HospitalInspections.org

Per observation on 8/22/2019, the facility failed to ensure that all means of egress are continuously maintained free of all obstructions. The findings include the following:

1. Per observation on 8/22/2019, and accompanied by the Facilities Director, second floor inspection revealed that trash & soiled linen containers are stored in teh protected corridor next to the OR rooms.

2. Per observation on 8/22/2019, and accompanied by the Facilities Director, second floor inspection revealed that a linen cart was blocking the far alarm pull station next to the exit door.

Per observation on 8/22/2019, facility failed to ensure that all horizontal exits are being used in accordance to regulatory requirements. The findings include the following:

Per observation on 8/22/2019, and accompanied by the Facilities Director, third floor inspection revealed that waiting room & corridor were renovated to new office space, exit sign shall be removed. (Nursing Director Office)

Per observation on 8/22/2019, facility failed to ensure storage rooms sprinklers were free of obstructions. The findings include the following:

Per observation on 8/22/2019, and accompanied by the Facilities Director, inspection revealed that storage rooms on the first, second and third floors have obstructions to sprinkler discharge pattern. NFPA 13 Figure A.8.5.5.1 Obstructions to Sprinkler Discharge Pattern Development for Standard Upright or Pendent Spray Sprinklers. Storage within 18 inches of the sprinkler head will reduce the distribution of the water and hinder the effectiveness of the automatic sprinkler system to control and contain fire.

Per observation on 8/22/2019, facility failed to ensure that vertical openings are enclosed with construction have a fire-resistant rating of at least 1 hour. The findings include the following:

Per observation on 8/22/2019. and accompanied by the Facilities Director, third floor inspection revealed that the fire doors have penetrations that are not properly fire stopped above the ceilings in the smoke barrier walls.

Per observation on 8/22/2019 the facility failed to ensure that corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. The findings include the following:

1. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor corridor inspection revealed that there are penetrations above the corridor smoke barrier door walls above the ceiling that are not properly fire stopped.

2. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that there is an acoustical ceiling tile missing in the ceiling in the IT room.

3. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that there is an acoustical ceiling tile missing in the ceiling in the housekeeping closet.

4. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor medical gas storage room inspection revealed that there are penetrations on the outside wall that are not properly fire stopped.

Per observation on 8/22/2019, the facility failed to ensure that doors close and latch according to regulatory requirements. The findings include the following:

1. Per observation on 8/22/2019, and accompanied by the Facilities Director, inspection of the first-floor lobby cafeteria revealed that the doors to the kitchen would not close as designed due to an impediment at the bottom of the door. A doorstop was being used to keep the doors in the open position.

2. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that the door leading to and from the kitchen did not latch when closed.

3. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that the door leading to and from the pharmacy did not latch when closed.

4. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that the fire doors located next to the elevator lobby did not close and latch.

5. Per observation on 8/22/2019, and accompanied by the Facilities Director, first floor inspection revealed that the red suite fire doors did not close and latch.

Per observation on 8/22/2019, facility failed to ensure that all regulatory requirements in NFPA 99 Chapter 6 Electrical Systems are being met. Findings include the following:

Per observation on 8/22/2019, and accompanied by the Facilities Director, second floor inspection revealed that next to the OR room a storage cart was blocking an electrical panel.

Per observation on 8/22/2019, the facility failed to ensure storage and use of liquid oxygen are in compliance with regulatory requirements. Findings include the following:

Per observation on 8/22/2019, and accompanied by the Facilities Director, second floor inspection revealed full and empty oxygen containers stored in the protected corridor next to the exit door.