HospitalInspections.org

Based on observation, it was revealed that the facility failed to mainntin the exit doors.

Findings include:
Between the hours of 1:30 pm and 2:30 pm it was found that there were doors in the faciity that were hard to open.

Examples include:

1) Room doors 135, 138 were hard to open.
2) D-14 double exit doors at ground level are hard to open to exit the facility.


The Director of Plant Operations confirmed these findings.

Based on observation and interview, it was revealed that the facility had a Dead-End corrdior in the Mobile MRI area.

Findings include:

On 11-6-19 at approximately 2:45 pm, it was revealed that a 39 foot Dead-End corridor was in the Mobile MRI area. The end of the corrdor had a door that was locked, and the exit sign had been removed. It was marked as NO EXIT.

Based on observation, the facility failed to maintain smoke resisting partition and doors separating the laboratory from other areas.

Findings include:

On 11-6-19 at approximately 2:35 pm it was revealed that the partitions separating the laboratory from other spaces could not be identified. This findings were confirmed by the Director of Plant Operations.

Based on observation and interview, it was revealed that the kitchen and dishwashing areas were open to the corridor.

Findings include:

On 11-6-19 at approximately 2:50 pm it was revealed that there were no doors separating the kitchen and dishwashing area from the exit corridor. These findings were confirmed by the Director of Plant Operations.

Based on interview and record review, the sensitivity test report for the smoke detectors was not available. Based on observation, an initiating device in the elevator mechanical room was missing a cover plate.

Findings include:

On 11-6-19 between the hours of 11:15 am and 2:30 pm it was revealed that the sensitivity test results for all the smoke and duct detectors in the building could not be located, and an initating device in the elevator mechanical room was missing a cover plate. The Direcor of Plant Operations confirmed these findings.

Based on observation, it was revealed that the facility failed to properly maintain the smoke and fire resistance of the corridor walls in the facility, and in the ceiling of the elevator equipment room.

Findings include:

On 11-6-19 at approximately 1:30 pm to 2:00 pm it was revealed that there were multiple unsealed penetrations above the drop ceilings. Examples include near room 102 (5 unsealed penetrations, near room 104 (4 unsealed penetrations) and near room 108 (a 3" x 3" unsealed penetration/opening). These findings were confirmed by the Director of Plant Operations.

on 11-6-19 at approximate 2:15 pm it was revealed that combustible orange foam was used as a fire stop in elevator equipment room. These findings were confirmed by the Director of Plant Operations.

Based on observation, it was revealed that the facility was not maintaining a safe distance of combustible material from a water heater.

Findings include:

On 11-6-19 at approximately 2:40 pm it was revealed that the Basement hallway had combustible material within three feet of a water heater. This was confirmed by the Director of Plant Operations. The material was moved beyond three feet at the time of the survey (corrected).

Based on observation and interview it was revealed that the facility failed to properly maintain cylinder storage.

Findings include:

On 11-6-19 at approximately 2:30 pm it was observed that there were seven gas cylinders in the EC-S1 Equipment Room in the OR Suite not marked as full or empty. The room was not designed for cylinder storage. This was confirmed by the Director of Plant Operations.