HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Director of Quality/Compliance/Safety, Director of Facilities, and Lead Facilities Tech it was observed that the facility failed to provide the following requirements:

A. AHU-1 serves the Surgical Suite with Operating Rooms where inhaled anesthesia is used. There is an existing Smoke Evacuation System, but the required Duct Detector for the fresh air intake damper on this air handling unit was missing.

B. The FIRE ALARM CONTROL PANEL, (2) BOOSTER PANELS had the required two batteries (for back-up power) in each panel location, but the POWER SUPPLY/CHARGER PANEL was missing the two required back-up batteries.

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Director of Quality/Compliance/Safety, Director of Facilities, and Lead Facilities Tech it was observed that the facility was not in compliance regarding the following:
There are two separate buildings which do not have the same owner.
The (3-story building) free-standing hospital was connected by a (single-story) " L " shaped connecting corridor link to a separate (multiple-story) free-standing non-Hospital building which has a separate owner from the Hospital. The required 2 hour fire separation between the Hospital building and the non-hospital building was missing. At the time of the survey, it was not determined whether the " L " shaped connecting corridor link was part of the licensed hospital. The answer to the ownership question regarding the " L " shaped connector will determine at which end of the connecting corridor link the 2 hour fire-rated separation wall is to be located.

Based on observations made during the survey of the facility between the hours of 9:00 am and 1:00 pm, while accompanied by the Director of Quality/Compliance/Safety, Director of Facilities, and Lead Facilities Tech it was observed that the facility was not in compliance with the following:

The " L " shaped connecting corridor link between the Hospital building and the non-hospital building had a partial height wall constructed across the full width of the corridor. Occupants walking from the Hospital building attempting to proceed towards the non-hospital building were blocked from entering the non-hospital building, and vice-versa. This partial height wall in effect has created a dead-end corridor. This is not acceptable. The wall shall be removed immediately.