HospitalInspections.org

K 011

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations in one instance within the facility.

Findings include:

Observation on August 10, 2010 at 2:45 pm revealed that the common wall doors between the Main Building and the 2000 Building lacked positive latching.

Interview with the Director of Facility Support Services on August 10, 2010 at 2:24 pm confirmed the common wall doors lacked positive latching.

K 017

Based upon observation and interview, the corridor walls do not meet the requirements of the regulations in seven instances on two of four floors within the facility.

Findings include:

Observation on August 10, 2010 between 1:30 pm and 3:00 pm revealed that the facility has areas where corridor walls that do not terminate at the underside of the deck above therefore lack the required half hour fire resistance rating required . This condition occurs at but may not be limited to the following locations:
1. The first floor corridor wall on the south side of the ramp to the 2000 Building
2. The first floor corridor wall across from room 105
3. The first floor corridor wall across from room 111
4. The corner of the first floor corridor wall across from room 120
5. The second floor corridor wall from ICU to across from room 210
6. The second floor corridor wall across from 204
7. The second floor corridor wall across from 211

Interview with the Director of Facility Support Services on August 12, 2010 at 11:30 am confirmed the above areas corridor walls do not terminate at the deck above.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in one instance on one of four floors.

Findings include:

Observation on August 10, 2010 at 10:30 am revealed that the second floor storage room door at 2071 lacked a self-closer.

Interview with the Director of Facility Support Services on August 10, 2010 at 10:30 am confirmed the storage room door lacked a self-closer.

K 033

Based upon observation and interview, the exit egress components do not have a fire resistive rating of at least one hour or are not arranged to provide a continuous path of egress as per regulations in ine instance on one of four floors.

Findings include:

Observation on August 10, 2010 at 2:15 pm revealed that the first floor OB stairwell doors had a gap greater than 1/8 inch between the doors and may not provide protection from smoke from other parts of the building.

Interview with the Director of Facility Support Services on August 10, 2010 at 2:15 pm confirmed the OB stairwell doors had a gap greater than 1/8 inch between the doors.

K 039

Based upon observation and interview the width of exit corridors are not clear and unobstructed in accordance with regulations in one instance on one of four floors.

Findings include:

Observation on August 10, 2010 at 11:40 pm revealed that the facility was charging a computer on wheels (COW) in the second floor exit corridor between rooms 214 and 215.

Interview with the Director of Facility Support Services on August 10, 2010 at 11:40 am confirmed that a computer on wheels (COW) in the exit corridor.

K 062

Based on observation and document review, it was determined the automatic sprinkler system was not continuously maintained in reliable operating condition or inspected and tested in accordance with regulation in three instances on one of four floors within the facility.

Findings include:

1. Observation and review of documentation on August 12, 2010 between 10:45 am and 12:10 pm revealed that the facility did not re-calibrate or replace the automatic sprinkler system gauges within the five year interval required.

Interview with the Director of Facility Support Services on August 11,2010 at 12:10 pm confirmed the automatic sprinkler system at five year intervals.

2. Observation on August 11, 2010 between 1:30 pm and 2:00 pm revealed that the facility had ceiling tiles out of the suspended ceiling grid in sprinklered areas. This condition occurred at the following locations:
A. The ground floor communications closet at door G01.
B. The ground floor O.R. storage room.

Interview with the Director of Facility Support Services on August 11, 2010 at 2:00 pm confirmed that ceiling tiles were out of the suspended ceiling at the above listed locations.

K 069

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations in one instance within the facility in two instances within the facility.

Findings include:

1. Interview with the Snack Shop kitchen staff on August 11, 2010 at 1:40 pm revealed that one of the staff was unfamiliar with procedures for manual activation of the extinguishing system over the cooking surface.

Interview with the Director of Facility Support Services on August 11, 2010 confirmed that this condition exists.

2. Observation on August 11, 2010 at revealed that the pull station for the hood extinguishment system was obscured from view by a bulletin board and was not readily accessible for use.

Interview with the Director of Facility Support Services on August 11, 2010 at 1:40 pm confirmed that the pull station was obscured from view.

K 076

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations in one instance on one of four floors within the facility.

Findings include:

Observation on August 11, 2010 at 11:30 am revealed that the facility had an unsecured Helium cylinder in the MRI mechanical control room.

Interview with the Director of Facility Support Services on August 11, 2010 at 11:30 am confirmed the Helium cylinder was unsecured.

K 077

Based upon observation and interview, the piped in medical gas system does not comply with regulations in one instance in one of two buildings.

Findings include:

Observation on August 11, 2010 at 9:50 am revealed the medical oxygen pipe above the suspended ceiling in room 129 is labeled incorrectly.

Interview with the Director of Facility Support Services on August 11, 2010 confirmed the medical oxygen pipe was labeled incorrectly.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment does not comply with Life Safety Code requirements or electrical safety policies in five instances on two of four floors within the facility.

Findings include:

1. Observation on August 11, 2010 between 1:20 pm and 2:45 pm revealed that the facility is utilizing surge protectors in an unsafe and unapproved applications. This condition occurs at the following locations:
A. The ground floor Pathologist Office in the Lab (had a surge protector plugged into another surge protector and two additional surge protectors plugged into another surge protector).
B. The basement Information Services Office (had two coffee pots and a refrigerator plugged into a surge protector).

2. Observation on August 11, 2010 between 11:05 am and 11:10 am revealed the unapproved utilization of extension cords at the following locations:
A. The Health Record Administrator office on the ground floor.
B. The Cashier Office on the ground floor.

Interview with the Director of Facility Support Services on August 11, 2010 at 2:45 pm confirmed the unapproved use of extension cords and the utilization of surge protectors in unapproved applications.