HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of 15 smoke compartments.

Findings include:

1. Observation on July 18, 2022, at 10:40 a.m., revealed the self-closing in the 85 east mechanical room, under the X-Ray department, was being held open with an unapproved hold-open device (angel iron).

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the self closing door deficiency.

Based on observation and interview, it was determined the facility failed to maintain stairways in one instance, affecting four of 15 smoke compartments.

Findings include:

1. Observation on July 18, 2022, at 11:10 a.m., revealed several items were being stored between the door to Stair E and the exit door on the second floor.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the stairway enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating between floors in two instance, affecting four of 15 smoke compartments.

Findings include:

1. Observation on July 18, 2022, revealed the following vertical opening enclosure deficiencies in the concrete deck above, in these locations:

a) 10:42 a.m., unsealed drain pipes in the 85 east mechanical room, under the X-Ray department;
b) 11:02 a.m., multiple unsealed pipes in facility supply, under the CT department.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the above listed unsealed vertical opening enclosure penetrations.

Based on documentation review, observation, and interview, it was determined the facility failed to perform the required monthly fire suppression system inspections for three of the last 12 months, affecting one of 15 smoke compartments.

Findings Include:

1. Observation and review of documentation on July 18, 2022, at 10:00 a.m., revealed the facility lacked documentation for monthly kitchen fire suppression system visual inspections for the months of April, May, and June.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the documentation for monthly inspections was not present at the time of the survey.

Based on documentation review and interview, it was determined the facility failed to perform the required biennial smoke detector sensitivity testing over the last 24 months, affecting the entire facility.

Findings Include:

1. Review of documentation on July 18, 2022, at 9:30 a.m., revealed the facility lacked documentation for a biennial smoke detector sensitivity test.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the documentation for sensitivity testing was not present at the time of the survey.

Based on documentation review and interview, it was determined the facility failed to perform the required biennial smoke detector sensitivity testing over the last 24 months, affecting the entire facility

Findings Include:

1. Review of documentation on July 18, 2022, at 9:30 a.m., revealed the facility lacked documentation for a biennial smoke detector sensitivity test.

Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in one instance, affecting one of 15 smoke compartments.

Findings include:

2. Observation on July 18, 2022, at 10:28 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation/operation of the automatic fire alarm system. There was a large hole in the ceiling of the receiving room, on the north side.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the above listed automatic fire alarm system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instance, affecting two of fifteen smoke compartments.

Findings include:

1. Observation on July 18, 2022, revealed the following automatic sprinkler system deficiencies:

a) 9:32 a.m., revealed there was an unsealed penetration in the ceiling above the electrical panel in the IT room on the fourth floor;
b) 9:47 a.m., an above ceiling inspection revealed multiple cables laying on-top of the sprinkler pipe in the corridor, by room 311 on the third floor.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in two instances, affecting four of 15 smoke compartments.

Findings include:

1. Observation on July 18, 2022, revealed the following smoke barrier wall deficiencies:

a) 10:01 a.m., an above ceiling inspection at the smoke barrier doors leading into the MRI corridor, revealed multiple unsealed data wires;
b) 10:15 a.m., an above ceiling inspection at the smoke barrier doors leading into stairwell A on the second floor, revealed multiple unsealed sprinkler pipes;

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m., confirmed the smoke barrier wall deficiencies

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles for two instances affecting two of fifteen smoke compartments.

Findings include:

1. Observation on July 18, 2022, revealed the following electrical outlets within six feet of a sink that where not GFCI protected:

a) 10:19 a.m., in the pathologist office, room 239;
b) 10:56 a.m., in the covid testing office, located in the old wellness center.

Interview with the Maintenance Director on July 18, 2022, at 1:30 p.m.., confirmed the above listed electrical receptacles were not GFCI protected.