HospitalInspections.org

Based on visual observation, the facility failed to provide smoke resistive and positive latching doors in 1 of 1 smoke compartment. This deficiency if not corrected could have the opportunity to cause harm to 14 of the 165 patients in the facility.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following corridor doors were observed having no positive latching mechanisms:
2 sets of doors in MRI

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

Based on visual observation the facility failed to provide a 1 hour fire rated stairwell in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 165 patients in the hospital.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the OR / HR stairwell enclosure was observed having 2 flex duct penetrations which compromises the 1 hour fire rating and both of these ducts are supplying air into the enclosure from a HVAC unit that serves other areas in the hospital.

Based on visual observation the facility failed to maintain the integrity of the 1 hour fire walls protecting hazardous areas in 3 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 66 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m 2 flex duct and 1 conduit penetrations were observed in each of the the soiled utility rooms on 2nd, 3rd, and 4th floors.

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 1 of 1 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ER doors by rooms 6 and 7 and MRI area

Based on visual observation the facility failed to provide special locking which complies with Fire Marshal Memorandum 2009-05 in 2 of 9 smoke compartments. This deficiency if not corrected could have the potential to cause harm to 24 of the 164 patients in the building.

Findings: During tour of building on 11-29-2012 between 9:00 a.m. and 3:30 p.m. the following doors were observed having magnetic locking devices that do not meet the requirements of Fire Marshal Memorandum 2009-05.
ICU suite
Endo entrance door
OR entrance door

Central Sterile processing

Based on visual observation the facility failed to provide a 2 bulb fixture at 1 exit, of 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 10 of the 164 patients if not corrected.

Findings: During tour of building on 11-29-2012 the employees exit discharge did not have a 2 bulb fixture connected to the emergence power source.

Based on visual observation the facility failed to provide sprinkler protection in 1 of 2 smoke compartments on the 1st floor. This deficiency if not corrected could have the potential to cause harm to 22 of the 164 patients in the building.

Findings: During tour of building on 11-30-2012 between 9:00 a.m. and 3:30 p.m. the Women's Center entrance area was observed having no sprinkler protection.