HospitalInspections.org

MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of three shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 11:06 AM revealed the incomplete shaft around the linen chute, in second floor room 246, was not existent.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:06 AM confirmed the chute was not enclosed.

3. Observation on July 25, 2012, at 11:07 AM revealed the pipe chase shaft, in second floor room 247, was not complete around ductwork.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:07 AM confirmed the wall was not complete.

4. Observation and interview on July 25, 2012, at 11:08 AM revealed the doors to the pipe chase within the facility, lacked self closing hardware and were equipped only with a deadbolt.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 confirmed the doors did not automatically close and latch.

**Note: Interview with Facility Maintenance Manager III during the revisit survey performed on January 30, 2013, between 11:10 AM and 11:40 AM confirmed that items 2, 3 and 4 were not corrected.**

MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of two shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 9:21 AM revealed three penetrations to the linen shaft, inside second floor room 287.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:21 AM confirmed the unsealed penetrations.

**Note: Interview with Facility Maintenance Manager III during the revisit survey performed on January 30, 2013, at 10:15 AM confirmed that item 2 was not corrected.**

MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 1:23 PM revealed the double doors by room 196, on the first floor, lacked a coordinator.

Interview with the Institution Safety Manager on July 25, 2012, at 1:23 PM confirmed the doors required a coordinator, to properly close in the frame.

**Note: Interview with Facility Maintenance Manager III during the revisit survey performed on January 30, 2013, at 10:00 AM confirmed that item 1 was not corrected.**