HospitalInspections.org

Based upon observations and staff interviews on 11/30/16 between approximately 0830 and 1400 hours the facility has failed to maintain the ability of doors to close and be kept closed upon release of their automatic door closers. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
-The cross-corridor fire doors on the 5th floor near the Respiratory area failed to close and latch.
-The cross-corridor fire doors on the 5th floor near the 5 Center Area failed to close and latch.
-The East cross-corridor fire doors near the Cath Lab Waiting room failed to close and latch.
-The cross-corridor fire doors near room #207 failed to close and latch.
-The 1st floor cross-corridor fire doors near Surgery Waiting Room CC1040 failed to close and latch.
-The cross-corridor near Radiology failed to close and latch.
-The cross-corridor fire doors into the St. Elizabeth room failed to close and latch.

The above was discussed and acknowledged by the Facility Maintenance staff who said they had not previously observed the doors failing to close and latch.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the facility between approximately 0830 and 1400 hours the facility has failed to maintain the battery backup lighting in an operative condition. This could result in tripping and fall injuries to residents, staff and/or visitors.

The findings include, but are not limited to:
The battery backup Emergency Egress light in OR #5 did not illuminate when tested.

There is no battery backup Emergency Egress light in Cardiac OR #2.

The above was discussed and acknowledged by the Maintenance Staff who said they were unaware of the inoperative lights.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the campus between approximately 0830 and 1400 hours the facility has failed to maintain exit signs to be continuously illuminated in the event of primary power failure . This could result in failure to identify exits and/or a delay in evacuation of residents, staff and/or visitors.


The findings include, but are not limited to:
-The internally illuminated exit sign at the entrance to and exit from the exit stairwell #4 did not illuminate in normal operation.
-The internally illuminated exit sign at the entrance to the ICU exit did not illuminate in normal operation.


The above was discussed and acknowledged by the Facility Maintenance Staff who said they had not previously observed the inoperative exit signs.

Based upon record review, observation and staff interviews on 11/30/16 during the physical tour of the facility between approximately 0830 and 1400 hours the facility has failed to install, test, and maintain a Manual and Automatic Fire Alarm System in accordance with NFPA 70 National Electrical Code and NFPA 72 which could result in the failure of fire alarm activation or notification to staff in the event of a fire endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

-The basement corridor that led to the Kitchen suite had a measured distance of 35 feet between installed smoke detectors.
-The section of the 3rd floor corridor beyond the smoke barrier doors near the EEG Room had no installed smoke detector within the corridor.

Per NFPA 72-17.7.3.2.3.1 the maximum distance between smoke detectors is 30 feet.


The above was discussed and acknowledged by the Facility Maintenance Staff who said they were unaware of the missing smoke detector and that they were unaware of the excessive distance between the basement corridor detectors.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the facility, the facility has failed to maintain doors capable of resisting smoke or fire for at least 20 minutes. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
On 11/30/16 during the physical tour of the facility between 0830 and 1400 hours:
-The basement storage/ conference room door to the corridor failed to close and latch.
-The Old Dialysis room door to the corridor failed to close and latch.
-The elevator lobby door near the main lobby failed to close and latch.
-The Emergency Preparedness door into the exit stairwell failed to close and latch.
- The Equipment Storage Door to the corridor near room #462 had an unsealed through-penetration in the door.
-The 3rd Floor Clean Utility Room door to the corridor across from Cath Lab #2 was blocked open and prevented from fully closing / latching.
-The Rehab Clinic door to the corridor failed to close and latch.
-The Waiting room door to the corridor near ICU rooms #8-15 failed to close and latch.
-The Family Conference room door that opens to the corridor had unsealed through-penetrations above and below the doorknob.
-The storage room door that opens to the corridor across from room #231 failed to close and latch.
-The Cashier's room door that opens to the corridor failed to close and latch.
-The Admitting office's room door that opens to the corridor failed to close and latch.
-The Laboratory Break Room door that opens to the corridor was blocked open and prevented from fully closing and latching.



The above was discussed with the Facility Maintenance Staff who said they had not previously observed the doors to not close and latch.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the campus between approximately 0830 and 1400 hours, the facility has failed to properly maintain the Type 1 EES in the facility in accordance with NFPA 99 and NFPA 70. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The electrical panels containing Life Safety Branch circuits and Critical Branch Circuits in the 3rd floor EES Closet were not identified / labeled the same as multiple other electrical panels throughout the facility containing Life Safety Branch circuits that were identified on the exterior of the electrical panel by Yellow Labels and Critical Branch panels that were marked with a Red label.
Per NFPA 70 (National Electrical Code):
700.10 Wiring, Emergency System.
(A) Identification. All boxes and enclosures (including transfer
switches, generators, and power panels) for emergency
circuits shall be permanently marked so they will be readily
identified as a component of an emergency circuit or system.


The above was discussed and acknowledged by the Facility Maintenance Staff who said all panels containing Life Safety Branch Circuits should have Yellow Labels, while the Critical should have Red labels to identify them.





Based upon observations and staff interviews on 11/30/16 during the physical tour of the campus between approximately 0830 and 1400 hours, the facility has failed to properly maintain their Emergency Generator Equipment in the facility in accordance with NFPA 110. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

There were no battery backup emergency lighting devices in all of the Facility's rooms containing the Backup Generators and Transfer switch gear as required by NFPA 110 7.3.1.

The above was discussed and acknowledged by the Facility Maintenance Staff who said they were unaware battery backup emergency lighting units were required in these rooms.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the facility between approximately 0830 and 1400 hours, the facility has failed to restrict the use of powerstrips to providing power to permitted electrical equipment, using extension cords and on a temporary basis and from ensuring all electrical wiring is in accordance with NFPA 70. This could result in a fire from overheating of the extension cord due to the prolonged power draw or result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
-There was an unsecured powerstrip hanging by it's cord at the Plant Office desk.
-There was a powestrip plugged into another powerstrip in the Bio-Med area.
-There was a powerstrip plugged into another powerstrip in the Shipping and Receiving area.
-There was an unsecured powerstrip hanging by it's cord in the MicroBiology office.
-There was an unsecured powerstrip hanging by it's cord in the 6th floor staffing office.
-There was an unsecured powerstrip hanging by it's cord in the Cath Lab reception office.
-There was an unsecured powerstrip hanging by it's cord in the Schumacher Clinic Partners office.
-There was a powerstrip plugged into another powerstrip in the Gift Shop.
-There was an extension cord used in place of permanent wiring in the Gift Shop.
-There was a powestrip plugged into another powerstrip at the Nurse's Station in Nuclear Medicine.

The above was discussed and acknowledged by the Facility Maintenance Staff who said they had not previously observed the improper usage of powerstrips.

Based upon observations and staff interviews on 11/30/16 during the physical tour of the facility between approximately 0830 and 1400 hours the facility has failed to provide signage where oxygen is in use or stored. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There is no Warning signage for the Oxygen Storage room located in the Old Shop.
There is no Warning signage for the exterior Liquid Oxygen storage yard.

The above was discussed and acknowledged by the Facility Maintenance Staff who said they were unaware of the signage requirement.