HospitalInspections.org

Based on observations and staff interview, the facility did not ensure that the two-hour fire resistance rated common barrier walls were maintained.

The findings include:

1) On the afternoon of 3/26/2014 observation on the 6th floor common barrier wall revealed that an unknown spray foam sealant was used to seal the various penetrations passing through the wall. Concurrent interview with staff # ? revealed that the facility did not have any verification that this foam was an approved fire sealant.

2) On the afternoon of 3/26/2014 observation on the 5th. floor common barrier wall revealed that the outside edges of a square sheetrock patch on the brick barrier wall was not sealed with a UL listed fire stopping sealant.

The above findings were concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that the ½-hour fire resistance rated existing smoke barrier walls were maintained.


The findings include:

1) On the afternoon of 3/26/2014 observation of the smoke barrier walls within the 6th. and 7th. floor revealed that an unknown spray foam sealant was used to seal the various penetrations passing through the wall. This unknown spray was partially covered by approved fire stopping materials around some of the wall penetrations. Concurrent interview with staff #1 revealed that the facility did not have any verification that this foam was an approved fire sealant.

2) On the afternoon of 3/26/2014 observation of the smoke barrier walls within the 5th. floor revealed that there was an unsealed datawire penetration.

The above findings were concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that their hazardous areas smoke tiight walls were maintained.

The finding was:

On 3/24/2014 at 2:05 PM observation in the Emergency Department revealed that within the Soiled Utility Room there was an unsealed penetration.

The above finding was concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that portable space heating devices were prohibited from the hospital.

The finding was:

On 3/24/14 at 11:30 AM observation in the Labor and Delivery On-Call Room revealed that a portable space heater was found next to a bed.

The above finding was concurrently verified by Staff #1.

Based on observation and staff interview the facility's means of egress was not continuously maintained free of obstruction or impediment in case of an emergency.

The finding was:

On 3/24/14 at 2:10 PM observation in the Emergency Department revealed that an Emergency Exit access door was blocked by a wheelchair, 2 IV poles and an IV cart.

The above finding was concurrently verified by Staff #1.

Based on observation and staff interview the facility did not have a Type 1 Essential Electrical System that was divided into the critical branch, the life saferty branch and the emergency system.

The finding was:

On the afternoon of 3/26/2014, while touring the facility, observation of the facility's electrical panels revealed that there essential electrical system (EES) had two branches - a critical branch, and a normal branch.

Concurrent interview with Staff #1 revealed that the hospital's EES was installed before the requirements required three separate branches. Staff #1 also stated that because there has been no major modification projects, the facility was not required to comply/upgrade their EES system to current NFPA 99 standards.

Based on observations and staff interview, the facility did not ensure that the two-hour fire resistance rated common barrier walls were maintained.

The findings include:

1) On the afternoon of 3/26/2014 observation on the 6th floor common barrier wall revealed that an unknown spray foam sealant was used to seal the various penetrations passing through the wall. Concurrent interview with staff # ? revealed that the facility did not have any verification that this foam was an approved fire sealant.

2) On the afternoon of 3/26/2014 observation on the 5th. floor common barrier wall revealed that the outside edges of a square sheetrock patch on the brick barrier wall was not sealed with a UL listed fire stopping sealant.

The above findings were concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that the ½-hour fire resistance rated existing smoke barrier walls were maintained.


The findings include:

1) On the afternoon of 3/26/2014 observation of the smoke barrier walls within the 6th. and 7th. floor revealed that an unknown spray foam sealant was used to seal the various penetrations passing through the wall. This unknown spray was partially covered by approved fire stopping materials around some of the wall penetrations. Concurrent interview with staff #1 revealed that the facility did not have any verification that this foam was an approved fire sealant.

2) On the afternoon of 3/26/2014 observation of the smoke barrier walls within the 5th. floor revealed that there was an unsealed datawire penetration.

The above findings were concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that their hazardous areas smoke tiight walls were maintained.

The finding was:

On 3/24/2014 at 2:05 PM observation in the Emergency Department revealed that within the Soiled Utility Room there was an unsealed penetration.

The above finding was concurrently verified by Staff #1.

Based on observations and staff interview, the facility did not ensure that portable space heating devices were prohibited from the hospital.

The finding was:

On 3/24/14 at 11:30 AM observation in the Labor and Delivery On-Call Room revealed that a portable space heater was found next to a bed.

The above finding was concurrently verified by Staff #1.

Based on observation and staff interview the facility's means of egress was not continuously maintained free of obstruction or impediment in case of an emergency.

The finding was:

On 3/24/14 at 2:10 PM observation in the Emergency Department revealed that an Emergency Exit access door was blocked by a wheelchair, 2 IV poles and an IV cart.

The above finding was concurrently verified by Staff #1.

Based on observation and staff interview the facility did not have a Type 1 Essential Electrical System that was divided into the critical branch, the life saferty branch and the emergency system.

The finding was:

On the afternoon of 3/26/2014, while touring the facility, observation of the facility's electrical panels revealed that there essential electrical system (EES) had two branches - a critical branch, and a normal branch.

Concurrent interview with Staff #1 revealed that the hospital's EES was installed before the requirements required three separate branches. Staff #1 also stated that because there has been no major modification projects, the facility was not required to comply/upgrade their EES system to current NFPA 99 standards.