HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there issues with the smoke barrier at the following locations:

1) The Rad/Surgery smoke barrier, south corridor wall had a white caulk that may not be a fire caulk.
2) The smoke barrier at the Imaging Entry Door had sleeves that were not sealed.
3) The smoke barrier at the Service Corridor to the Nursing Unit had penetrations that must be sealed.
4) The smoke barrier between the Lobby and the Nursing Unit had sleeves and conduits that were not sealed.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was a missing closer on the door to the Administration File Room.

Based on observation the facility failed to provide adequate clearance for the sprinkler heads.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was storage of items above an 18 inch plane below the sprinkler head shields in the Materials Management Room.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there were the following issues.

A. There was parking with a distance of less than 10 feet from the oxygen yard.
B. The Medical Gas Closet was not fire sealed for a portion of the top of the wall.
C. The door to the Medical Gas Closet did not have the proper signage for nitrous oxide. See below/

The medical gas closet shall have a door labeled with the following re. NFPA 99, 2002: 5.1.3.1.5.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide adequate lighting at the generator

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was not a light on a 90 minute battery backup at the generator.

Based on observation the facility failed to provide an acceptable location for alcohol based hand rub dispensers at some locations.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there were alcohol based hand rub dispensers at less than 6 inches horizontally from electrical switches or receptacles at: 1) ED Triage, and 2) the Lab.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there issues with the smoke barrier at the following locations:

1) The Rad/Surgery smoke barrier, south corridor wall had a white caulk that may not be a fire caulk.
2) The smoke barrier at the Imaging Entry Door had sleeves that were not sealed.
3) The smoke barrier at the Service Corridor to the Nursing Unit had penetrations that must be sealed.
4) The smoke barrier between the Lobby and the Nursing Unit had sleeves and conduits that were not sealed.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was a missing closer on the door to the Administration File Room.

Based on observation the facility failed to provide adequate clearance for the sprinkler heads.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was storage of items above an 18 inch plane below the sprinkler head shields in the Materials Management Room.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there were the following issues.

A. There was parking with a distance of less than 10 feet from the oxygen yard.
B. The Medical Gas Closet was not fire sealed for a portion of the top of the wall.
C. The door to the Medical Gas Closet did not have the proper signage for nitrous oxide. See below/

The medical gas closet shall have a door labeled with the following re. NFPA 99, 2002: 5.1.3.1.5.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide adequate lighting at the generator

The inspector observed, while accompanied by the Corporate Director of Plant Services, the Maintenance Director, the Chief Nursing Officer, and the Maintenance Mechanic during the hours of the inspection from 9:00 am to 1:15 pm on 3/27/2014 that there was not a light on a 90 minute battery backup at the generator.