HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the floor-ceiling separation, for two of three floors within the component.

Findings include:

1. Observation on May 13, 2019, at 2:07 PM revealed a partially-sealed 5" sleeve in the floor of the 3rd floor Endo Suite Electrical Closet, by Room 385.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain the rating of the smoke barrier walls, in four of twenty smoke zones within the component.

Findings include:

1. Observation on May 14, 2019, at 11:25 AM revealed a penetration of a bundle of yellow cables above the smoke barrier doors, by Room 267.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed there was a penetration.


2. Observation on May 14, 2019, at 1:04 PM revealed a penetration of a 4-inch hot water line above the smoke barrier doors, outside the Maintenance Office on the 1st floor.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed there was a penetration.

Based on document review and interview, it was determined the facility failed to record required information on the weekly and monthly battery checks, in 3 of 3 generators, which serve the component.

Findings include:

1. Review of documentation on May 13, 2019, at 10:30 AM revealed the facility did not note, on the weekly battery inspections, the electrolyte level was being checked.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed the facility had failed to record electrolyte levels were checked.


2. Review of documention on May 13, 2019, at 10:45 AM revealed the facility failed to note, on the monthly battery inspections, the specific gravity level number.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed the facility had failed to record the level number of the specific gravity of the batteries.

Based on observation and interview, it was determined the facility failed to monitor the use of electrical equipment, in one of twenty smoke zones within the component.

Findings include:

1. Observation on May 14, 2019, at 11:37 AM revealed an extension cord was being used to power a microwave oven, in the 1st floor Lab Break Area.

Interview at the time of the exit conference with the President & Chief Executive Officer, the Chief Operations Officer and the Director of Facilities on May 14, 2019, at 2:45 PM confirmed the unauthorized use of an extension cord.