HospitalInspections.org

Based on interviews on 1/03/2022-1/07/2022 the facility started a project within the hospital, with out submitting a application to our office.
§133.167 (g)(3) Minor project. If a hospital owner/operator believes that a proposed project is a minor project as described in §133.161(a)(2)(C) of this title (relating to Requirements for Buildings in which Existing Licensed Hospitals are Located), the hospital owner/operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work.

Based on observations made on 1/03/2022 - 01/07/2022 the facility failed to maintain 8 feet in patient corridors. It was observed on several floors that storage and beds were being left in the hallways, thus not maintaining the required 8 foot width of aisles and corridors.

Based on observations made from 1/03/2022 - 1/07/2022 the facility failed to properly secure the high and low pressure oxygen in the required rooms 1 hour rating 360 degrees around the room. Based on observations made on my exit 01/07/2022 the high and low pressure tanks are not located in any rated room, and the tanks are not secure or stored properly.

Based on an observation made on 1/04/2022 the facility failed to maintain the cleanness of the filters in the kitchen hood. It was observed that several filters have a large amount of grease build up on them.

Based on observations made on 1/03/2022 and also based on several interviews and formal questions, the facility failed to have its fire alarm system tested and inspected properly during the required intervals yearly. The facility failed to inspect its fire alarm system at least twice a year from 2019-2021

Based on observations made from 1/03/2022 - 1/07/2022 the facility failed to maintain the fire sprinkler heads in the facility. Two locations in the hospital had sprinkler heads to close to the ceiling. These sprinkler heads needed to be lowered to the proper height to provide adequate protection.
"Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.." - NFPA 13; 2010: 8.5.5.2.1?
"Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3." - NFPA 13; 2010: 8.5.5.3*

Based on observations made on 1/03/2022 and several interviews of the Director of facilities, the facility failed to have its sprinkler system inspected at the required intervals yearly. At least 2 quarterly fire sprinkler inspections were missed from 2019-2021.

Based on an observation made on 1/07/2022 the facility failed to adequately maintain the ICU roof top HVAC units. The filers in the roof top units were damaged or completely plugged up with dirt. All pre filters and final filters were affected.