HospitalInspections.org

Based on observation and interview, it was determined the facility failed to provide the required building construction type, affecting the entire component

Findings include:

1. Observation on October 25, 2021, at 1:50 pm, revealed the building is a Type II (000) construction type and lacks the complete automatic sprinkler system protection that is required for this type of construction.

Exit interview with the facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the component requires a complete automatic sprinkler system protection.

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of stairtowers on one of three levels.

Findings include:

1. Observation on October 26, 2021, at 8:55 am, revealed an air exchange opening was installed in the stair tower wall with the penthouse.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the air exchange opening in the stair tower.

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors on one of two levels.

Findings include:

1. Observation on October 25, 2021, at 3:20 pm, revealed the door to soiled linen #1445 failed to latch in the corresponding frame.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the door lacked positive latching.

Based on observation and interview, it was determined the facility failed to install complete sprinkler coverage on one of two levels.

Findings include:

1. Observation on October 26, 2021, at 9:20 am, revealed the covered patio area lacked sprinkler protection and storage of combustible tables and chairs.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the lack of sprinkler protection.

2. Observation on October 26, 2021 at 9:30 am, revealed several ceiling tiles missing in the 1st floor computer room that had concealed style pendant sprinklers.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the missing ceiling tile could cause a delay in sprinkler activation.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in two locations on one of two levels.

Findings include:

1. Observation on October 25, 2021, between 2:25 pm and 3:25 pm, revealed the following corridor doors could not latch or were not smoke tight while latched:

a. At 2:25 pm, Vocational Workshop #1034 not smoke tight.
b. At 3:25 pm, patient room 16-4 Ward 7, could not be closed due to the bed blocking the frame.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the door defiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors on one of two levels.

Findings include:

1, Observation on October 25, 2021, at 2:45 pm, revealed the smoke barrier doors in the administration section, doors #1019 were installed with an astragal but lacked a coordinator device.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the doors lacked a coordinator device.

Based on observation and interview, it was determined the facility failed to monitor the use of surge protection deceives on one of two levels.

Findings include:

1. Observation on October 25, 2021, at 2:10 pm, revealed two power tap/surge protection devices plugged into each other Room 1317.

Exit interview with facility CEO, COO, and maintenance manager on October 26, 2021, at 1:30 pm, confirmed the "daisy chained" power taps.