an interview, Staff Q confirmed the finding.

Based on observation, interview, and record review, the facility failed to provide emergency lighting in accordance with section 7.9. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

On 05/19/16 at 9:22 AM a tour was conducted of the facility with Staff MM and NN.

On 05/19/16 at 9:24 AM battery operated lighting was observed in both the men's and women's changing rooms. When tested, the lighting in the men's room flickered, and the one in the women's changing area did not work at all.

On 05/19/16 a review of the facility's life safety code documentation was completed. The review did not reveal any testing of the battery operated lighting in the men's and women's changing areas.

On 05/19/16 at 9:30 AM in an interview, Staff NN confirmed the observation.

Based on interview and record review, the facility failed to have supervisory personnel instructed on how to implement a fire drill. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

On 05/19/16 a review of the facility's life safety code documentation was completed. The review revealed a fire drill was conducted on 04/15/16 at 12:45 PM. In the critique section the Rescue, Alarm, Contain, and Extinguish concepts were not marked as reviewed, and whether employees were able to locate and verbalize proper use of extinguishers was also not marked as to whether they did or not.

The review revealed a second drill was conducted on 04/27/16 at 8:00 AM. The review revealed staff did not close doors, turn off all unnecessary equipment, reassure people of their safety, or clear all corridors an exits of obstructions in preparation for potential relocation or evacuation.

The review revealed both drills were conducted by Staff ZZ.

On 05/19/16 at 9:15 AM in an interview Staff ZZ stated he did not know the right way to conduct a fire drill.

On 05/19/16 at 9:20 AM in an interview, Staff OO said she did not know Staff ZZ did not know the right way to conduct a fire drill.

Based on observation and interview, the facility failed to ensure each sprinkler head was kept clean and free of obstructions within 18 inches. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

1. On 05/17/16 at 9:25 AM a tour was taken of the third floor with Staff Q and R.

a. On 05/17/16 at 10:20 AM observation within the three south clean utility room near the nursing station revealed a sprinkler head covered with gossamer like dust between the head and the struts and the color of the bulb obscured.

On 05/17/16 at 10:20 AM in an interview, Staff Q confirmed the finding.

b. On 05/17/16 at 10:42 AM observation of the sprinkler head by the door within respiratory care room 346 revealed a sprinkler head covered with gossamer like dust between the head and the struts and the color of the bulb obscured.

2. On 05/17/16 at 11:55 AM a tour was conducted of Level A with Staff Q and R.

a. On 05/17/16 at 11:55 AM observation of the occupational and physical therapist office space revealed it contained cubical work areas with two shelving units on top of each cube. Further observation revealed one row of cubicles was placed directly underneath a sprinkler head and there was less than 18 inches of clearance between it and the head.

On 05/17/16 at 11:55 AM in an interview, Staff Q confirmed the observation.

b. On 05/17/16 at 1:55 PM the gym revealed a sprinkler head covered with gossamer like dust between the head and the struts and the color of the bulb was obscured and another in the bathroom with the struts and spinner corroded.

On 05/17/16 at 1:55 PM in an interview, Staff Q confirmed the finding.

c. On 05/17/16 at 2:05 PM observation of the sprinkler head in the women's bathroom opposite room A238 revealed a sprinkler head covered with gossamer like dust between the head and the struts and the color of the bulb was obscured.

On 05/17/16 at 2:05 PM in an interview, Staff Q confirmed the finding.

Based on interview, observation, and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients and visitors to the facility. The facility census was 58 patients.

Findings include:

On 05/16/16 at 1:42 PM a tour was conducted of the fifth floor with Staff Q and R.

On 05/16/16 at 1:54 PM observation above the drop down ceiling in the soiled utility room revealed a motorized duct damper.

On 05/19/16 at 1:00 PM a review of the facility's life safety code documentation was completed. The review did not reveal where the motorized damper in question or where any other of the motorized dampers were tested.

On 05/19/16 at 3:15 PM in an interview Staff MM stated they were unable to locate documentation that showed the motorized dampers were tested.