HospitalInspections.org

Based on observation and interview the facility failed to ensure that 2 sets of fire door separations could close to a latched position.

Findings include:

Observations during tour on 03/17/17 between 9:00 a.m. and 9:45 a.m. with Staff A (Director of Facilities Management) and Staff B (Regional Director of Operations) revealed two doors which failed to latch at the following 2 locations:
1 door leaf on the set of fire barrier doors outside of the CT (Computerized Axial Tomography) room failed to close to a latched position.
1 door leaf on the set of fire barrier doors outside of the main Pharmacy Suite failed to close to a latched position.

Interview with Staff A and Staff B confirmed the findings and locations.

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.


Based on observations and interview the facility failed to ensure that battery operated emergency lighting is located at the ATS (Automatic Transfer Switch) locations.

Findings include:

Observations during tour on 03/17/17 with Staff A (Director of Facilities Management) and Staff B (Regional Director of Operations) revealed that 1 of the main electrical rooms on the lower level contains ATS panel #4, #5, #6, and #7. This electrical room failed to be equipped with battery powered emergency lighting.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on observations and interview the facility failed to ensure that 1 Mechanical/Boiler room has complete sprinkler coverage.

Findings include:

Observations during tour on 03/17/17 between 11:30 a.m. and 11:45 a.m. with Staff A (Director of Facilities Maintenance) and Staff B (Regional Director of Operations) revealed that the existing Mechanical/Boiler room, on the lower level, has an area approximately 30' x 40' in which sprinkler system coverage is not present. This area represents approximately 1/4 of the room. Additionally, in this Mechnical/Boiler room there is 1 section of HVAC (Heating, Ventilation, and Air Conditioning) ductwork, approximately 6' wide x 25' long which is located underneath a sprinklered section of the Mechanical/Boiler room and is effectively blocking the sprinkler coverage of this area.

Interview with Staff A and Staff B confirmed the findings and locations.

Based on observations and interview the facility failed to ensure that extension cords are not used as permanent wiring and non-hospital grade plug strips are in use.

Findings include:

Observations during tour on 03/17/17 between 9:55 a.m. and 10:10 a.m. with Staff A (Director of Facilities Management) and Staff B(Regional Director of Operations) revealed that 1 office in the Pathology suite has an extension cord (approximately 12' long) running from an outlet to the desk. Plugged into that extension cord is 1 non-hospital grade plug strip and additionally there is 1 non-hospital grade plug strip plugged into the non-hospital grade plug strip. Computers, monitors, lighting, and miscellaneous equipment is being powered from this electrical connection.

Interview with Staff A and Staff B confirmed the findings and location.