HospitalInspections.org

Based on observations, the facility failed maintain clear paths of egress.

The findings included:

1. Observation on 02/03/2020 at 10:09 AM, revealed 10 beds and a pallet of boxes stored in the corridor of the Stringfield building in the basement. NFPA 101, 7.1.3.2.3 (2012 Edition)

2. Observation on 02/03/2020 at 10:23 AM, revealed a pallet of boxes stored in the basement corridor by the Stringfield and Central cross corridor doors. NFPA 101, 7.1.3.2.3 (2012 Edition)

The maintenance staff were present when these deficiencies were identified, and were later acknowledged by the maintenance staff and hospital administrators during the exit conference on 02/05/2020.

Based on record review, the facility failed to maintain the kitchen suppression system.

The finding included:

Records review on 02/03/2020 at 8:45 AM, revealed the facility failed to ensure the kitchen suppression system piping was inspected for internal obstructions every 6 months.
NFPA 101, 19.3.2.5 (2012 Edition), NFPA 96, 10.2.6 (2011 Edition) NFPA 17, 11.3.1.1 (2009 Edition)

The maintenance staff were present when this deficiency was identified, and was later acknowledged by the maintenance staff and hospital administration during the exit conference on 02/05/2020.

Based on observation, the facility failed to maintain the sprinkler system.

The findings include:

1. Observation at 10:17 AM showed 2 of 10 sprinkler heads with paint on the deflector in the Administrative conference room.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.5
NFPA 25, 2011 Edition 5.2.1, 5.2.1.1.2(6), 5.2.1.1.2(3)

2. Observation at 3:13 PM showed 3 bent sprinkler heads at room #26 in PCU.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.5
NFPA 25, 2011 Edition 5.2.1, 5.2.1.1.2(6), 5.2.1.1.2(3)

3. Observation at 1:29 PM showed 1 sprinkler head missing an escutcheon ring at room #2140 on 2 central.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.1.1*
NFPA 13, 2010 Edition 6.2.7, 6.2.7.2*

4. Observation at 1:35 PM showed 1 sprinkler head missing an escutcheon ring in the storage room next to elevator #9.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.1.1*
NFPA 13, 2010 Edition 6.2.7, 6.2.7.2*

5. Observation at 2:20 PM showed 1 sprinkler head missing an escutcheon ring at the 2 south front desk entry doors.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.1.1*
NFPA 13, 2010 Edition 6.2.7, 6.2.7.2*

6. Observation on 02/03/2020 at 3:50 PM, revealed 1 of 1 sprinkler in the bathroom of room 7332 was corroded.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.5
NFPA 25, 2011 Edition 5.2.1, 5.2.1.1.2, 5.2.1.1.2

7. Observation on 02/04/2020 at 11:04 AM, revealed 1 of 1 sprinkler painted in front of the 6th Central Nurse Managers Office.
NFPA 101, 2012 Edition 19.3.5.1, 9.7.5
NFPA 25, 2011 Edition 5.2.1, 5.2.1.1.2, 5.2.1.1.2

The Maintenance staff was present when these deficiencies were identified and were acknowledged by Administration and Maintenance staff during the exit conference on 2/5/2020.

Based on record review, the facility failed to maintain portable fire extinguishers.

The findings included:

Record review with the Maintenance Mechanic II on 2/3/2020 at 11:00 AM, showed the 1C12 kitchen K-class fire extinguisher 5 year hydrostatic test was completed in January 2014
NFPA 101, 2012 Edition 19.3.5.12, 9.7.4.1*
NFPA 10, 2010 Edition 8.3.1

The maintenance staff were present when this deficiency was identified, and was later acknowledged by the maintenance staff and hospital administrators during the exit conference on 02/05/2020.

Based on observations, the facility failed to maintain electrical equipment.

The finding included:

1. Observation on 02/03/2020 at 9:45 AM, revealed 4 daisy-chained power strips in the Stringfield basement EVS office.
NFPA 99, 10.4.2.2 (2012 Edition) CMS S&C 14-46-LSC

2. Observation on 02/03/2020 at 11:37 AM, revealed power strips connected together in the following locations:
9th Floor IT Department
1. Cubicle 3.
2. Cubicle 4.
3. Cubicle 5.
4. Cubicle 8.
5. Cubicle 9.
5th Floor nurses station across from 5625
NFPA 99, 10.4.2.2 (2012 Edition) CMS S&C 14-46-LSC

The maintenance staff were present when these deficiencies were identified, and were later acknowledged by the maintenance staff and hospital administration during the exit conference on 02/05/2020.

Based on observations, the facility failed to maintain the oxygen storage area ventilation.

Observation on 02/03/2020 at 1:55 PM, revealed no exhaust within 12 inches of the floor in the basement bulk oxygen storage room of the Kidd Building (161 "E" sized cylinders stored).
NFPA 99, 9.3.7.5 (2012 Edition) NFPA 99, 9.3.7.5.2.5 (2012 Edition) NFPA 99, 9.3.7.5.3.3 (2012 Edition)

The maintenance staff were present when this deficiency was identified, and was later acknowledged by the maintenance staff and hospital administration during the exit conference on 02/05/2020.