HospitalInspections.org

While surveying the main hospital facility, the inspector observed in several locations penetrations from the corridor or use spaces into the elevator shaft which had not been sealed with a fire rated material. The majority of the 13 elevator shafts were sampled and the following were found deficient. 1) 2nd floor Stewart Or elevator above the ceiling tiles from the corridor into the shaft. 2) Memorial Wing penthouse TV repair room into the shaft.

While surveying the main hospital facility, the inspector observed in several locations penetrations from the corridor into the stair enclosure which had not been sealed with a fire rated material. The majority of the 16 stair enclosures were sampled and the following were found deficient.
1) West Wing top floor (Stair S-11) Above the ceiling tiles corridor into enclosure.
2) 3rd floor Thompson rear stair the use of expansion foam used to seal the all to the under side of the floor pan above.
3) Emergency Department front stairs (newest stairs)above the ceiling tiles corridor to the enclosure.
4) Ross Wing 2nd floor (OR rear stairs) above ceiling tiles from the corridor to the enclosure.

While surveying the main hospital facility, the inspector observed the lack of adequate fixed fire suppression within the main kitchen's exhaust hood over the cooking equipment which can produce a grease laden vapor.
1) Two large kettles (1 provided with a cover and one where the cover had been removed completely) and one small kettle (provided with a cover) were observed without any fixed suppression provided above them. When the cooks were questioned what was prepared in the kettles a variety of foods were listed including soups, graves and meats. Meats are known to produce grease laden vapors.
2) A 6 burner gas stove was observed in which one of the suppression nozzles was pointed down and slightly off to the side of the burners. A second suppression nozzle was also present but had been pushed up into the hood and was found located above the electrical conduit for the lighting fixture within the exhaust hood. A question exist as to how long the nozzle had been in that position and if, with that nozzle in the down position, the two nozzles would have adequately protected the stove.

This inspector observed the soiled linen chute door in the 2nd floor of Memorial wing, had numerous unnecessary holes in the doorframe and in the two pieces of metal that make up the inside and outside faces of the door. These holes are from the past attachment of a self closure and other items that are no longer used. Additionally, the latching mechanism had no markings to indicate that it was a listed latch which would allow it to be used on a listed linen chute door. Due to these holes, the problem with latch, the door and doorframe have lost their one hour fire protection rating required by NFPA 101 chapter 19.5.4, 9.5, 8.4.

While surveying the main hospital facility, the inspector observed in several locations penetrations from the corridor or use spaces into the elevator shaft which had not been sealed with a fire rated material. The majority of the 13 elevator shafts were sampled and the following were found deficient. 1) 2nd floor Stewart Or elevator above the ceiling tiles from the corridor into the shaft. 2) Memorial Wing penthouse TV repair room into the shaft.

While surveying the main hospital facility, the inspector observed in several locations penetrations from the corridor into the stair enclosure which had not been sealed with a fire rated material. The majority of the 16 stair enclosures were sampled and the following were found deficient.
1) West Wing top floor (Stair S-11) Above the ceiling tiles corridor into enclosure.
2) 3rd floor Thompson rear stair the use of expansion foam used to seal the all to the under side of the floor pan above.
3) Emergency Department front stairs (newest stairs)above the ceiling tiles corridor to the enclosure.
4) Ross Wing 2nd floor (OR rear stairs) above ceiling tiles from the corridor to the enclosure.

While surveying the main hospital facility, the inspector observed the lack of adequate fixed fire suppression within the main kitchen's exhaust hood over the cooking equipment which can produce a grease laden vapor.
1) Two large kettles (1 provided with a cover and one where the cover had been removed completely) and one small kettle (provided with a cover) were observed without any fixed suppression provided above them. When the cooks were questioned what was prepared in the kettles a variety of foods were listed including soups, graves and meats. Meats are known to produce grease laden vapors.
2) A 6 burner gas stove was observed in which one of the suppression nozzles was pointed down and slightly off to the side of the burners. A second suppression nozzle was also present but had been pushed up into the hood and was found located above the electrical conduit for the lighting fixture within the exhaust hood. A question exist as to how long the nozzle had been in that position and if, with that nozzle in the down position, the two nozzles would have adequately protected the stove.

This inspector observed the soiled linen chute door in the 2nd floor of Memorial wing, had numerous unnecessary holes in the doorframe and in the two pieces of metal that make up the inside and outside faces of the door. These holes are from the past attachment of a self closure and other items that are no longer used. Additionally, the latching mechanism had no markings to indicate that it was a listed latch which would allow it to be used on a listed linen chute door. Due to these holes, the problem with latch, the door and doorframe have lost their one hour fire protection rating required by NFPA 101 chapter 19.5.4, 9.5, 8.4.