HospitalInspections.org

Based on observations during facility walk through inspection with the hospital administrator and plant manager on 05/02/2012, it was noted that one set of cross-corridor smoke barrier doors (located near the respiratory therapy department) did not close fully during the testing of the fire alarm system. the doors were held open by magnetic hold-open devices which released when the fire alarm system was activated during the test. They failed to close completely, leaving a large vertical air gap between the meeting edges of the pair of door leafs.

Based on observations during the walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, it was noted that the face of the fire alarm master panel lacked identifying labeling listing the electrical panel and individual circuit numbers supplying power to the fire alarm system. The system was powered from circuits # 9 and #11 of Life Safety Branch panel "EL".

Based on observations during the walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, the following conditions were noted;

(a). a closet labeled "Biohazard Storage" was not provided with a mechanical ducted exhaust system.

(b). the HVAC unit (located on the roof) serving the Surgical Suite lacked a functioning manometer gauge to monitor the effectiveness of the final filter. One of the sensing tubes across the final filter bed was disconnected.

Based on discussions and observations during the facility walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, it was noted that there was no remote alarm annunciator panel for the emergency generator located at the plant manager's office or work area. A remote annunciator panel was located at the 24 hour staffed main nurse station. However the Code also requires that an additional annunciator be located at the office/work area of the person responsible for maintaining the generator.

Based on observations during facility walk through inspection with the hospital administrator and plant manager on 05/02/2012, it was noted that one set of cross-corridor smoke barrier doors (located near the respiratory therapy department) did not close fully during the testing of the fire alarm system. the doors were held open by magnetic hold-open devices which released when the fire alarm system was activated during the test. They failed to close completely, leaving a large vertical air gap between the meeting edges of the pair of door leafs.

Based on observations during the walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, it was noted that the face of the fire alarm master panel lacked identifying labeling listing the electrical panel and individual circuit numbers supplying power to the fire alarm system. The system was powered from circuits # 9 and #11 of Life Safety Branch panel "EL".

Based on observations during the walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, the following conditions were noted;

(a). a closet labeled "Biohazard Storage" was not provided with a mechanical ducted exhaust system.

(b). the HVAC unit (located on the roof) serving the Surgical Suite lacked a functioning manometer gauge to monitor the effectiveness of the final filter. One of the sensing tubes across the final filter bed was disconnected.

Based on discussions and observations during the facility walk through inspection of the facility with the hospital administrator and plant manager on 05/02/2012, it was noted that there was no remote alarm annunciator panel for the emergency generator located at the plant manager's office or work area. A remote annunciator panel was located at the 24 hour staffed main nurse station. However the Code also requires that an additional annunciator be located at the office/work area of the person responsible for maintaining the generator.