HospitalInspections.org

Per observation on 11/25, facility failed to ensure that doors are kept in a closed position unless held open by a release device that complies with regulatory requirements. The findings include the following:

Per observation on 11/25, and accompanied by the Director of Engineering, inspection revealed that the Kitchen door needs to have a door closure and should lock & latch.

Per observation on 11/25, facility failed to ensure corridors are maintained to provide for convenient removal of nonambulatory patients. The findings include the following:

Per observation on 11/25, and accompanied by the Director of Engineering, inspection revealed that the 4th floor corridor has storage boxes located in the exit path.

Per observations on 11/25 and 12/2, facility failed to ensure all hazardous areas are protected according to regulatory requirements. The findings include the following:

1. Per observation on 11/25, and accompanied by the Director of Engineering, inspection revealed that there are penetrations in the wall above the doorway and was not properly fire stopped.

2. Per observatios on 11/25, and accompanied by the Director of Engineering, inspection revealed that a new steel beam installed in the elevator room does not have the proper rated fire protection.

3. Per observation on 11/25, and accompanied by the Director of Engineering, inspection revealed that the Fire Pump Room has penetrations in the wall.

4. Per observation on 11/25, and accompanied by the Director of Engineering, inspection revealed that the 3rd floor N.W. Wing Utility Room steel I beam is missing fire proofing section 3"x 3".

5. Per observatios on 12/2, and accompanied by the Director of Engineering, inspection revealed that IT Room on the 2nd floor has penetration on the walls and storage of combustible materials in the room.

6. Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that the Air Handler room on the 2nd floor has penetration in the walls and the storage of combustible materials in the room.

7. Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that the Electrical Room 1126W on the 1st floor has several penetrations in the wall.

8. Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that that the basement level N.W. electrical room wall has several penetrations above the door.

Per observation on 12/2, facility failed to ensure interior walls and ceiling finishes meet regulatory requirements. Findings include the following:

1. Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that Room 276E on located on the second floor has penetration in the broken tiles in the ceiling.

2. Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that in the 2nd floor ICU suite there is penetration in the wall above the smoke doors.

Per observation on 12/2, facility failed to ensure that smoke barrier doors comply with regulatory requirements. The findings include the following:

Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that the door located on the 3rd floor, next to N.W. Woman's and Children's Center has a one inch gap between the doors when closed.

Per observation on 12/2, facility failed to ensure that requirements for smoke and carbon monoxide alarms is being met. Findings include the following:

Per observation on 12/2, and accompanied by the Director of Engineering, inspection revealed that on the 2nd floor in the old nursing school wing, there are three bedrooms used by staff for sleeping quarters. There are no smoke alarms or carbon monoxide detectors located in these rooms. NFPA - 101 Chapter 24

Per observation on 11/25, facility failed to ensure all gas and electric utilities comply with regulatory requirements. The findings include the following:

Per observations on 11/25, and accompanied by the Director of Engineering, inspection revealed that there are penetrations in the electrical room ceiling and wall located on the 3rd floor.