HospitalInspections.org

Based on observation and interview it was determined the facility failed to maintain the required fire resistance between floors, affecting two of four floors.

Findings include:

1. Observation on November 5, 2024, at 12:20 p.m., revealed a four-inch PVC pipe through the basement ceiling outside the electrical office #0305 lacked a fire collar.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the lack of an approved fire stop system for the PVC pipe penetration.

Based on observation and interview, it was determined the facility failed to maintain means of egress free and unobstructed on one of two floors.

Findings include:

1. Observation on November 5, 2024, at 12:14 p.m., revealed wooden skids and storage containers were being stored in the lab corridors.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the items were being stored in the corridors.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on three of four floors.
Findings include;
1. Observation on November 5, 2024, between 9:30 a.m., and 12:17 p.m., revealed the following hazardous area doors failed to latch in the corresponding frame.
a. At 9:30 a.m., 3rd floor, equipment storage room.
b. At 11:15 a.m., 1st floor, storage room 1485.
c. At 12:04 p.m., basement, transformer room 0835.
d. At 12:17 p.m., basement, mechanical room 0311.
Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the doors lacked positive latching.

2. Observation on November 5, 2024, at 12:28 p.m., revealed an unsealed pipe penetration around a 2 inch pipe near the single door #100 of the basement mechanical room.
Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the space around the pipe was not sealed.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers on one of four floors.
Findings include:
1. Observation on November 5, 2024, at 10:13 a.m., revealed a portable fire extinguisher outside room 2341 was blocked from immediate use by a bed.
Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the bed was blocking access to the fire extinguisher.

Based on observation and interview, it was determined the facility failed to maintian the required smoke resistance of corridor walls on one of four floors.

Findings include:

1. Observation on November 5, 2024, at 12:30 p.m., revealed a pipe penetration of the corridor wall near door d0140 in the basement IT department.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the pipe penetration was not sealed.

Based on observation and interview, it was determined the facility failed to maintain corridor openings on two of four floors.

Findings include:

1. Observation on November 5, 2024, between 10:00 a.m., and 12:17 p.m., revealed the following:

a. At 10:00 a.m., Room 2202 not smoke tight.
b. At 10:05 a.m., Room 2206 failed to latch.
c. At 10:39 a.m., Room 2502 not smoke tight.
d. At 12:17 p.m., Basement level, Biomedical room door, was warped and could not properly close into corresponding frame

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the piped in medical gas system on one of four floors.

Findings include:

1. Observation on November 5, 2024, at 12:02 p.m., revealed steel metallic cabling in contact with a copper medical gas line in mechanical room 0813.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the steel cabling in contact with the copper pipe.

Based on observation and interview, it was determined the facility failed to maintain the electrical system wiring components on one of four floors.

Findings include:

1. Observation on November 5, 2024, at 10:13 a.m., revealed an open junction box in room 2335, 2nd floor.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the junction box lacked a cover.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of multiple outlet power taps.

Findings include:

1. Observation on November 5, 2024, at 11:10 a.m., pharmacy on the 1st floor, multiple outlet power tap was powering several small appliances.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the power tap was powering non-electronic appliances.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of an outlet multiplier on one of three floors, of this component.

Findings include:

1. Observation on November 5, 2024, at 10:10 a.m., 1st floor, Staff Lounge, revealed a outlet multiplier used to power a coffee maker.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on November 5, 2024, at 1:00 p.m., confirmed the outlet multiplier was being used for non-electronic appliances.