HospitalInspections.org

Based on facility tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a one half hour fire resistance rating. Additionally, this facility failed to ensure the two hour fire rated barrier which served as a smoke barrier was constructed to provide at least a one half hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 309.

Findings include:

Facility tour of the first floor took place on 03/06/12 with staff members O and P. During tour of building T observation was made of the double smoke barrier door number 1079 having a gap greater than one eighth inch between the door leafs when in the closed position.
Additionally, just north of J1500 and above the ceiling tile, observation was made of one small hole, two unsealed three inch insulated lines and one unsealed flex line.

North of T1152 to the right of the double doors and above the ceiling tiles observation was made of two one inch holes.

One open end conduit observed above the ceiling tile near A152.

Approximately midway within the corridor separating the M building from the X building and near the exit sign observation was made of four penetrations in the two hour fire rated construction above the ceiling tile as: one unsealed black wire, two small holes and one unsealed bundle of blue and white wires.


These findings were verified by both staff members during tour of the first floor smoke barriers. On 03/08/12 staff member P stated all deficiencies were addressed on this floor.

Based on facility tour and staff verification it was determined this facility failed to ensure the laundry chute which opened directly onto a corridor was protected with at least a one hour fire rated construction. This had the potential to affect all those utilizing this area of the facility. The neonatal patient census at the time of the survey was 16.

Findings include:

Tour of the neonatal care unit within the one hour smoke barrier and and third floor area beyond the smoke barrier to the outer walls took place on 03/07/12 with staff members P and S. Observation was made of a laundry chute door located outside the smoke compartment of the neonatal care unit and adjacent to the elevators. This laundry chute door was open to the corridor and failed to latch shut when tested. This was verified by staff P and S during tour.
This writer was notified on 03/08/12 by staff P that the door in question had been repaired.