HospitalInspections.org

K200 Means of Egress Requirements - Other
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform inspection of doors in means of egress annually from 2020 to 2023.

K374 Subdivision of Building Spaces - Smoke Barrier Doors
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Observed during tour, there were various of instances of damaged astragal at cross-corridor fire-rated doors.

K712 Fire Drills
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Based on review of the records, there were no fire drill logs corresponding to the period from July to December of 2022. In the second half of 2020, drills held around 2pm and 3pm were frequently selected. Note, fire drills are held at unexpected times under varying conditions that integrate "simulation of emergency fire conditions." Additionally, per NFPA 101 (2012), "drills should consider the ability to move patients to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs."

K901 Fundamentals - Building System Categories
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Based on review of the records, facility failed to include a hazard vulnerability assessment during its annual risk assessment for 2021 to 2022. As noted in the hazard vulnerability analysis (HVA), "the HVA tool is a living document. As they occur throughout the calendar year, incidents that align with the "Alert Type" on the HVA should be cataloged."

K906 Gas and Vacuum Piped Systems - Central Supply System Operations
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Observed during tour, there was no means of mechanical exhaust in the medical gas room. [The Standard] Mechanical Ventilation:
"Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction." - NFPA 99, 2012, 9.3.7.5.3.1
"Mechanical exhaust inlets shall be unobstructed and shall draw air from within 1 foot of the floor and adjacent to the cylinder or containers." - NFPA 99, 2012, 9.3.7.5.3.3

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Maintenance Technician, during the hours of the inspection from 3:30 pm to 7:00 pm on 05/15/2023, that there were the following issues:
1) Observed during tour, there was no red plug powered from the Life Safety branch at the generator location.
2) Based on review of the records, there was no 4-hour load bank at interval not exceeding 36 months ever performed at facility.