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WAYNE MEMORIAL HOSPITAL
Doors with Self-Closing Devices
Tag No.: K0223
Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting three of four floors.
Findings include:
1. Observation on April 19, 2022, between 8:30 a.m. and 12:45 p.m., revealed the following:
a. 8:30 a.m. - The 4th floor, common wall doors to the 02 building could not close and latch.
b. 10:20 a.m. - The 2nd floor Medical Records room door was chocked open.
c. 12:45 p.m. - The 1st floor domestic hot water room door closer was disabled.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the door deficiencies.
Stairways and Smokeproof Enclosures
Tag No.: K0225
Based on observation and interview, it was determined the facility failed to maintain exit stair towers, affecting four of four floors.
Findings include:
1. Observation on April 19, 2022, at 10:00 a.m., revealed a Mechanical room door opening directly into the 2nd floor ICU south stair tower.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the Mechanical room door deficiency.
Emergency Lighting
Tag No.: K0291
Based on observation and interview, it was determined the facility failed to maintain battery powered emergency lighting units, affecting one of four floors.
Findings include:
1. Observation on April 19, 2022, at 9:30 a.m., revealed the lack of battery powered emergency lighting units located in the 2nd floor Endoscopy Procedure Rooms, which would automatically illuminate in the event of a normal power disruption.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the lack of battery back-up emergency lighting.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting one of six floors.
Findings include:
1. Observation on April 19, 2022, at 2:20 p.m., revealed an unsealed penetration located in the 3rd floor Electrical room.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the penetration.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler systems, affecting one of four floors.
Findings include:
1. Observation on April 19, 2022, at 2:45 p.m., revealed wires attached to the sprinkler piping located at the 1st floor Cardiology Waiting room.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the wires attached to the sprinkler piping.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one-half hour fire resistance rating, affecting one of six floors.
Findings include:
1. Observation on April 19, 2022, at 2:00 p.m., revealed unsealed penetrations located above the cross-corridor doors near room #326.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the penetrations.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one-half hour fire resistance rating, affecting two of four floors.
Findings include:
1. Observation on April 19, 2022, between 8:15 a.m. and 11:20 a.m., revealed unsealed penetrations in the following locations:
a. 8:15 a.m. - The 4th floor Clinic Registration room.
b. 11:20 a.m. - The 1st floor Radiology Breakroom.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the penetrations.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0374
Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors, affecting one of four floors.
Findings include:
1. Observation on April 19, 2022, at 8:12 a.m., revealed the 4th floor Clinic Registration room smoke barrier door lacked fire-rated glass.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the glass was not fire-rated.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting one of four floors.
Findings include:
1. Observation on April 19, 2022, at 11:20 a.m., revealed the 1st floor Radiology Breakroom had an unauthorized surge protector in use for a microwave oven.
Exit interview with facility representative #1, on April 19, 2022, at 2:45 p.m., confirmed the surge protector in use.