HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 08/17/2016, while being accompanied by the Director of Maintenance, the facility shall verify that two-hour separation between hospital and non-hospital clinic renovation exists. Provide cut sheets of the two-hour rated storefront system

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire resistance rating of the rated barrier. The central supply door, which is a rated fire door, was held open by a door wedge. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied to the fire alarm.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to provide the direction of the egress path. No exit sign existed at nurse station, near sub waiting area.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain proper clearance from the fire sprinkler head. Light fixture blocked water coverage in the ICU department ' s clean room.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at several places thorough out (central supply and kitchen ' s ware wash room).

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain exit. Exit was locked and blocked by furniture. This was marked by eit sign however, it was not a required exit.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to secure a few medical gas cylinders. All cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain non patient rooms. Renovated non patient spaces still had nurse call and med gas in activity room (only med gas outlets existed) and operating room storage (both nurse call and med gas outlets existed).

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the clearance in front of the electrical panel boards and transfer switches in the emergency electrical room.

Based on observations during the survey walk of the facility on the afternoon of 08/17/2016, while being accompanied by the Director of Maintenance, the facility shall verify that two-hour separation between hospital and non-hospital clinic renovation exists. Provide cut sheets of the two-hour rated storefront system

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire resistance rating of the rated barrier. The central supply door, which is a rated fire door, was held open by a door wedge. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied to the fire alarm.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to provide the direction of the egress path. No exit sign existed at nurse station, near sub waiting area.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain proper clearance from the fire sprinkler head. Light fixture blocked water coverage in the ICU department ' s clean room.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at several places thorough out (central supply and kitchen ' s ware wash room).

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain exit. Exit was locked and blocked by furniture. This was marked by eit sign however, it was not a required exit.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to secure a few medical gas cylinders. All cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain non patient rooms. Renovated non patient spaces still had nurse call and med gas in activity room (only med gas outlets existed) and operating room storage (both nurse call and med gas outlets existed).

Based on observations during the survey walk of the facility on the morning of 08/17/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the clearance in front of the electrical panel boards and transfer switches in the emergency electrical room.