HospitalInspections.org

Based on observation and interview, the facility failed to meet requirements for one of over ten egress doors.

Findings include:

Observation on April 26, 2023, at 11:41 a.m., revealed the first floor emergency exit door, located in the nuclear medicine area, required significant force to open.

Interview with the maintenance director on April 26, 2023, at 11:41 a.m., confirmed the above egress door required significant force to open.

Based on observation and interview, the facility failed to meet emergency lighting requirements in one of six locations.

Findings include:

Observation on April 26, 2023, at 1:01 p.m., revealed the second floor OB delivery room emergency light did not illuminate when tested.

Interview with the maintenance director on April 26, 2023, at 9:52 a.m., confirmed the above emergency light did not illuminate when tested.

Based on observation and interview, the facility failed to meet requirements for one of over ten hazardous enclosures.

Findings include:

Observation on April 26, 2023, at 12:50 p.m., revealed the second floor soiled utility door, located across from room 2704, failed to positively latch in the frame.

Interview with the maintenance director on April 26, 2023, at 12:50 p.m., confirmed the above soiled utility room door failed to latch in the frame.

Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of one system.

Findings include:

1. Document review on April 26, 2023, at 9:20 a.m., revealed the following deficiences on the fire alarm inspection report, conducted March 31, 2023. The facility was unable to provide documentation that the deficiencies were corrected at the time of the survey:
A. (9:20 a.m.) Six duct detectors could not be located and were not inspected;
B. (9:20 a.m.) Seven heat detectors failed.

Interview with the maintenance director on April 26, 2023, at 9:20 a.m., confirmed the above inspection deficiences were not corrected.

2. Observation on April 26, 2023, at 1:20 p.m., revealed the fire panel had a trouble signal present on the fire alarm panel.

Interview with the maintenance director on April 26, 2023, at 1:20 p.m., confirmed the trouble signal was present due to construction.

Based on document review and interview, the facility failed to meet sprinkler system testing and maintenance requirements for one of one system.

Findings include:

Document review on April 26, 2023, at 1:10 p.m., revealed the facility was unable to provide documentation for sprinkler gauge replacements.

Interview with the maintenance director on April 26, 2023, at 1:10 p.m., confirmed the facility did not have sprinkler gauge replacement documentation at the time of the survey.

Based on observation and interview, the facility failed to meet requirements for one of over five smoke compartments.

Findings include:

1. Observation on April 26, 2023, at 12:22 p.m., revealed the second floor electrical room, located across from the sim lab, had an unsealed penetration with blue wires fed through the smoke wall.

2.Observation on April 26, 2023, at 11:53 a.m., revealed the first floor electric room 'L21' had an open penetration located around a piece of conduit.

Interview with the maintenance director on April 26, 2023, at 11:53 a.m., confirmed the above deficiencies.

Based on document review and interview, the facility failed to meet requirements for HVAC systems for one of one system.

Findings include:

Document review on April 26, 2023, at 10:02 a.m., revealed the facility was unable to provide fire/smoke damper inspection documentation at the time of the survey.

Interview with the maintenance director on April 26, 2023, at 10:02 a.m., confirmed the facility was unable to provide the above documentation. The facility is in the process of scheduling a fire/smoke damper inspection.

Based on document review, observation, and interview, the facility failed to meet door maintenance and testing requirements for one of one facility.

Findings include:

1. Document review on April 26, 2023, at 9:52 a.m., revealed the facility's last documented annual door inspection was completed between January and March of 2022.

Interview with the maintenance director on April 26, 2023, at 9:52 a.m., confirmed the last annual fire door inspection was completed between January and March of 2022.


2. Observation on April 26, 2023, at 11:43 a.m., revealed the trauma bay fire door failed to positively latch without additional force.

3. Observation on April 26, 2023, between 9:00 a.m. and 2:00 p.m., revealed the door and frame rating tags on the first floor were painted over and illegible.

Interview with the maintenance director on April 26, 2023, at 2:00 p.m., confirmed the above fire door failed to latch without additional force.

Based on document review and interview, the facility failed to meet gas and vacuum-piped system inspection and testing operation requirements for one of one system.

Findings include:

Document review on April 26, 2023, at 9:44 a.m., revealed the medical gas inspection report, dated July 21, 2022, listed a leaking oxygen outlet in the nursery. The facility failed to provide documentation that the deficiency was corrected at the time of the survey.

Interview with the maintenance director on April 26, 2023, at 9:44 a.m., confirmed the deficiency was not corrected, and that parts were on order.

Based on observation and interview, the facility failed to meet requirements for two of two generator annunciator panels.

Findings include:

Observation on April 26, 2023, at 1:40 p.m., revealed the following generator annunciator panel deficiencies:
A. (1:40 p.m.) The hospital generator annunciator panel's alarm speaker was taped over;
B. (1:40 p.m.) The hospital generator annunciator panel's lamps did not illuminate when tested;
C. (1:40 a.m.) The emergency room generator annunciator panel was in fault mode due to contruction.

Interview with the maintenance director on April 26, 2023, at 1:40 p.m., confirmed the above deficiencies.

Based on document review and interview, the facility failed to meet essential electrical equipment requirements for one of two generators.

Findings include:

Document review on April 26, 2023, at 9:33 a.m., revealed the fuel sample, dated February 8, 2023, was rated abnormal and required fuel polishing. The facility failed to have the deficiency corrected at the time of the survey.

Interview with the maintenance director on April 26, 2023, at 9:33 a.m., confirmed the above fuel sample deficiency was not corrected.

Based on observation and interview, the facility failed to meet electrical equipment requirements for one of over fifty rooms.

Findings include:

1. Observation on April 26, 2023, at 12:10 p.m., revealed the penthouse had an extension cord plugged in, with heat tape wrapped around it and duct taped to the sprinkler line.

2. Observation on April 26, 2023, at 12:19 p.m., revealed the first floor office 'A15' had two power strips plugged into each other.

Interview with the maintenance director on April 26, 2023, at 12:19 p.m., confirmed the above extension cord was in use and taped to the sprinkler line.