HospitalInspections.org

Based on document review and interview, the facility does not ensure that the fire alarm system is tested annually at the Dundee Family Health Center extension clinic.

Findings include:

Document review on 05/14/2021 at 1:45 PM revealed the fire alarm inspection at Dundee Family Health Center extension clinic, was last completed by a contractor on 09/11/2019.

Interviews with Staff (T), Maintenance Supervisor, and Staff (U), Maintenance Manager, verified the above finding as identified.

Based on observation and interview the facility did not maintain all corridor walls with a minimum ½-hour fire resistance rating.


Findings include:

Observations on 05/12/2021 at 2:10 PM, on the ground floor, outside the janitors' closet, above the drop ceiling, revealed an insulated pipe penetrating the corridor wall without a fire rated system.

Observations on 05/12/2021 at 3:20 PM, on the second floor, outside the nurse station, above the drop ceiling, revealed information technology cables penetrating the corridor wall without a fire rated system.

Interviews with Staff (T), Maintenance Supervisor, and Staff (U), Maintenance Supervisor, verified the findings as identified.

Based on observation and interview, the hospital does not ensure that the corridor doors fully close.


Findings include:

Observations on 05/12/2021 at 2:05 PM, on the ground floor, in the corridor leading to the skilled nursing facility, revealed the right leaf of the fire rated cross corridor doors did not fully close when allowed to swing from the full open position.

Interviews on 05/12/2021 with Staff (T), Maintenance Supervisor, and Staff (U), Maintenance Supervisor, verified this finding as it was identified.

Based on observation and interview, the facility does not ensure that all smoke barrier construction is maintained.


Findings include:

Observations on 05/12/2021 at 3:00 PM on the first floor, above the drop ceiling in front of the main hospital elevator, revealed a vertical wire chase penetrating the underside of floor 2 with the fire stopping pulled away.

Observations on 05/13/2021 at 9:30 AM on the second floor, above the drop ceiling in front of the main hospital elevator, revealed a vertical wire chase penetrating the underside of floor 3 with the fire stopping pulled away.

Interviews with Staff (T), Maintenance Supervisor, and Staff (U), Maintenance Manager, verified the above findings as identified.