HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain two-hour fire barriers that separated the Type II (000) fire sprinkled areas from the Type II (111) non-fire sprinkled areas. This condition would allow fire to spread past the fire barriers.

Findings are:
Observation during the facility tour on 3/22/16, from 11:39 am to 11:49 am revealed:
1. A hole around a plastic conduit in the two-hour fire barrier by Therapy above the suspended ceiling failed to be sealed on both sides of the barrier.
2. A hole around a plastic conduit in the two-hour fire barrier by the Vending Room above the suspended ceiling failed to be sealed on both sides of the barrier.

In an interview conducted at the time of observation, (3/22/16, from 11:39 am to 11:49 am), Maintenance A confirmed the unsealed penetrations.

Based on observation and staff interview, the facility failed to provide positive latching hardware for the Acute Wing IT Room corridor door, so the door resisted the passage of smoke. This condition would allow smoke to migrate into the exit corridor.
Findings are:
Observation during the facility tour on 3/22/16, at 11:23 am revealed the Acute Wing IT Room corridor door failed to have positive latching hardware installed in the door. The door was held shut by a deadbolt lock, only.
In an interview conducted at the time of observation, (3/22/16, at 11:23 am), Maintenance A acknowledged that the door failed to latch.

Based on observation and staff interview, the facility failed to provide self-closing doors for the X-Ray Storage Room and the Sterilizer Room. This condition would allow smoke and fire to migrate into the exit corridor.

Findings are:
Observation during the facility tour on 3/22/16, from 11:04 am to 11:10 am revealed:
1. The X-Ray Storage Room door that separated the storage room from the X-Ray failed to self-close. Combustible storage was stored in the room that exceeded 50 square feet.
2. The Sterilizer Room, which contained a sterilizer classified as a boiler, failed to be separated from the exit corridor by a self-closing door.

In an interview conducted at the time of observation, (3/22/16, from 11:04 am to 11:10 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment as listed. This condition would potentially cause an electrical fire.

Findings are:
Observation during the facility tour on 3/22/16, from 10:47 am to 11:40 am revealed:
1. Two open junction boxes in the Boiler Room behind the boilers on the exterior wall failed to have covers installed on the boxes.
2. A light fixture hung by the wires in the X-Ray Storage Room, and failed to be secured to the ceiling.
3. Microwaves, toasters and other appliances were plugged into power strips in the Therapy Closet, and the high current draw appliances failed to be plugged directly into hardwired outlets.

In an interview conducted at the time of observation, (3/22/16, from 10:47 am to 11:40 am), Maintenance A acknowledged the findings.