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WAYNE MEMORIAL HOSPITAL
Vertical Openings - Enclosure
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to maintain one vertical opening, affecting five of five floors.
Findings include:
1. Observation on October 28, 2019, at 11:03 a.m., revealed the attic-level elevator machine room door required adjustment to fully latch within the corresponding door frame assembly.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the vertical opening deficiency.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of five floors.
Findings include:
1. Observation on October 28, 2019, at 9:37 a.m., revealed the basement-level O.R. supply room door lacked smoke-tight integrity.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the hazardous area enclosure deficiency.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting two of five floors.
Findings include:
1. Observation on October 28, 2019, between 9:55 a.m. and 11:22 a.m., revealed the following:
a. 9:55 a.m., a ceiling tile was lacking within the basement-level electrical room.
b. 11:22 a.m., an escutcheon plate was lacking within the third floor, south nurse's station.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the automatic sprinkler system deficiencies.
Corridor - Doors
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of five floors.
Findings include:
1. Observation on October 28, 2019, between 11:20 a.m. and 11:33 a.m., revealed the following doors lacked smoke-tight integrity:
a. 11:20 a.m., fourth floor Nourishment Room.
b. 11:33 a.m., third floor Patient Room 308.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the corridor opening deficiencies.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0374
Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of five floors.
Findings include:
1. Observation on October 28, 2019, at 11:44 a.m., revealed the first floor ER smoke barrier separation doors exhibited a gap greater than 1/8 inch.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the smoke barrier separation door deficiency.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0374
Based on observation and interview, it was determined the facility failed to maintain two sets of smoke barrier separation doors, affecting two of six floors.
Findings include:
1. Observation on October 29, 2019, between 9:00 a.m. and 9:30 a.m., revealed the third and fourth floor smoke barrier separation doors lacked astragals.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the smoke barrier separation door deficiencies.
Gas and Vacuum Piped Systems - Maintenance Pr
Tag No.: K0907
Based on observation and interview, it was determined the facility failed to maintain the medical gas systems in one location, affecting one of five floors.
Findings include:
1. Observation on October 28, 2019, at 10:12 a.m., revealed the medical air piping within the basement-level boiler room came in contact with a dissimilar metal in one location.
Exit interview with the facilities manager on October 29, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the medical gas piping deficiency.