HospitalInspections.org

Based on documentation and interview the facility failed to provide a policy for subsistence needs for the staff and patients in case of an emergency

Findings include:

Documentation review on November 6, 2019, at 11:30 a.m., revealed the facility did not have provisions for sewage and waste disposal.

Interview with the facilities manager on November 6, 2019, at 11:30 a.m., confirmed the policy did not include provisions for sewage and waste disposal.

Based on a documentation and interview it was determined the facility failed to provide adequate training for all staff.
Findings include:
Document review on November 6, 2019, at 1:00 p.m., determined that all employees had not been trained in the emergency preparedness program.
Interview with the building services supervisor and the facilities manager on November 6, 2019, at 1:00 p.m., confirmed the above deficiencies.

Based on observation and interview the facility failed to secure the two hour separation on the building construction types

Findings include:

Observation on November 6, 2019, at 10:30 a.m., revealed that near the nurses' locker room, above fire door 1683, there was a penetration of the fire wall with data cable running thru it.

Interview with the facilities manager on November 6, 2019, at 10:30 a.m., confirmed the penetration of the fire wall.

Based on observation and interview, the facility failed to have a fully functioning egress door.
Findings include:
Observation on November 5, 2019, at 11:41 a.m., determined that the Rehab Works fire egress door, had an additional locking device attached to the door.
Interview with the building services supervisor and the facilities manager on November 5, 2019, at 1:03 p.m., confirmed the above deficiency existed.

Based on observation and interview the facility failed to secure the stairtower door

Findings include:

Observation on November 5, 2019, at 11:15 a.m., revealed stairtower door 2233A, did not latch in its frame, with a self closing device.

Interview with the facilities manager on Novemeber 5, 2019, at 11:15 a.m., confirmed the door did not latch.

Based on the observation and interview, it revealed the facility failed to meet horizontal exit door requirements.
Findings include:
Observation on November 5, 2019, between 10:30 a.m. and 1:30 p.m., revealed the doors did not latch in their frame in the following locations:
A. (10:53 a.m.), corridor 3357, third floor;
B. (11:41 a.m.), corridor 2233A.
Interview with the building services supervisor and the facilities manager on November 6, 2019, at 11:41 a.m., confirmed the above deficiencies.

Based on the observation and interview, the facility failed to keep the hazardous areas protected in the following locations:
Observation on November 5, 2019, between 9:20 a.m. and 10:30 a.m., revealed the hazardous areas doors.
A. (9:20 a.m.), door 3300B, third floor, had three holes penetrating the door;
B. (10:11 a.m.), door 1493, soiled utility room, first floor, did not latch.
Interview with the building services supervisor and the facilities manager on November 6, 2019, at 10:11 a.m., confirmed the above deficiencies.

Based on observation and interview the facility failed to ensure the one hour fire resistive integrity of the laboratory.

Findings include:

Observation on November 5, 2019, at 1:37 p.m., revealed that the main laboratory door had no latching hardware and was being secured with a special locking arrangement.

Interview with the facilities manager on November 5, 2019, at 1:37 p.m., confirmed the door to the laboratory did not have latching mechanisms.

Based on observation and interview, the facility failed to maintain the fire alarm system requirements.
Finds include:
Observation on November 5, 2019, at 10:27 a.m., determined that above door 3325A, there was an open penetration, near a heat detector.
Interview with the building services supervisor and the facilities manager on November 5, 2019, at 10:27 a.m., confirmed the above deficiency existed.

Based on observation and interview, the facility failed to maintain the sprinkler system.
Findings include:
Observation on November 5, 2019, between 10:00 a.m. and 1:30 p.m., the following sprinkler deficiencies were revealed:
A. (10:00 a.m.), third floor, room 3302A, had a sprinkler head within twelve inches of a light fixture;
B. (1:18 p.m.), first floor, at the leased building (DD), new registration window, the right side closet had a sprinkler located within eighteen inches of the top shelf, obstructing the flow of the automatic sprinkler.
Interview with the building services supervisor and the facilities manager on November 5, 2019, at 1:18 p.m., confirmed the automatic sprinkler deficiencies listed above existed.

Based on observation and interview, the facility failed to inspect and maintain the fire rated smoke barriers.
Findings include:
Observation on November 5, 2019, between 10:00 a.m. and 11:45 a.m., revealed fire rated wall penetrations in the following locations:
A. (10:04 a.m.), above door 1683, near nurses' locker room, had a wire penetration;
B. (10:18 a.m.), above door 3323, near the soiled linen room, had a wire penetration;
C. (11:41 a.m.), above door 2233B, there was an unsealed penetration;
D. (10:33 a.m.), room 1200, on the right-hand side, had a copper pipe cut off in a rated wall causing a penetration.
Interview with the building services supervisor and the facilities manager on November 6, 2019, at 11:41 a.m., confirmed the above deficiencies.

Based on the observation and interview, the facility failed to meet the requirements for electrical equipment.
Findings include:
Observation on November 6, 2019, between 10:45 a.m. and 1:30 p.m., the following extension cord issues were revealed:
A. (10:45 a.m.), room 3318, an extension cord was hanging by its cord and had a coffee pot plugged into it;
B. (1:10 p.m.) second floor, medical records, had a microwave plugged into a surge protector.
Interview with the building services supervisor and the facilities manager on November 6, 2019, at 1:10 p.m., confirmed the above deficiencies.