HospitalInspections.org

Based on observation and staff interview, the facility does not ensure that the two-hour fire rated barrier separating the surgical suite from the medical unit is maintained.

Findings Include:

Observations on 07/10/24 at 1:40 PM on the second floor, above the drop ceiling over the 90-minute fire rated corridor doors to the surgery department, revealed an open space from the drop ceiling to the floor above spanning the width of the corridor without a two-hour fire rated barrier constructed.

Interview on 07/10/24 at 1:40 PM with Staff (E), Facility Manager, verified this finding.

Based on observation and staff interview, the facility does not ensure that the openings in exit enclosures are limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure per The National Fire Protection Association (NFPA) 101, 7.1.3.2.1(9).

Findings Include:

Observations on 07/10/24 at 1:45 PM in the second-floor stairwell landing by room 216, revealed a 90-minute fire rated door to a heating, ventilation, and air conditioning (HVAC) mechanical closet.

Interview on 07/10/24 at 1:45 PM with Staff (E), Facility Manager, verified that the 90-minute fire rated door to an HVAC closet in the stairwell did not meet the regulation.

Based on observation and staff interview, the facility does not ensure that the horizontal exit is maintained with a minimum of a two-hour fire resistance-rated barrier.

Findings Include:

Observations on 07/10/24 at 1:00 PM on the first floor, above the drop ceiling over the 90-minute fire rated doors near the lobby, revealed information technology cables penetrating the two-hour fire barrier wall without a fire rated system in place.

Interview on 07/10/24 at 1:00 PM with Staff (E), Facility Manager, verified this finding.

Based on observation and staff interview, the facility does not ensure that the suite separation barrier walls are maintained.

Findings Include:

Observations on 07/10/24 at 1:15 PM on the first floor, above the drop ceiling over the 45-minute fire rated doors to the 1988 addition, revealed a penetration along the top of the wall where the drywall meets the ceiling. The joint was not sealed leaving an approximately one-inch gap the width of the corridor without a one-hour fire rated system in place.

Observations on 07/10/24 at 1:30 PM on the second floor, above the drop ceiling over the 45-minute fire rated doors to the critical care unit, revealed information technology cables penetrating the one-hour fire barrier wall without a fire rated system in place.

Observations on 07/10/24 at 1:45 PM on the second floor, above the drop ceiling over the 45-minute fire rated corridor doors to respiratory care, revealed information technology cables penetrating the one-hour fire barrier wall without a fire rated system in place.

Interview on 07/10/24 with Staff (E), Facility Manager, verified these findings as observed.

Based on observation and staff interview, the facility does not ensure that the Line Isolation Monitor (LIM), is tested at intervals of less than or equal to 1 month by actuating the LIM test switch.

Findings include:

Interview on 07/11/24 at 2:00 PM with Staff (E), Facility Manager, revealed that the Line Isolation Monitor identified during the facility tour in the emergency department was not being tested monthly and verified they were unaware of the testing requirement.