HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain self-closing doors to be free of obstruction from closing, in one of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, at 1:42 PM revealed the Housekeeping door was held open with a rubber wedge.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed the door was wedged open.

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors to be within allowed gap margins, in one of three stairtowers within the component.

Findings include:

1. Observation on January 10, 2019, at 2:05 PM revealed the Stairtower 2 door , Door 126, had a gap exceeding one eighth of an inch, on the 1st floor.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed the door exceeded the allowed gap margin.

Based on observation and interview, it was determined the facility failed to maintain exit signs to be illuminated, in one of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, at 12:45 PM revealed the exit sign, in Stairtower 1 2nd floor, was not lit.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed the exit sign was not illuminated.

Based on observation and interview, it was determined the facility failed to maintain hazardous area walls to resist the passage of smoke, in one of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, at 1:45 PM revealed open abandoned pipes, in Room 12 in the basement.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed there were penetrations.


2. Observation on January 10, 2019, at 2:10 PM revealed a penetration of a wall, in Supply Room 256.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to install the same type sprinkler head in a given area, in one of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, at 1:15 PM revealed two types of sprinkler heads were installed, in Room 8 in the basement.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed the sprinkler heads did not match.

Based on observation and interview, it was determined the facility failed to monitor storage to be more than eighteen inches from the sprinkler head, in one of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, at 12:50 PM revealed a fan was stored within eighteen inches of the sprinkler head, in the 3rd floor Chute Room.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed there was storage within eighteen inches of the sprinkler deflector.

Based on observation and interview, it was determined the facility failed to monitor trash and soiled-linen containers, to not exceed 32 gallons in a 64 square foot area, outside of a protected room, in two of ten smoke zones within the component.

Findings include:

1. Observation on January 10, 2019, between 12:10 PM and 1:05 PM revealed trash containers, equaling more than 32 gallons in a 64 square foot area, at the following locations:

a. 12:10 PM, 2nd floor Nurses' Station;
b. 12:15 PM, 2nd floor Hair Dresser;
c. 1:05 PM, 4th floor Staff Kitchen.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed total capacity of trash exceeded the allowed limits.

Based on document review and interview, it was determined the facility failed to inspect doors with ratings, throughout the component.

Findings include:

1. Review of documentation on January 10, 2019, at 10:30 AM revealed the facility failed to include rated corridor doors in the annual fire door inspection.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 10, 2019, at 4 PM confirmed the rated corridor doors had not been included in the annual inspection.