HospitalInspections.org

During the vaildation survey on April 29, 2019 at 1330 hours it was determined through observation of the physical environment and interview with the hospital staff that the sliding door assembly used as an exit discharge from the Emergency Dept by the Ambulance Area is locked by a magnetic device during "Lock Down" situations. At these times, the doors will not open as indicated
by the signs posted on the doors "Push To Open In An Emergency".

During the validation survey on April 29, 2019 at 1030 hours it was determined through review of the facility records, observation of the physical environment, and interview with the hospital staff that the kitchen hood fire extinguishing system is not maintained as required by NFPA 96. The most recent Inspection Summary provided for review during this survey, dated 2/26/2019 documented that the kitchen hood fire extinguishing system 1) Pressure cylinder is not within hydrotest date as required, 2) Ansul regulator testing is not within the required test date, 3) manual pull not tripped and functioning properly as required, 4) all cables and pulleys are not in acceptable condition as required, and 5) release mechaism is not operating as required. The system is identified as not in compliance with NFPA standards.

1) During the validation survey on April 29, 2019 at 1015 hours it was determined through review of the hospital's records and interview with the hospital staff that the wet standpipe system(s) in the hospital building is not documented as having a required annual inspection and test of the system(s) within the past year. Also, the dry standpipe system(s) for the hospital parking garage structure is not documented as having a 5-year hydrostatic test, flow test, or an annual inspection and test since 1/18/2010.

2) During the validation survey on April 29, 2019 at 1400 hours it was determined through observation of the physical environemt and interview with the hopsital staff that 23 of 23 automatic sprinkler heads in the ambulance area are showing visual signs of corrosion.

During the validation survey on April 29, 2019 at 1345 hours it was determined through observation of the physical environment and interview with the faciility staff that in the egress corridor at O C 252 there was a 1 cubic yard (approx 173 gallons) wheeled trash container that was unattended.