HospitalInspections.org

Based on record review and interview, the provider failed to conduct the required every six-month inspection of the facility's cooking ductwork exhaust system for the range hood for the calendar year 2023. Findings include:

1. Record review revealed there was no documentation the kitchen hood exhaust ductwork had been inspected for cleanliness and grease build-up in 2023.

Interview with the maintenance supervisor at 1:55 p.m. on 8/7/24 revealed he was unaware of the ductwork inspection requirements.

The deficiency affected the requirements for the kitchen range hood exhaust system.

Based on observation and record review, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (gauge replacement and the 5-year internal pipe inspection). Findings include:

1. Observation at 10:05 a.m. on 8/7/24 revealed the gauges for the sprinkler system had last been replaced 5/29/18. Gauges are required to be calibrated or replaced every five years.

Record review at 2:15 p.m. on 8/7/24 revealed the contractor for sprinkler maintenance had noted the deficiency in the 2023 annual inspection, but had not corrected the deficiency.

2. Observation at 10:08 a.m. on 8/7/24 revealed there was no tag available for a five-year internal pipe inspection.

Record review at 2:15 p.m. on 8/7/24 revealed the contractor for sprinkler maintenance had noted the deficiency in the 2023 annual inspection, but had not corrected the deficiency.

Interview with the maintenance supervisor at the time of the observation confirmed that condition.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiencies affected two of numerous required maintenance items for the automatic sprinkler system.

Based on observation and interview, the facility failed to protect medical gas storage as required. Forty-one H-cylinders (10,004 cubic feet) were stored in a hazardous room with no functioning exhaust available.

Findings include:

1. Observation on 8/7/24 at 11:30 a.m. revealed the oxygen storage room for the piped medical gas system held 41 H-cylinders or 10,004 cubic feet of oxygen. A maximum of 3000 cubic feet of gas storage was allowed in a room without continuous exhaust. Interview with the maintenance supervisor at the time of observation revealed he was not aware the exhaust system was not working. Further investigation by the maintenance supervisor revealed the exhaust fan motor was burned out and an order for a replacement motor was placed.

The deficiency affected one of three smoke compartments.