HospitalInspections.org

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the door on the Third Floor Employee Breakroom, third floor storage room (#365), storage room (#337), second floor diet kitchen at room #229, housekeeping closet at room #233, storage room at room #247, second floor staff lounge, second floor waiting room at Obstetrics, linen room (#218), electrical room in the IT Storage Room, Vending Room (#166), Gift Shop storage room, equipment room in the Control Room (C107), Mechanical Room (M1-4) and blood culture room in the Lab in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings include:

On 6/8/10 at approximately 10:51am, by observation and interview of the Director of Plant Operations, the door on the third floor employee breakroom failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 10:55am, by observation and interview of the Director of Plant Operations, the door on the third floor storage room (#365) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 10:58am, by observation and interview of the Director of Plant Operations, the door on the third floor storage room (#337) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:18am, by observation and interview of the Director of Plant Operations, the door on the second floor diet kitchen at room #229 failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:20am, by observation and interview of the Director of Plant Operations, the door on the housekeeping closet at room #233 failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:28am, by observation and interview of the Director of Plant Operations, the door on the storage room at room #247 failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:29am, by observation and interview of the Director of Plant Operations, the door on the second floor staff lounge failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:38am, by observation and interview of the Director of Plant Operations, the door on the second floor waiting room at Obstetrics failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:45am, by observation and interview of the Director of Plant Operations, the door on the linen room (#218) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 12:48pm, by observation and interview of the Director of Plant Operations, the door on the electrical room in the IT storage room failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:20pm, by observation and interview of the Director of Plant Operations, the door on the Vending Room (#166) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:32pm, by observation and interview of the Director of Plant Operations, the door on the Gift Shop storage room failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 2:04pm, by observation and interview of the Director of Plant Operations, the door on the equipment room in the Control Room (C107) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 2:10pm, by observation and interview of the Director of Plant Operations, the door on the mechanical room (M1-4) failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/9/10 at approximately 10:25am, by observation and interview of the Director of Plant Operations, the door on the blood culture room in Lab failed to close and latch properly when tested. This finding was verified with the Director of Plant Operations at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier wall at the Administration Wing, mechanical room (M3-1), Sleep Lab Tech Room, smoke barrier wall at room #203, smoke barrier wall at room #233, smoke barrier wall at room #266, Mezzanine IT Storage Room, telephone room in the Mezzanine, smoke barrier wall at room #117, communication closet (T113), smoke barrier wall at Main Lobby Entrance (T103) and smoke barrier wall at Ambulatory Surgery to Sterile Corridor in accordance with the LSC, section 19.3.7.3. This deficient practice could affect all occupants including residents, staff and visitors. Findings include:

On 6/8/10 at approximately 11:04am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at the Administration Wing failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:07am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall in the Mechanical Room (M3-1) failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:10am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall in the Sleep Lab Tech Room failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:15am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at room #203 failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:22am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at room #233 failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 11:31am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at room #266 failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 12:46pm, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall in the Mezzanine IT Storage Room failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 12:54pm, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall in the Telephone Room in the Mezzanine failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:30pm, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at room #117 failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:35pm, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall in the Communication Closet (T113) failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:38pm, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at the Main Lobby Entrance (T103) failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/9/10 at approximately 10:46am, by observation and interview of the Director of Plant Operations, penetrations of the smoke barrier wall at Ambulatory Surgery to Sterile Corridor failed to be properly sealed. This finding was verified with the Director of Plant Operations at the time of discovery.

Based upon record review, observation and staff interview it was determined that the facility failed to ensure staff to be familiar with the facilities fire evacuation procedures by failing to conduct first shift fire drill in the fourth quarter of 2009 and staff failing to clear corridor at room #256 during fire alarm activation in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors. Findings include:

On 6/8/10 at approximately 10:13am, during record review and interview of the Director of Plant Operations, the facility failed to conduct/document first shift fire drill in the fourth quarter of 2009. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/9/10 at approximately 12:38pm, by observation and interview of the Director of Plant Operations, staff failed to clear the corridor on the second floor at room #256 during fire alarm activation. This finding was verified with the Director of Plant Operations at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure testing of the roll-up fire shutter in the Medical Records room on the first floor in accordance with the LSC, section 9.6.1.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings include:

On 6/8/10 at approximately 1:26pm, by observation and interview of the Director of Plant Operations, the roll-up fire shutter in the Medical Records room on the first floor failed to be tested. This finding was verified with the Director of Plant Operations at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the sprinkler system was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove wires from sprinkler pipe above the ceiling at room #117 and having missing escutcheon's in the staff lounge (T117). This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings include:

On 6/8/10 at approximately 1:30pm, by observation and interview of the Director of Plant Operations, the facility failed to remove wires from sprinkler pipe above the ceiling at room #117. This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/8/10 at approximately 1:39pm, by observation and interview of the Director of Plant Operations, the facility failed to replace missing escutcheon's in the Staff Lounge (T117). This finding was verified with the Director of Plant Operations at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by having electrical surge protectors chained together in the Lab (room #136) and having a blocked electrical panel in mechanical room #M2-1. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings include:

On 6/9/10 at approximately 10:15am, by observation and interview of the Director of Plant Operations, the facility failed to remove electrical surge protectors that were chained together in the Lab (room #136). This finding was verified with the Director of Plant Operations at the time of discovery.

On 6/9/10 at approximately 10:15am, by observation and interview of the Director of Plant Operations, the facility had blocked electrical panels in mechanical room #M2-1. This finding was verified with the Director of Plant Operations at the time of discovery.