HospitalInspections.org

Based on observation and interview it was determined that the facility failed to inspect the smoke detection system, on one of one levels.

Findings include:

Observation on October 18, 2018, at 7:30 a.m., revealed the First Floor, electrical closet, outside the Coumadin Clinic, had gaps in the lay-in ceiling assembly that would delay the activation of the smoke detector.

Interview with the Senior Maintenance Tech 2, on October 18, 2018, at 7:30 a.m., confirmed the First Floor, electrical closet, outside the Coumadin Clinic, had gaps in the lay-in ceiling assembly that would delay the activation of the smoke detector.

Based on observation and interview it was determined that the facility failed to inspect and maintain the automatic sprinkler system per NFPA 13 and NFPA 25, on two of three levels.

Findings include:

1. Observation on October 17, 2018, at 1:15 p.m., revealed the Second Floor, Dining Room, had decorations hanging from the lay-in ceiling that would affect the operation of the sprinklers.

Interview with the Senior Maintenance Tech 2, on October 17, 2018, at 1:15 p.m., confirmed the Second Floor, Dining Room, had decorations hanging from the lay-in ceiling that would affect the operation of the sprinklers.

2. Observation on October 18, 2018, between 8:04 a.m. and 8:20 a.m., revealed the following sprinkler deficiencies:
A. (8:04 a.m.) First Floor, Radiology Room # 3, had two sprinkler escutcheons hanging from the sprinkler that would affect the operation of the sprinklers.
B. The following locations had quick response and fusible link standard response sprinklers in the same compartment: (at the time of survey the facility was unable to verify the operating temperatures of the two different sprinklers)
1. (8:15 a.m.) First Floor, Stress Lab Prep Room
2. (8:17 a.m.) First Floor, Chief Information Officer Office
3. (8:20 a.m.) First Floor, Respiratory Therapy Work Room/Office

Interview with the Senior Maintenance Tech 2, on October 18, 2018, at 8:20 a.m., confirmed the sprinkler deficiencies listed above existed.

Based on observation and interview it was determined that the facility failed to inspect smoke barrier walls, on one of three levels.

Findings include:

Observation on October 18, 2018, at 7:55 a.m., revealed the First Floor, Radiology Janitor closet, rear wall, had an unsealed three inch penetration, plugged with a plastic cup, located approximately four feet above the floor.

Interview with the Senior Maintenance Tech 2, on October 18, 2018, at 7:55 a.m., confirmed the First Floor, Radiology Janitor closet, rear wall, had an unsealed three inch penetration, plugged with a plastic cup, located approximately four feet above the floor.

Based on observation and interview it was determined that the facility failed to install and maintain electrical outlets per NFPA 70, on one of three levels.

Findings include:

1. Observation on October 18, 2018, between 8:05 a.m. and 8:12 a.m., revealed the following locations had electrical outlets installed directly above the sink that lacked GFCI protection:
A. (8:05 a.m.) First Floor, Radiology Staff Lounge
B. (8:12 a.m.) First Floor, Nuclear Medicine Hot Lab, Receptacle REC 2-12

Interview with the Senior Maintenance Tech 2, on October 18, 2018, at 8:12 a.m., confirmed the electrical outlets listed above were not on a GFCI circuit.