HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to ensure the two hour common wall and/or doors in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 11:45 AM revealed the fire barrier doors at Radiology lacked positive latching with the self-closer.

Interview with the Director of Facilities on September 13, 2016 at 11:45 AM confirmed the fire barrier doors lacked positive latching with the self-closer.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 10:30 AM revealed the corridor door for the Public Meeting room lacked positive latching in its' frame.

Interview with the Director of Facilities on September 13, 2016 at 10:30 AM confirmed the corridor lacked positive latching in its' frame.

Based on observation and interview it was determined the facility failed to provide appropriate signage indicating doors or passageways that are not a way of exit which may be mistaken for an exit is properly labeled on one of twelve exit discharges.

Findings include:

Observation on September 13, 2016 at 11:30 AM revealed the corridor doors to the MRI trailer were labeled Emergency Exit. The corridor doors do not provide access to an exit discharge when the MRI trailer was on site.

Interview with the Director of Facilities on September 13, 2016 at 11:30 AM confirmed the labeled doors did not lead to an exit discharge when the MRI trailer was on site.

Based on observation and interview it was determined the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 10:25 AM revealed the smoke wall by room 1307 had unsealed penetrations above the lay-in ceiling, around a cable tray and an unsealed penetration next to the cable tray.

Interview with the Director of Facilities on September 13, 2016 at 10:25 AM confirmed the unsealed penetrations existed.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in compliance in one area of the entire building.

Findings include:

Observation on September 13, 2016, at 1:20 PM revealed that soiled utility room 1710 lacked positive latching with the self-closer.

Interview with the Director of Facilities on September 13, 2016, at 1:20 PM confirmed the soiled utility room lacked positive latching with the self-closer.

Based on observation and interview it was determined the facility failed to maintain the automatic sprinkler system in continuous operating condition in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 11:43 AM revealed, by Radiology room 1540, a red wire and two data wires were draped over the sprinkler pipes.

Interview with the Director of Facilities on September 13, 2016 at 11:43 AM confirmed the wires were draped over the sprinkler pipes.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and equipment in accordance with the National Electric Code in one room in the entire building.

Findings include:

1. Observation on September 13, 2016 at 11:10 AM revealed the Gift Shop had a surge protector suspended from the counter by the surge protector power cord.

Interview with the Director of Facilities on September 13, 2016 at 11:10 AM confirmed the surge protector was suspended by the surge protector power cord.

2. Observation on September 13, 2016, at 11:20 AM revealed the Lab office had an unapproved application of a coffee maker plugged into a surge protector.

Interview with the Director of Facilities on September 13, 2016 at 11:20 AM confirmed the unapproved application of a surge protector.

Based on observation and interview, it was determined that the facility failed to ensure the two hour common wall and/or doors in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 11:45 AM revealed the fire barrier doors at Radiology lacked positive latching with the self-closer.

Interview with the Director of Facilities on September 13, 2016 at 11:45 AM confirmed the fire barrier doors lacked positive latching with the self-closer.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 10:30 AM revealed the corridor door for the Public Meeting room lacked positive latching in its' frame.

Interview with the Director of Facilities on September 13, 2016 at 10:30 AM confirmed the corridor lacked positive latching in its' frame.

Based on observation and interview it was determined the facility failed to provide appropriate signage indicating doors or passageways that are not a way of exit which may be mistaken for an exit is properly labeled on one of twelve exit discharges.

Findings include:

Observation on September 13, 2016 at 11:30 AM revealed the corridor doors to the MRI trailer were labeled Emergency Exit. The corridor doors do not provide access to an exit discharge when the MRI trailer was on site.

Interview with the Director of Facilities on September 13, 2016 at 11:30 AM confirmed the labeled doors did not lead to an exit discharge when the MRI trailer was on site.

Based on observation and interview it was determined the facility failed to maintain smoke barriers with at least a one half hour fire resistance rating in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 10:25 AM revealed the smoke wall by room 1307 had unsealed penetrations above the lay-in ceiling, around a cable tray and an unsealed penetration next to the cable tray.

Interview with the Director of Facilities on September 13, 2016 at 10:25 AM confirmed the unsealed penetrations existed.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in compliance in one area of the entire building.

Findings include:

Observation on September 13, 2016, at 1:20 PM revealed that soiled utility room 1710 lacked positive latching with the self-closer.

Interview with the Director of Facilities on September 13, 2016, at 1:20 PM confirmed the soiled utility room lacked positive latching with the self-closer.

Based on observation and interview it was determined the facility failed to maintain the automatic sprinkler system in continuous operating condition in one area of the entire building.

Findings include:

Observation on September 13, 2016 at 11:43 AM revealed, by Radiology room 1540, a red wire and two data wires were draped over the sprinkler pipes.

Interview with the Director of Facilities on September 13, 2016 at 11:43 AM confirmed the wires were draped over the sprinkler pipes.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and equipment in accordance with the National Electric Code in one room in the entire building.

Findings include:

1. Observation on September 13, 2016 at 11:10 AM revealed the Gift Shop had a surge protector suspended from the counter by the surge protector power cord.

Interview with the Director of Facilities on September 13, 2016 at 11:10 AM confirmed the surge protector was suspended by the surge protector power cord.

2. Observation on September 13, 2016, at 11:20 AM revealed the Lab office had an unapproved application of a coffee maker plugged into a surge protector.

Interview with the Director of Facilities on September 13, 2016 at 11:20 AM confirmed the unapproved application of a surge protector.