HospitalInspections.org

Based on observation and interview, the facility does not ensure the integrity of the fire/smoke rated walls.

Findings include:

During facility tour on 1/14/11, it was observed that penetrations were present in the fire/smoke walls in the following locations:
--the rated wall in the doctor's lounge above fire door 1B47;
--at the deck of the doctor's lounge above the fire door in BHU;
--in Pain Management above the smoke doors;
--at the deck of the electrical room on D2;
--in the wall adjacent to fire door 2E138;
--above the fire doors on C3 - rehabilitation;
These findings were verified by Staff #51 on 1/14/11.

Based on document review, observation and interview, 3 of 3 battery operated emergency lighting units at the Southport Internal Medicine site are not tested monthly and annually to ensure functionality.

Findings include:

Review on 1/12/11 of battery emergency lighting documentation in the office of Staff #7 did not reveal evidence that the units at the Southport Internal Medicine site had been tested monthly for 30 seconds or annually for 90 minutes.

During tour of the Southport Internal Medicine site on 1/13/11, it was observed that 2 of 3 battery operated emergency lighting units were not operational. During interview on 1/13/11, Staff #49 indicated that she had not observed these lights being tested by the facility maintenance personnel.


Based on observation and interview, the facility does not ensure that the battery operated emergency lighting in 2 of 2 operating rooms activates immediately upon loss of electrical power. (Rooms 3 and 4)

Findings include:

During tour of the operating room suite on 1/12/11, it was noted that the battery emergency lighting did not activate immediately upon loss of electrical power. During interview, Staff #42 indicated that the emergency lighting in these operating rooms does not activate for approximately 5 to 10 seconds when the main electrical power is interrupted.

Based on document review and interview, the facility does not ensure that 4 of 4 fire drills are conducted annually at the Southport Internal Medicine site.

Findings include:

Review on 1/13/11 of documentation provided at Southport Internal Medicine site did not reveal evidence that fire drills had been conducted during 2009 or 2010. During interview, Staff #49 and 50 revealed that they could not recall when a fire drill had been performed. Fire drills must be conducted at unexpected times under varying conditions at least once/quarter/shift. The drills must indicate the date, time, scenario, staff attendees, drill evaluation and follow up action that occurred. Without this documentation, it is not possible to determine if staff has received adequate training and participation in fire drills.

Based on document review, the facility does not ensure that 22 of 31 fire dampers operate properly, have adequate access panels or are properly located in the floor. (Fire dampers FD-OR-1 through 3; FD-P2-1 through 6; and FD-P7-1 through 7, 9, 11, 13 through16)

Findings include:

Review on 1/12/11 of the fire damper report dated 12/20/09 revealed that corrective action is required for 22 of 31 fire dampers, as follows:
---the damper spring on 3 fire dampers had been damaged by vise grips and 2" x 4" pieces of wood (FD-P2-1, 2 and 4);
---the access panels for 3 fire dampers were lacking or inadequate in size to allow access to the damper (FD-P2-3 and 6; and FD-P3-2);
---the fire dampers were not located in the floor for 22 fire dampers. The fire dampers must be in the plane of the floor that it is protecting. The dampers that failed because they were not located in the floor must be replaced (FD-OR-1 through 3; FD-P2-1 through 6; and FD-P7-1 through 7, 9, 11, 13 through 16).

This finding was verified with Staff #7 on 1/12/11.


Based on document review, the facility does not ensure that the DACT Sealed Lead Acid Battery for the fire alarm system is maintained and operational.

Findings include:

Review on 1/11/11 of the fire alarm inspection report did not reveal evidence that the DACT Sealed Lead Acid Battery was operational during the 10/13/10 fire alarm inspection. The report indicated that the measured capacity Amp-hours (Ah) failed the load test. This parameter was left blank, indicating that the reading obtained for this parameter tested less than 3.25 Ah or less that 65% of the rated load (5Ah). Documentation was not provided to verify that the battery had been replaced and retested to ensure the proper operation of the device.


Based on document review and interview, the facility does not ensure that 12 of 26 smoke dampers operate properly and have access panels. (Smoke dampers SD-P3-1, 5, 7, 8, 13, 14; and SD-SPD-4, 5, 7, 9, 11, 12)

Findings include:

Review on 1/12/11 of the smoke damper report dated 12/20/09 revealed that corrective action is required for 12 of 26 smoke dampers, as follows:
--9 failed smoke dampers had damper blades that did not close upon activation of the fire alarm system (SD-P3-1, 7, 8, 13 and 14; SD-SPD-7, 9, 11, 12);
--2 failed smoke dampers did not have access panels (SD-SPD-4 and 5);
--1 failed smoke damper did not have an actuator present to allow the smoke damper to open and close properly with the activation of the fire alarm system (SD-P3-5).

This finding was verified with Staff #7 on 1/12/11.


Based on document review and interview, the facility does not ensure that 75 of 75 visual/audio-visual (V/AV) devices and the magnetic hold open devices that comprise the fire alarm system are inspected annually.

Findings include:

Review on 1/11/11 of the fire alarm inspection report did not reveal evidence that the 75 V/AV devices were tested during the 10/13/10 fire alarm inspection. The report indicated that the devices were "not tested per customer request". All notification devices must be tested upon installation and at intervals not to exceed one year.

Review on 1/11/11 of the fire alarm inspection report also did not reveal evidence that the magnetic hold open devices were tested during the 10/13/10 fire alarm inspection. The activation of the fire alarm system must initiate the closing of all doors throughout the facility.

These findings were verified with Staff #43 on 1/11/11.


Based on document review, the facility does not ensure that V/AV devices are present in occupied areas of the facility.

Findings include:

Review on 1/11/11 of the fire alarm inspection report dated 10/13/10 did not reveal evidence that V/AV devices were present on the ground floor. V/AV devices must be provided in all occupied areas of the facility. These devices must be located, mounted and tested in accordance with NFPA 72, 1999 edition.


Based on document review, the facility does not ensure that 25 of 25 fixed temperature heat detectors (St. Joseph's Medical Center) and 1 of 1 fixed temperature heat detectors (EMAC Building) are tested every five years.

Findings include:

Review on 1/11/11 of the fire alarm inspection report did not reveal evidence that fixed temperature heat detectors were tested annually during the 10/13/10 fire alarm inspection. The report indicated that a visual inspection only was performed on the 25 fixed temperature heat detectors in the St. Joseph's Medical Center, and the one such device in the EMAC Building. A minimum of two fixed temperature heat detectors must be tested on each initiating circuit annually. Different detectors must be tested each year so that within five years, all fixed temperature heat detectors have been tested.

Based on document review and interview, the facility does not ensure that the deficiencies identified in 4 of 4 sprinkler inspection reports were corrected. (Reports dated 1/15/10, 4/27/10, 7/30/10 and 10/10/10)

Findings include:

Review on 1/12/11 of the sprinkler inspection reports dated 1/15/10, 4/27/10, 7/30/10 and 10/10/10 did not reveal evidence that corrective action had been performed on the sprinkler system during 2010. Each of the reports indicated that supplies in the 6th floor accounting office and x-ray records stored in the basement were located less than 18 inches from the ceiling.

This finding was verified with Staff #7 on 1/12/11.


Based on document review and interview, the facility does not ensure that the deficiencies identified in 5 of 5 sprinkler inspection reports were corrected. (HSB extension clinic reports dated 1/13/10, 4/27/10, 7/30/10, 10/20/10 and 1/07/11)

Findings include:

Review on 1/12/11 of the HSB extension clinic sprinkler inspection reports did not reveal evidence that corrective action had been performed on the sprinkler system during 2010 and 2011. The reports indicated the following:
---Inspection reports dated 1/13/10, 4/27/10 and 7/30/10 indicated that the sprinkler piping in the basement was corroded;
---Inspection reports dated 10/20/10 and 1/7/11 indicated that the sprinkler piping in the basement was corroded and the sprinkler heads and the piping in the R.O. dialysis system were corroded.

This finding was verified with Staff #7 on 1/12/11.

Based on observation and interview, the facility does not ensure that adequate ventilation is provided in the endoscopy scope processing room, endoscopy scope storage area, 2 of 2 endoscopy treatment rooms, 2 of 2 operating rooms (3 and 4), soiled utility room (3C), patient toilet room (3C), 6 of 6 exam rooms (Southport Internal Medicine site), endoscopy clean supply room, endoscopy pre-admission patient toilet room and the janitor's closet adjacent to endoscopy area.

Findings include:

During facility tours from 1/10/11 through 1/14/11, it was observed that the ventilation was inadequate in the following areas:
---In the endoscopy scope processing room, it was observed that supply and exhaust were not provided in this room. Upon arrival to this area, it was observed that the door entering this room from the corridor and the doors into the treatment rooms from the scope processing room were not closed and did not have self closing devices present;
---In the room utilized for clean scope storage and in the endoscopy clean supply room, supply air was not provided to ensure that the room maintained positive pressure;
---In the 2 endoscopy treatment rooms, air supply or return air were not provided to ensure that the rooms maintained a minimum of six air changes per hour;
---In operating rooms 3 and 4, laminar air flow was not provided. The 2 exhaust vents at floor level in each room were not operational;
---In the soiled utility room on 3C, the patient toilet room on 3C, the endoscopy pre-admission patient toilet room and the janitor's closet adjacent to endoscopy area, the exhaust fans were not operational; and
---In the 6 exam rooms at the Southport Internal Medicine site, ventilation was not provided to ensure that the rooms maintained a minimum of six air changes per hour.

These findings were verified with Staff #7 on 1/12/11.

Based on observation and interview, the facility does not ensure that the medical air piping distribution system is utilized for patient care only.

Findings include:

While observing endoscope processing on 1/11/11, it was noted that Staff #28 utilized piped medical air to blow down the processed scopes in the final phase of processing. Piped medical air must not be utilized for cleaning or blowing down scopes, either before or after the processing phase.

During interview on 1/11/11, Staff #28 and 32 indicated that they were not aware that the piped medical air could not be utilized for this activity.

Based on observation and interview, the facility does not ensure that 2 of 2 medical gas shutoff valves are located outside of the anesthetizing locations.

Findings include:

During facility tour on 1/12/11, it was observed that the medical gas shutoff valves were located within the anesthetizing (operating rooms) locations. These medical gases consisted of oxygen, medical air, nitrous oxide, nitrogen and vacuum. If the shutoff valves remain within the anesthetizing locations, additional shutoff valves must be located near the operating room door that leads to the central core. The additional shutoff valves must allow staff outside of the anesthetizing location the ability to shut off the gas supplied to the room in the event of an emergency.

This finding was verified with Staff #42 on 1/12/11.

Based on document review and interview, the facility does not ensure that 2 of 2 disaster drills are performed annually at the Southport Internal Medicine site.

Findings include:

Review on 1/13/11 of the documentation provided at Southport Internal Medicine site did not reveal evidence that disaster drills had been performed. During interview, Staff #49 and 50 revealed that they could not recall when a disaster drill had been performed. When questioned what they would do in the event of an emergency or a disaster, they were both unsure as to what they would do in a disaster situation.

Based on observation, interview and document review, the facility does not ensure that the endoscopy processing room and the ER overflow area each have an emergency eye wash station.

Findings include:

During facility tour on 1/11/11, it was observed that the facility utilizes 2.6% glutaraldehyde for high level disinfection of the endoscopes in the endoscopy processing room. However, the processing room did not have an emergency eye wash station, although one was noted to be located in treatment room #1. An eye wash station must be immediately available and cannot be blocked by any obstruction, such as a door. This finding was verified by Staff #28 and 32 on 1/11/11.

Review on 1/11/11 of the Eye Wash Station Inspection Compliance Log revealed that the eyewash station in the overflow area of the emergency room was located in the employee toiletroom. An eye station must be immediately available and cannot be blocked by any obstruction, such as a door. This finding was verified by Staff #43 on 1/11/11.


Based on policy and procedcure review, document review and interview, the facility does not ensure that 25 of 40 eye wash stations are tested weekly. (GEW2, GEW4, GEW9, 1EW4, 1EW9, 1EW5, 1EW11, 1EW6, 1EW7 ,1EW10, 1EW8, 1EW12, 2EW2, 2EW4, 2EW5, 2EW7, 2EW8, 2EW9, 3EW2, 3EW3, 5EW2, 5EW1, EC-EW1, BEW1, EM3EW1)

Findings include:

Review on 1/11/11 of policy #FE 2.9.1 "Eyewash Station & Emergency Showers - Inspection & Testing" (effective 7/1/10) revealed that emergency eyewash stations must be inspected and tested weekly.

Review on 1/11/11 of eye wash testing reports for 8/1/10 through 12/30/10 revealed that the eye wash stations have not been not tested weekly, as follows:
--Eyewash stations GEW2 and GEW9 were not tested the weeks of 8/1/10, 8/10/10, 9/5/10, 10/10/10, 10/24/10, 10/31/10, 11/14/10, 1121/10, 1128/10, 12/5/10, 12/12/10, 12/19/10 and 12/26/10;
--Eyewash stations 1EW4, 1EW9, 1EW5, 1EW11, 1EW6, 1EW7, 1EW10 and GEW4 were possibly not tested (illegible) the week of 11/10/10;
--Eyewash stations 1EW8 and 2EW8 were not tested during the month of 12/10;
--Eyewash station 1EW12 was not tested the weeks of 8/10/10, 9/10/10 and 12/10/10;
--Eyewash station 2EW7 was not tested the weeks of 12/12/10, 12/19/10 and 12/26/10;
--Eyewash station 2EW9 was not tested during the months of 8/10, 9/10 and 10/10;
--Eyewash station 3EW3 was not tested during the months of 8/10, 9/10, 10/10 and 11/10;
--Eyewash station 5EW1 was not tested during the months of 9/10, 10/10, 11/10 and 12/10;
--Eyewash station 5EW2 was not tested the weeks of 8/1/10, 9/19/10, 9/26/10, 10/3/10, 10/10/10, 11/7/10, 11/21/10, 11/28/10, 12/5/10, 12/12/10, 12/19/10 and 12/26/10;
--Eyewash stations 2EW2, 2EW4, 2EW5, 3EW2, EC-EW1, BEW1 and EM3EW1 were not tested.
These findings were verified with Staff #43 on 1/11/11.

Based on document review, the facility does not ensure that 3 of 12 vacuum alarms are transmitted to the AFP-200 alarm panel. (D2 and D3 nurse's stations and GI Lab)

Findings include:

Review on 1/13/11 of the Annual Alarm Test Report for the medical gas system revealed that three vacuum alarms, at the D2 and D3 nurse's stations and GI Lab, were not transmitted and received at the AFP-200 Alarm Panel during the 10/13/10 inspection. With these visual/audible signals not being received at the alarm panel, signals are not transmitted to the master alarm that is monitored in two separate locations, and facility staff would not be aware that problems have been encountered with the vacuum system.

Based on observation and interview, the facility does not ensure that adequate electrical protection is provided in the endoscopy processing room.

Findings include:

During facility tour on 1/11/11, it was observed that the facility did not provide electrical protection for the automatic scope processing unit, Custom Ultrasonics - System 83 Plus 9, as a ground fault circuit interrupter was not provided for this electrical outlet.

This finding was verified with Staff #32 on 1/11/11.

Based on document review and interview, the facility does not ensure that corrective action was performed for the deficiencies that were identified during 2 of 2 elevator inspections. (11/09 and 6/10)

Findings include:

Review on 1/12/11 of elevator inspection reports indicated that deficiencies had been identified during the 11/09 and 6/10 elevator inspections, as follows:
--For elevators #1-4: a pit light and GFCI duplex receptacle with a switch accessible from the access entrance must be installed;
--For elevators #1-6: pit ladders must be installed; and
--For elevator #11:
----a cover is required that is level, non-combustible, and secured to the pit floor sump crock,
----water and oil shall not be allowed to collect in the pit,
----the car light must operate, and
----the alarm bell must operate.
Documentation was not provided to verify that these identified deficiencies had been corrected.

These findings were verified with Staff #7 on 1/12/11.