HospitalInspections.org

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to maintaining the ability of fire-rated doors to latch and remain closed in two (second floor stairwell west door and third floor east corridor) of seven areas observed. The failed practice had the potential to affect all patients, visitors, and staff by allowing smoke and fire to pass from one side of the barrier to the other in the event of a smoke and fire event. Findings follow:

A.) During a tour of the facility on 11/17/2015 at 1300, it was observed the fire-rated door on the west side of the stairwell on the second floor of Building #1 was unable to latch when released.
B.) During a tour of the facility on 11/17/2015 at 1300, it was observed that the fire-rated door in the east corridor of the Acute Care Unit of Building #1 was unable to latch when released.
C.) During the tour the Director of Plant Operations/Maintenance verified the doors did not latch when released.

Based on observation and interview, it was determined there were three unsealed penetrations of the smoke barrier with a material which was fire and smoke rated in two (above the drop-down ceiling in corridor near Room 108 and above the fire-rated door near Room 108) of seven areas observed. The unsealed smoke barrier had the potential to affect all patients visitors and staff by allowing smoke to pass from one side of the barrier to the other in the event of a smoke and fire event. Findings follow:

A.) During a tour of the facility with the Director of Physical Operations/Maintenance, the following was observed:
1) One pipe penetrating the fire and smoke barrier above the fire-rated door near Room 108.
2) One metal electrical conduit in the fire and smoke barrier above the drop-down ceiling in the corridor near Room 108.
3) One hole in the fire and smoke barrier above the drop-down ceiling in the corridor near Room 108.
B.) During the tour the above conditions in A were verified by the Director of Plant Operations/Maintenance.

Based on observation it was determined that the cover of an electrical panel had been removed and was not replaced in one (Mechanical Room east side of Building #1 on the first floor) of three areas observed. The failed practice had the potential to affect all patients, visitors, and staff by not protecting staff working in that area from electrical shock and it could not provide protection against sparks which had the potential to cause a fire event. Findings follow:

A.) During a tour of the facility on 11/17/2015 at 1300, it was observed the cover of an electrical panel had been removed but not replaced in the Mechanical Room on the first floor of Building #1.
B.) During the tour the Director of Plant Operations/Maintenance verified that the cover had not been replaced on the panel.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to maintaining the ability of fire-rated doors to latch and remain closed in two (second floor stairwell west door and third floor east corridor) of seven areas observed. The failed practice had the potential to affect all patients, visitors, and staff by allowing smoke and fire to pass from one side of the barrier to the other in the event of a smoke and fire event. Findings follow:

A.) During a tour of the facility on 11/17/2015 at 1300, it was observed the fire-rated door on the west side of the stairwell on the second floor of Building #1 was unable to latch when released.
B.) During a tour of the facility on 11/17/2015 at 1300, it was observed that the fire-rated door in the east corridor of the Acute Care Unit of Building #1 was unable to latch when released.
C.) During the tour the Director of Plant Operations/Maintenance verified the doors did not latch when released.

Based on observation and interview, it was determined there were three unsealed penetrations of the smoke barrier with a material which was fire and smoke rated in two (above the drop-down ceiling in corridor near Room 108 and above the fire-rated door near Room 108) of seven areas observed. The unsealed smoke barrier had the potential to affect all patients visitors and staff by allowing smoke to pass from one side of the barrier to the other in the event of a smoke and fire event. Findings follow:

A.) During a tour of the facility with the Director of Physical Operations/Maintenance, the following was observed:
1) One pipe penetrating the fire and smoke barrier above the fire-rated door near Room 108.
2) One metal electrical conduit in the fire and smoke barrier above the drop-down ceiling in the corridor near Room 108.
3) One hole in the fire and smoke barrier above the drop-down ceiling in the corridor near Room 108.
B.) During the tour the above conditions in A were verified by the Director of Plant Operations/Maintenance.

Based on observation it was determined that the cover of an electrical panel had been removed and was not replaced in one (Mechanical Room east side of Building #1 on the first floor) of three areas observed. The failed practice had the potential to affect all patients, visitors, and staff by not protecting staff working in that area from electrical shock and it could not provide protection against sparks which had the potential to cause a fire event. Findings follow:

A.) During a tour of the facility on 11/17/2015 at 1300, it was observed the cover of an electrical panel had been removed but not replaced in the Mechanical Room on the first floor of Building #1.
B.) During the tour the Director of Plant Operations/Maintenance verified that the cover had not been replaced on the panel.