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. Completed 12/31/12

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. Completed 03/12/2013

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, on second floor room 247, was not complete around ductwork. Deficiency was not corrected 03/12/2013

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. Deficiency was not corrected 03/12/2013

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 AM 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.**

**Observation made during a revisit survey on March 12, 2013, revealed that only a metal grate separated the 3nd floor from the 2nd floor, in room 247. This was confirmed by the Chief Executive Officer during the exit interview.