HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire rated floor/ceiling assembly in two instances, affecting three of four floors.

Findings Include:

1. Observation on June 5, 2017, at 1:14 p.m., revealed the second floor teledata room had multiple improperly sealed 4-inch conduit penetrations, opening to the third floor and multiple open and improperly sealed 4-inch conduit penetrations, opening to the first floor.

Interview with the Facility Administrator and Maintenance Director on June 5, 2017, at 2:30 p.m., confirmed the improperly sealed and open conduits were present.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting one of four floors.

Findings include:

1. Observation on June 5, 2017, at 1:55 p.m., revealed improperly sealed penetrations on both sides of the smoke barrier wall, above the 3rd floor Yellow Unit corridor smoke barrier doors.

Interview with the Facility Administrator and Maintenance Director on June 5, 2017, at 2:30 p.m., confirmed the improperly sealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in one instance, affecting one of four floors.

Findings include:

1. Observation on June 5, 2017, at 1:45 p.m., revealed an unsecured oxygen cylinder and the empty oxygen cylinders were not segregated from the full cylinders, in the third floor oxygen store room 356.

Interview with the Facility Administrator and Maintenance Director on June 5, 2017, at 2:30 p.m., confirmed the medical gas storage issues were present.