HospitalInspections.org

Based on observation and document review the facility did not maintain all walls with a fire resistance rating.

Findings Include:

Observation during the facility tour on 09/18/2019 at 11:00 AM revealed a six foot wide by three foot high area above the drop ceiling in the corridor above the door to the imaging suite that had no rated material.

Review of the facility floor plans on 09/18/2019 at 11:00 AM indicated that this was a 1-hour rated smoke partition.

Interview with Staff (P), Facilities Manager 09/18/2019 at 11:30 AM verified the above findings.

Based on document review and interview the facility did not maintain the medical gas system. The vacuum line from the ceiling in two of two operating rooms had low flow rate.

Findings Include:

Review of the medical gas system inspection report from MedPipe, dated 02/28/2019 revealed that the vacuum line from the ceiling of operating room numbers 1 and 2 had a flow rate, measured in standard cubic feet per minute (SCFM), of 1.6 SCFM in both operating rooms. The vacuum should be 3.0 scfm or greater. The low flow was due to leaking fittings.

Interview with Staff (P), Facilities Manager revealed that MedPipe was called on 09/19/2019 at 1:15 PM to determine if the leaking fittings were repaired. MedPipe informed Staff (P) that the fittings had not been repaired.

Based on interview the one of one generator is not exercised under load for 30 minutes 12 times a year in 20-40-day intervals.

Findings Include:

Interview with Staff (P), Facilities Manager on 09/18/2019 at 3:30 PM revealed that a new generator was installed two months ago. The generator had not had a monthly load test since installation. Not performing a load test has the potential to result in mechanically deficient items not being identified as part of preventative maintenance procedures; which could lead to a failure during an actual event when the emergency power supply system is needed.

Based on interview the three of three generator transfer switches were not tested monthly.

Findings Include:

Interview with Staff (P), Facilities Manager on 09/18/2019 at 3:45 PM revealed that all of the transfer switches were replaced two months ago and had not undergone monthly testing since they were replaced. Not testing the transfer switches has the potential to result in mechanically deficient items not being identified as part of the preventative maintenance procedures; which could lead to a failure during an actual event when the emergency power supply system is needed.