HospitalInspections.org

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. Atrium Hallway: Double Doors: Above Ceiling: There was a penetration in the smoke barrier that needed to be sealed.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. They were: Documentation showing that draperies, curtains and fabrics meets the requirements in NFPA-701 was not available for review.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. They were: Documentation showing that Risk Assessment: Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99, was not available for review.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. Back Storage Room: There were medical gas cylinders with a combined volume that exceeded 300 cubic feet that were not stored in an acceptable room.

3 Requirements for Cylinder Storage of Less Than 300 Cubic Feet of Gas
3.1 Cylinders with contents totaling less than 300 cubic feet of gas per smoke compartment (22,500 sq. ft. maximum) are not required to be stored in enclosures of any type.

4 Requirements for Cylinder Storage of 300-3,000 Cubic Feet of Gas
4.1 Cylinder storage must be located either outdoors in a lockable enclosure or indoors in a lockable enclosed space constructed of non-combustible or limited-combustible materials.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. The medical gas alarm panel for WAGD was showing a red warning with a numerical reading of 99. However, there was not an audible warning.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. An electrical room was being used to store a small ladder.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. They were: Documentation showing that main and feeder circuit breakers are inspected annually, was not available for review.

The inspector observed, while accompanied by the Director of Operations during the hours of the inspection from 9:00 am to 11:30 am on 2/26/2020 that there were the following issues. There was an electrical receptacle that was located below the 5 foot limit.

Locations for central supply systems and the storage of medical gases shall meet the following requirements: (5) Be compliant with NFPA 70, National Electrical Code, for ordinary locations, with electrical devices located at or above 5 feet above finished floor to avoid physical damage - NFPA 99, 2002, 5.1.3.3.2(5).