HospitalInspections.org

Main Hospital Building basement
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The mechanical room # 3 has an access door that does not have self closing spring installed to keep the door from being left in the open position in the 2 hour rated wall. (This items was corrected before the end of the survey)

Main Hospital Building 2 south
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The smoke wall was incomplete at the Soiled Linen room. (This items was corrected before the end of the survey)

Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The smoke door at 1-249 did not release with activation of the fire alarm system.
B. The smoke door at 3-NA3-006 did not release with activation of the fire alarm system.

Main Hospital Building bed repair shop
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. Door 3W3.085 to the bed repair shop did not close and latch when tested.
B. Door 3W-087 did not close and latch when tested.

Main Hospital Building 2nd floor
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include: There is a dead end corridor condition ending at door M2W2-040.

Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
1. There were two ranges of motion to exit from the following areas:
A. Room with door 2N-080
B. Pharmacy Surveyors Conference room
C. Men ' s bathroom 3-NA Door 3-051 (This items was corrected before the end of the survey)
D. Chapel door 1-112. (This items was corrected before the end of the survey)

2. There was no solid non slick surface other than grass and soil at the required exit from the OR Suite leading from door1-005 PST to the public way.

3. The door mail II 1-003 in the egress corridor required more than 15 lbs for force to activate the panic hardware. (This items was corrected before the end of the survey)

Main Hospital Building Fire alarm system
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The strobe light in the AUNA door 3NA3-066 did not activate with activation of the fire alarm system.
B. The strobe light near main 2 1-249 did not activate with activation of the fire alarm system.
C. The duct detectors have a build up of dust and lint on the sampling tubes at 6th South unit nurses station.
D. The duct detectors have a build up of dust and lint on the sampling tubes at 5th North air handler # 17

Main Hospital Building 3rd floor
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The GI Lab near door 2N2-080.

Main Hospital Building loading dock
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: There are backflow valves that serve the loading dock that are not electrically supervised.

Main Hospital Building sprinkler riser room at the PST Basement
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The tamper alarms for the M1-99 and #9 failed to give a supervisory signal when tested.
B. Tamper alarm for # 10 near the PIV was not able to be tested.

Main Hospital Building basement
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The mechanical room # 3 in the West wing basement has duct detectors installed with out an access door to view the sampling tubes. (This items was corrected before the end of the survey)

Main Hospital Building 8th floor South
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. There were computers on wheels that were stored in the egress corridor and not in immediate use near room 6-805.
B. 2nd floor surgical suite for the main OR is not defined and currently has items in the exit egress corridor.
C. There were charting tables in the AUNA area near 3NA 3-066 and 3-082 that would not retract to the up position when tested. (This items was corrected before the end of the survey)

Main Hospital Building 1st floor loading dock cylinder room
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The main oxygen distribution room had a mixture of full and empty oxygen cylinders.

Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:
A. There were housekeeping items store in front of electrical panels in the room with door 2N2-058. ( This item was corrected before the end of the survey)
B. 3rd floor MICU room with entry at door PST3-038 the medical refrigerator noted as vaccine refrigerator was not verified to be on an emergency circuit. (This items was corrected before the end of the survey)