HospitalInspections.org

Based on observation it was determined that the smoke barrier wall does not meet the requirements per regulation in one area of the smoke barrier.

Findings include:

Observation on July 23, 2013 at 10:00 am revealed an unsealed smoke barrier penetration at the wire tray above the suspended ceiling in the corridor outside the Data closet.

Interview with the Environmental Services Supervisor (ESS) on July 23, 2013 at 10:00 am confirmed the unsealed penetration of the smoke barrier wall.

Based on observation and interview, the hazardous areas do not comply with the regulations in one area of the entire building.

Findings include:

Observation on July 23, 2013, at 11:00 am revealed the E.R. Triage had a fire shutter that was blocked from closing completely.

Interview with ESS on July 23, 2013, at 11:00 am confirmed the fire shutter was blocked from closing completely

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per regulations in one of five smoke zones.

Findings include:

Observation on July 23, 2013, at 10:45 am revealed the X-Ray File Room lacks proper fire sprinkler protection.

Interview with ESS on July 23, 2013, at 10:45 am confirmed the X-Ray File Room lacks proper fire sprinkler protection.

Based upon observation and interview, the facility did not inspect, test and/or maintain the required automatic sprinkler system as per regulations in one of five smoke zones.

Findings include:

1. Observation on July 23, 2013, at 11:05 am revealed the facility had storage within 18 inches of a fire sprinkler in the Pharmacy.

Interview with ESS on July 23, 2013, at 11:05 am confirmed the storage within 18 inches of a fire sprinkler.

2. Observation on July 23, 2013 at 10:35 am revealed the facility had items placed within 18 inches of the fire sprinkler in the Gift Shop storage closet.

Interview with the ESS on July 23, 2013 at 10:35 am confirmed the items stored were within 18 inches of the fire sprinkler

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations in two of five smoke zones.

Findings include:

1. Observation on July 23, 2013, at 10:00 am revealed the Maintenance Shop had a water hose hanging on the fire extinguisher and the fire extinguisher was not visible.

Interview with ESS on July 23, 2013, at 10:00 am confirmed the above conditions existed.

2. Observation on July 23, 2013, at 12:40 pm revealed the Cafeteria had a wet chemical fire extinguisher mounted higher than five feet above the floor.

Interview with ESS on July 23, 2013, at 12:40 pm confirmed the fire extinguisher was mounted higher than five feet above the floor.

3. Observation on July 23, 2013 at 10:35 am revealed that a wheelchair blocked immediate access to the fire extinguisher in Pre-OP.

Interview with the ESS on July 23, 2013 at 10:35 am confirmed the wheelchair blocked immediate access to the fire extinguisher.

Based on interview, it was determined the cooking equipment/facilities do not comply with regulations on one of one floors.

Findings include:

Observation on July 23, 2013 at 12:35 pm revealed the facility lacks the monthly "quick check" for the kitchen hood fire suppression systems and remote manual pull stations in the kitchen.

Interview with the ESS on July 23, 2013 at 12:35 pm confirmed the facility is not conducting the "quick check" for the kitchen hood suppression systems.

Based on observation and interview the piped in medical gas system does not comply with regulations on one of one floors.

Findings include:

1. Observation on July 23, 2013 at 10:50 am revealed the emergency shut-off valves in the E.R. are blocked by a bed and wheelchairs.

Interview with the ESS on July 23, 2013 at 10:50 am confirmed the emergency shut-off valves were blocked from immediate access.

2. Observation on July 23, 2013 at 1:10 pm revealed the emergency shut-off valves for the Procedure Room on the O.R. were blocked from immediate access by a cart .

Interview with the ESS on July 23, 2013 at 1:10 pm confirmed the emergency shut-off valves blocked from immediate access.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of one floors.

Findings include:

Observation on July 23, 2013 at 11:05 am revealed that a microwave oven was plugged into a surge protector in the Pharmacy.

Interview with the ESS on July 23, 2013 at 11:05 am confirmed the microwave oven was plugged into a surge protector.

Based on observation it was determined that the smoke barrier wall does not meet the requirements per regulation in one area of the smoke barrier.

Findings include:

Observation on July 23, 2013 at 10:00 am revealed an unsealed smoke barrier penetration at the wire tray above the suspended ceiling in the corridor outside the Data closet.

Interview with the Environmental Services Supervisor (ESS) on July 23, 2013 at 10:00 am confirmed the unsealed penetration of the smoke barrier wall.

Based on observation and interview, the hazardous areas do not comply with the regulations in one area of the entire building.

Findings include:

Observation on July 23, 2013, at 11:00 am revealed the E.R. Triage had a fire shutter that was blocked from closing completely.

Interview with ESS on July 23, 2013, at 11:00 am confirmed the fire shutter was blocked from closing completely

Based upon observation and interview, it was determined the facility's automatic fire sprinkler system is not installed as per regulations in one of five smoke zones.

Findings include:

Observation on July 23, 2013, at 10:45 am revealed the X-Ray File Room lacks proper fire sprinkler protection.

Interview with ESS on July 23, 2013, at 10:45 am confirmed the X-Ray File Room lacks proper fire sprinkler protection.

Based upon observation and interview, the facility did not inspect, test and/or maintain the required automatic sprinkler system as per regulations in one of five smoke zones.

Findings include:

1. Observation on July 23, 2013, at 11:05 am revealed the facility had storage within 18 inches of a fire sprinkler in the Pharmacy.

Interview with ESS on July 23, 2013, at 11:05 am confirmed the storage within 18 inches of a fire sprinkler.

2. Observation on July 23, 2013 at 10:35 am revealed the facility had items placed within 18 inches of the fire sprinkler in the Gift Shop storage closet.

Interview with the ESS on July 23, 2013 at 10:35 am confirmed the items stored were within 18 inches of the fire sprinkler

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations in two of five smoke zones.

Findings include:

1. Observation on July 23, 2013, at 10:00 am revealed the Maintenance Shop had a water hose hanging on the fire extinguisher and the fire extinguisher was not visible.

Interview with ESS on July 23, 2013, at 10:00 am confirmed the above conditions existed.

2. Observation on July 23, 2013, at 12:40 pm revealed the Cafeteria had a wet chemical fire extinguisher mounted higher than five feet above the floor.

Interview with ESS on July 23, 2013, at 12:40 pm confirmed the fire extinguisher was mounted higher than five feet above the floor.

3. Observation on July 23, 2013 at 10:35 am revealed that a wheelchair blocked immediate access to the fire extinguisher in Pre-OP.

Interview with the ESS on July 23, 2013 at 10:35 am confirmed the wheelchair blocked immediate access to the fire extinguisher.

Based on interview, it was determined the cooking equipment/facilities do not comply with regulations on one of one floors.

Findings include:

Observation on July 23, 2013 at 12:35 pm revealed the facility lacks the monthly "quick check" for the kitchen hood fire suppression systems and remote manual pull stations in the kitchen.

Interview with the ESS on July 23, 2013 at 12:35 pm confirmed the facility is not conducting the "quick check" for the kitchen hood suppression systems.

Based on observation and interview the piped in medical gas system does not comply with regulations on one of one floors.

Findings include:

1. Observation on July 23, 2013 at 10:50 am revealed the emergency shut-off valves in the E.R. are blocked by a bed and wheelchairs.

Interview with the ESS on July 23, 2013 at 10:50 am confirmed the emergency shut-off valves were blocked from immediate access.

2. Observation on July 23, 2013 at 1:10 pm revealed the emergency shut-off valves for the Procedure Room on the O.R. were blocked from immediate access by a cart .

Interview with the ESS on July 23, 2013 at 1:10 pm confirmed the emergency shut-off valves blocked from immediate access.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of one floors.

Findings include:

Observation on July 23, 2013 at 11:05 am revealed that a microwave oven was plugged into a surge protector in the Pharmacy.

Interview with the ESS on July 23, 2013 at 11:05 am confirmed the microwave oven was plugged into a surge protector.