HospitalInspections.org

Through observation during the course of the survey, conducted June 8, 2016, it was determined that the facility failed to maintain the interior finish of rooms in accordance with 18.3.3.2.


During the walk through of the facility, with the Maintenance Director, three (3) rooms did not conform with the interior finish requirements of section 18.3.3.2, and had missing ceiling tiles:
A) Mechanical room 1108
B) Room 1652
C) Room 1653

These deficiencies could effect two of five smoke compartments.

Through observation during the survey, June 8, 2016, it was determined that the facility failed to arrange doors protecting hazardous areas to automatically close upon activation of the fire alarm system.

During the walk through of the facility, with the Maintenance Director, the facility utilized foot wedges to hold open the following doors.
A) 1102
B) 1201
C) 1218
D) 1221
E) 1322
F) 1331
G) 1371
H) 1521
I) 1705


This deficiency could effect four of five smoke compartments.

Through observation during the survey, June 8, 2016, it was determined that the facility failed to maintain the smoke barrier walls per 18.3.7.3


During the walk through of the facility, with the Maintenance Director, there were unsealed penetrations in the following smoke barrier walls above the ceiling:
A) 1600 corridor at the ER entrance
B) 1600 corridor at Endoscopy on both sides of the hall
C) Ambulance garage inside and outside the electrical room


These deficiencies could effect three of five smoke compartments.

Through observation, during the survey June 8, 2016, it was determined that the facility failed to maintain the smoke barrier doors per 18.3.7.6.


During the walk through of the facility, with the Maintenance Director, the following cross corridor smoke barrier doors did not shut and seal:
A) corridor 1300
B) corridor 1600
C) corridor 1700


These deficiencies could effect three of five smoke compartments.

Through record review and discussions with the staff during the survey, June 8, 2016, it was determined that the facility failed to conduct fire drills at on each shift quarterly per 18.7.1.2.


During the review of the facility records, with the Maintenance Director, no documentation was available for 3rd quarter 2015 night shift drill and 4th quarter 2015 day shift drill.


This deficiency could effect the entire facility.

Through a review of the records and discussions with staff during the survey, June 8, 2016, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the annual testing of the fire alarm system.


This deficiency could effect the entire facility.

Through observation during the survey, June 8, 2016, it was determined that the facility failed to install and maintain the sprinkler system per NFPA 13.


During the walk through of the facility, with the Maintenance Director, sprinkler escutcheons were missing in room 1108 and the Pharmacy.



This deficiency could effect two of five smoke compartments.

Through record review during the survey, June 8, 2016, it was determined the facility failed to exercise and test the fire dampers at least every four years as required by the 1999 edition of NFPA 90-A, Section 3-4.7.

During the review of the facility records with the Director of Environmental Services, documentation was not available to verify the required test and maintenance of the fire dampers.


This deficiency could effect the entire facility.

Through record review during the survey, June 8, 2016, it was determined the facility failed to inspect and professionally clean the kitchen exhaust system on a semi-annual basis.

During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection and cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). The last documented cleaning of the exhaust system was February 2015.



This deficiency could effect one of five smoke compartments.

Through observation during the survey, June 8, 2016, it was determined that the facility failed to maintain Med Gas storage per NFPA 99.


During the walk through of the facility, with the Maintenance Director:
A) Med Gas Storage Room 1738 had unsecure med gas cylinders
B) Rooms 1516 and 1518 had unsecure "E" size oxygen tanks



These deficiencies could effect two of five smoke compartments.

Through observation and document review during the survey, June 8, 2016, it was determined that the facility failed to maintain the generator emergency function per NFPA 110, 6-4.1

During the review of the facility records, observation and testing, with the Maintenance Director, documentation was not available for weekly generator inspections.


This deficiency could effect the entire facility.

Through observation during the survey, June 8, 2016, it was determined that the facility failed to install and maintain the electrical wiring in accordance NFPA 70, (National Electrical Code).

During the walk through of the facility, with the Maintenance Director, an extension cord was used to feed the lab printer.


This deficiency could effect one of five smoke compartments.

Through record review and staff interviews during the survey, June 8, 2016, it was determined that the facility failed to establish a written fire watch procedure when the required fire alarm system or sprinkler system is out of service for more than 4 hours in a 24-hour period.


During the review of the facility records, the facility failed to provide a written fire watch policy for fire alarm and sprinkler system out of service procedure.


This deficiency could effect the entire facility.