HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain doors required to be self or automatic closing on two of five floors.

Findings include:

1. Observation on November 20, 2024, between 9:28 a.m., and 10:21 a.m., revealed the following;

a. At 9:28 a.m., the smoke barrier doors at the 3rd floor maternity entrance failed to close smoke tight.
b. At 10:21 a.m., the double doors into the cardio area on the 1st floor lack a required coordinating device, these doors are part of a horizontal exit.

Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the self closing door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of stair tower doors in one of approximately seven exit stair towers.

Findings include;

1. Observation on November 20, 2024, at 10:00 a.m., revealed the stair tower door in the administration area on the 3rd floor had a gap across the top in excess of required tolerance for a metal door.

Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the gap was in excess of 3/16 of an inch.

Based on observation and interview, it was determined the facility failed to maintian the sprinkler system on two of five floors.

Findings include:

1. Observation on November 20, 2024, between 9:14 a.m., and 10:35 a.m., revealed the following;

a. At 9:14 a.m., on the 3rd floor a sprinkler in the cath lab soiled utility room was missing an escutcheon.
b. At 10:35 a.m., on the 1st floor several sprinklers in the main kitchen area were loaded with what appeared to be dust.

Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the sprinkler deficiencies.

Based on observation and interview, it was determined the facility failed to maintian medical as piping on one of five floors.

Findings include:

1. Observation on November 20, 2024, at 8:51 a.m., revealed various steel components were in contact with the copper medical gas lines in the linen room corridor of the basement.

Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the dissimilar metals in contact with the copper medical gas lines.