HospitalInspections.org

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the clear swing path for doors leading to corridors as required in Section 19.3.6.3 of the 2000 edition of the Life Safety Code, NFPA 101.

The Oncology Storage Room door on the First Floor did not have a clear wing path, preventing the door from fully opening.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the following hazardous areas did not conform to the requirements contained in Section 19.3.2.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Gap/hole in wall of 2nd floor Custodial Closet next to Patholgy, which violates the smoke-seal integrity of the room.

A walk-through with the Maintenance Director,February 26, 2015, determined by observation that the facility failed to maintain exit access in accordance with Section 7.2.1.6.1(d) of the 2000 edition of the Life Safety Code, NFPA 101.

The exit door for the NE Stairwell did not have signage indicating the use of delayed egress.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the fire drill records in accordance with Section 19.7.1.2 in the 2000 edition of the Life Safety Code, NFPA 101.

The fire drill records did not indicate the time nor shift in which the drill was performed.

Section 19.7.1.2 of the Life Safety Code requires drills to be conducted quarterly on each shift.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the required smoke detectors in accordance with Section 9.6.1.4 of the 2000 edition of the Life Safety Code, NFPA 101.

Smoke detector not secured to ceiling/loose in IT Closet on 2nd Floor.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the automatic fire sprinkler system had not been maintained in accordance with Section 4.6.12.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The fire sprinkler located in the IT Closet on the second floor is spaced too far below the ceiling.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that storage of an oxygen cylinder did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found unsecured in the OR Storage Room on the Second Floor.

According to NFPA 99 medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the electrical equipment was not in comformance with NFPA 70 in accordance with 9.1.2 of the 2000 edition of the Life Safety Code, NFPA 101.

An outlet box in the basement of the original building was missing coverplate.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the clear swing path for doors leading to corridors as required in Section 19.3.6.3 of the 2000 edition of the Life Safety Code, NFPA 101.

The Oncology Storage Room door on the First Floor did not have a clear wing path, preventing the door from fully opening.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the following hazardous areas did not conform to the requirements contained in Section 19.3.2.1 of the 2000 edition of the Life Safety Code, NFPA 101.

Gap/hole in wall of 2nd floor Custodial Closet next to Patholgy, which violates the smoke-seal integrity of the room.

A walk-through with the Maintenance Director,February 26, 2015, determined by observation that the facility failed to maintain exit access in accordance with Section 7.2.1.6.1(d) of the 2000 edition of the Life Safety Code, NFPA 101.

The exit door for the NE Stairwell did not have signage indicating the use of delayed egress.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the fire drill records in accordance with Section 19.7.1.2 in the 2000 edition of the Life Safety Code, NFPA 101.

The fire drill records did not indicate the time nor shift in which the drill was performed.

Section 19.7.1.2 of the Life Safety Code requires drills to be conducted quarterly on each shift.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the facility failed to maintain the required smoke detectors in accordance with Section 9.6.1.4 of the 2000 edition of the Life Safety Code, NFPA 101.

Smoke detector not secured to ceiling/loose in IT Closet on 2nd Floor.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the automatic fire sprinkler system had not been maintained in accordance with Section 4.6.12.1 of the 2000 edition of the Life Safety Code, NFPA 101.

The fire sprinkler located in the IT Closet on the second floor is spaced too far below the ceiling.

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that storage of an oxygen cylinder did not comply with the requirements of the 1999 edition of NFPA 99, Standard for Health Care Facilities.

An oxygen cylinder was found unsecured in the OR Storage Room on the Second Floor.

According to NFPA 99 medical gas storage shall be protected. NFPA 99, Section 4-3.1.1.2 (a) 3 states, "Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation."

A walk-through with the Maintenance Director, February 26, 2015, determined by observation that the electrical equipment was not in comformance with NFPA 70 in accordance with 9.1.2 of the 2000 edition of the Life Safety Code, NFPA 101.

An outlet box in the basement of the original building was missing coverplate.