HospitalInspections.org

1. Based on observation and interview the facility failed to properly maintain 2-hour fire rated common walls on one of four floors in this component.

Findings include:

a. Observation of the 2-hour fire rated common wall, located between mechanical room number 1 and the commercial laundry at 12:26 PM, on March 23, 2010, revealed the fire rated door had been held open by an unauthorized cord tied to the door handle.

Interview with maintenance representative #1 at 12:27 PM, on March 23, 2010, confirmed this condition.

1. Based on observation and interview the facility failed to properly configure vertical enclosures on two of four floors in this component.

Findings include:

Observation of fire rated vertical enclosures between 10:42 AM and 12:19 PM, on March 23, 2010, revealed the following deficiencies:

a. 10:42 AM - Second floor landing, East exit stair tower, unprotected horizontal penetration between two HVAC ducts located above the suspended ceiling.

b. 11:05 AM - First floor, protected passageway adjacent to the lab, walls in the proposed lobby expansion area have only one side sheathed with drywall and do not provide the required fire resistance rating.

c. 12:19 PM - First floor, mechanical chase to the right of the "C" elevator, had two unprotected horizontal penetrations.

Interview with maintenance representative #1 at 12:20 PM, on March 23, 2010, confirmed this condition.

1. Based on observation and interview the facility failed to properly maintain hazardous areas on two of four floors in this component.

Findings include:

Observation of hazardous areas between 10:21 AM and 12:42 PM, on March 23, 2010, revealed the following deficiencies:

a. 10:21 AM - Second floor, ICU soiled utility room, a hazardous area utilized to store trash, had an unprotected 1 inch diameter hole in the corridor door.

b. 12:42 PM - Ground floor, construction storage room, a hazardous area utilized to store various combustible construction materials, had a 6 inch by 12 inch open transfer grill to the bathroom.

Interview with maintenance representative #1 at 12:43 PM, on March 23, 2010, confirmed this condition.

1. Based on observation and interview it was determined the facility failed to properly maintain one exit corridor on one of four floors in this component.

Findings include:

a. Observation of the service corridor adjacent to the morgue at 12:47 PM, on March 23, 2010, revealed numerous lockers and a clothing rack, placed along each side of the corridor, were reducing the corridor width by three feet.

Interview with maintenance representative #1 at 12:48 PM, on March 23, 2010, confirmed this condition.

1. Based on documentation review and interview the facility failed to properly document two of twelve fire drills during the past year.

Findings include:

Review of fire drill documentation between 08:20 AM and 08:25 AM, on March 23, 2010, revealed the following deficiencies:

a. 8:20 AM - First quarter 2009, third shift fire drill report did not document the time the fire drill was conducted.

b. 8:25 AM - Fourth quarter 2009, third shift fire drill report did not document the time the fire drill was conducted.

Interview with maintenance representative #1 at 08:26 AM, on March 23, 2010, confirmed this condition.

1. Based on observation and interview the facility failed to properly maintain one heating cooling and ventilation (HVAC) duct on one of four floors in this component.

Findings include:

a. Observation of the HVAC duct located within the Second floor landing, East exit stair tower, at 10:45 AM, on March 23, 2010, revealed an unsecured fire damper inspection access panel within the stair tower.

Interview with maintenance representative #1 at 10:46 AM, on March 23, 2010, confirmed this condition.

1. Based on documentation review and interview the facility failed to properly maintain the dietary exhaust hood fire suppression system during the second half of the past year.

Findings include:

a. Review of dietary exhaust hood fire suppression system inspection and testing documentation at 8:30 AM, on March 23, 2010, revealed the facility did not have documentation available to support conducting the required semi-annual testing and inspection during the second half of 2009.

Interview with maintenance representative #1 at 8:31 AM, on March 23, 2010, confirmed this condition.

1. Based on observation and interview the facility failed to properly maintain the soiled linen chute on one of four floors in this component.

Findings include:

a. Observation of the second floor soiled linen chute access door, located in the exit corridor, at 10:22 AM, on March 23, 2010, revealed the door was unlocked.

Interview with maintenance representative #1 at 10:23 AM, on March 23, 2010, confirmed this condition.

1. Based on documentation review and interview the facility failed to properly test installed battery powered emergency lights during the past year.

Findings include:

a. Review of emergency lighting test documentation at 8:35 AM, on March 23, 2010, revealed the facility did not have documentation to support conducting the required annual 90 minute operational test during the past year.

Interview with maintenance representative #1 at 8:36 AM, on March 23, 2010, confirmed this condition.