HospitalInspections.org

Based upon observations and staff interviews on 3/16/15 during the physical tour of the facility between approximately 1045 and 1230 hours the facility has failed to maintain doors capable of resisting smoke. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
The ER Wing Med Room door to the corridor had a through penetration above the door latching hardware.


The above was discussed and acknowledged by the Maintenance Director he had not previously observed the hole in the door.

Based upon observations and staff interviews on 3/14/16 during the physical tour of the facility between approximately 1045 and 1230 hours the facility has failed to maintain smoke resistant partitions / smoke barriers to the required one half hour / one hour fire resistive rating. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
There was an unsealed penetration above the smoke barrier cross-corridor doors near the North Hall Nurse's Changing room.

The above was discussed and acknowledged by the Maintenance Director who said new IT cable had recently been run through and was unaware the penetrations were not sealed.

Based upon observations and staff interviews on 3/14/16 during the physical tour between approximately 1045 and 1230 hours, the facility has failed to maintain fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1 out of 2 sprinkler heads in the X-Ray room is obstructed by a permanently installed ductless heating unit.

The above was discussed and acknowledged by the Maintenance Director who said he had not previously observed the obstruction, and that the Ductless Heaters were recently installed.

Based upon record review and staff interviews on 3/14/16 during the physical tour of the facility between approximately 1045 and 1230 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility could only provide documentation of having the kitchen hood suppression system serviced/ inspected once in the past 12 months (required every 6 months).

The above was discussed and acknowledged by the Maintenance Director who said they were under contract to have the system serviced twice a year, and was unaware that it had not been done.

Based upon observations and staff interviews on 3/14/16 during the physical tour of the facility between approximately 1045 and 1230 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was an ABHR installed over an electrical outlet in Patient Room #1.

The above was discussed and acknowledged by the Maintenance Director who said he had not noticed the dispensers.