HospitalInspections.org

Based on observation and interview the facility did not ensure all corridors were maintained with at least ½ hour fire resistance rating.

Findings include:

During the facility tour on 06/05/2019 at 9:45AM, it was observed that above the drop ceiling in the corridor, outside of room 121, there was a 2-inch diameter, round, ducting that penetrated the corridor wall into room 121 which went to an exhaust grate. A large, 3-feet by 2-feet, section of drywall was removed from the corridor side. There was no indication the ½ hour fire resistance rating had been maintained.

Interview with Staff (Z), Mechanic, on 06/05/2019 at 9:45AM verified this finding.

Based on observation and interview, the facility did not ensure that all doors in corridor openings were constructed of material that resists fire for a minimum of 20 minutes.

Findings include:

During the facility tour, on 06/05/2019 at 10:15AM, it was observed that the doors to room 343, 350a, and the double doors to 350, had in each of the upper half of the doors a piece of clear plastic 2.5 feet by 2.5 feet. There was no indication of a fire resistance rating for the plastic.

Interview with Staff (Z), Mechanic, on 06/05/2019 at 10:30AM verified this finding.

Based on observation and interview the facility did not ensure that corridor walls were at minimum at least a ½ hour fire resistance rating.

Findings include:

During the facility tour, in the basement, on 06/04/2019 at 11:00AM, it was observed there was a 1 foot by 1.5 foot transfer grill in the corridor wall that communicated with the medical records room. The corridor is not sprinklered. This corridor is utilized by patients as the Bistro is located on this floor.

Interview with Staff (B), VP of Corporate Compliance, on 06/04/2019 at 11:00AM verified this finding.

Based on observation and interview the facility did not maintain the facility free of potential fire hazards.

Findings include:

During the facility tour, on 06/04/2019 at 10:15AM, in the elevator machine room, for the main elevator, there were three cloths, that were oil stained and two paper towels, that were saturated with oil on the floor of the room.

Interview with Staff (B), VP of Corporate Compliance, on 06/05/2019 at 10:15AM verified this finding.

Based on observation and interview the facility did not ensure that all medical gas cylinders were secured to prevent tipping over.

Findings include:

During the facility tour, on 06/05/2019 at 1:15PM, it was revealed that the was an oxygen H-tank in the electro-convulsive therapy room, that was on a floor stand. The thumb screw, that secures the tank to the stand, was not threaded to engage and secure the tank, making the tank subject to tipping.

Interview with Staff (B), VP of Corporate Compliance, on 06/05/2019 at 2:00PM verified this finding.