HospitalInspections.org

Based on observation and confirmed by interview, the facility failed to assure that corridor walls form a barrier to limit smoke from escaping as required by 18.3.6.1, 18.3.6.2

Per observation during the tour on 6/23/2010, it was observed that the Mailbox System on Level "A" allows the passage of smoke from a storage area to the corridor, fully sprinklered exitways must be smoke tight. This was confirmed by the Head of Engineering.

Based on observation and confirmed by interview, the facility failed to assure that all means of egress are free of all obstructions or impediments as required by 7.1.10.

Per observation on the tour of 6/23/10, there was storage at the base of stairway 4 and in the rear O.R. stairways. this was confirmed by the Head of Engineering.

Based on observation and confirmed by interview, the facility failed to assure monthly load testing as required by NFPA 110, 3.4.4.1

Per record review on the tour of 6/23/10, there were no monthly load tests done on the generator for January, February, March and April of 2010. This was confirmed by the Head of Engineering.

Based on observation and confirmed by interview, the facility failed to assure that corridor walls form a barrier to limit smoke from escaping as required by 18.3.6.1, 18.3.6.2

Per observation during the tour on 6/23/2010, it was observed that the Mailbox System on Level "A" allows the passage of smoke from a storage area to the corridor, fully sprinklered exitways must be smoke tight. This was confirmed by the Head of Engineering.

Based on observation and confirmed by interview, the facility failed to assure that all means of egress are free of all obstructions or impediments as required by 7.1.10.

Per observation on the tour of 6/23/10, there was storage at the base of stairway 4 and in the rear O.R. stairways. this was confirmed by the Head of Engineering.

Based on observation and confirmed by interview, the facility failed to assure monthly load testing as required by NFPA 110, 3.4.4.1

Per record review on the tour of 6/23/10, there were no monthly load tests done on the generator for January, February, March and April of 2010. This was confirmed by the Head of Engineering.