HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain one vertical enclosure affecting three of three levels in this component.

Findings include:

1. Observation on March 27, 2015, at 9:22 AM, revealed the heating cooling and ventilation (HVAC) duct work, located in the second floor same-day mechanical room, was not protected where it pierced the floor slab at the first and basement levels.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the HVAC duct has a fire damper installed but had large gaps around the duct where it passed through the floor.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting two of two floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on March 27, 2015, at 9:00 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

2. Observation on March 27, 2015, at 9:50 AM, revealed the facility did not have a remote annunciator or derangement signal, for the emergency generator, located at a constantly attended location within the hospital.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the emergency generator annunciator was located in the boiler room, and was not located in a constantly attended location during non-working hours.

Based on observation and interview, it was determined the facility failed to maintain one vertical enclosure affecting three of three levels in this component.

Findings include:

1. Observation on March 27, 2015, at 9:22 AM, revealed the heating cooling and ventilation (HVAC) duct work, located in the second floor same-day mechanical room, was not protected where it pierced the floor slab at the first and basement levels.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the HVAC duct has a fire damper installed but had large gaps around the duct where it passed through the floor.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting two of two floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on March 27, 2015, at 9:00 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

2. Observation on March 27, 2015, at 9:50 AM, revealed the facility did not have a remote annunciator or derangement signal, for the emergency generator, located at a constantly attended location within the hospital.

Exit interview with the Maintenance Supervisor on March 27, 2015, between 11:15 AM and 11:30 AM, confirmed the emergency generator annunciator was located in the boiler room, and was not located in a constantly attended location during non-working hours.