HospitalInspections.org

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on two of three floors.

Findings include:

1. Observation on June 4, 2013 between 10:00 am and 1:00 pm revealed the facility had corridor doors that were being held open with unapproved hold open devices at the following locations:
A. First floor Therapy room double doors were being held open with weights.
B. Ground floor Surgical Waiting room was held open with a wooden wedge.

Interview with the Director of Maintenance on June 4, 2013 at 1:00 pm confirmed the corridors were held open with unapproved hold-open devices.

2. Observation on June 4, 2013 at 11:30 am revealed the Radiology Suite corridor failed to close and latch consistently.

Interview with the Director of Maintenance on June 4, 2013 at 11:30 am confirmed the corridor door lacked positive latching.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one (1) hour on two of three floors.

Findings include:

Observation on June 4, 2013 between 10:05 am and 11:20 am revealed the facility had unsealed floor ceiling penetrations at the following locations:
A. Second floor West housekeeping closet.
B. First floor West housekeeping closet.

Interview with the Director of Maintenance on June 4, 2013 at 11:20 am confirmed the vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of three floors.

Findings include:

Observation on June 4, 2013 at 10:00 am revealed the second floor storage room 215 corridor door was being held open with an unapproved hold-open device (wooden wedge).

Interview with the Director of Maintenance on June 4, 2013 at 10:00 am confirmed the storage room corridor door was held-open with a wooden wedge.

Based on documentation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulation on one of three floors.

Findings include:

1. Observation on June 4, 2013 at 11:30 am revealed the fire extinguisher in the ground floor electrical room was blocked from immediate access by items stored within the room.

Interview with the Director of Maintenance on June 4, 2013 at 11:30 am confirmed the fire extinguisher was blocked from immediate use.

2. Observation on June 4, 2013 at 11:50 am revealed the fire extinguisher in the PACS room was not inspected for the months of April and May 2013.

Interview with the Director of Maintenance on June 4, 2013 at 11:50 am confirmed the fire extinguisher in the PACS room was not inspected for the months of April and May 2013.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of three floors.

Findings include:

Observation on June 4, 2013 between 9:50 am and 11:20 am revealed the facility was utilizing unapproved electrical practices at the following locations:
A. An extension cord was being utilized in the second floor Cardiac Rehab office.
B. First floor Respiratory office had a refrigerator plugged into a surge protector.
C. Ground floor O.R. break room had a microwave oven plugged into a surge protector.

Interview with the Director of Maintenance on June 4, 2013 at 11:20 am confirmed the facility was utilizing unapproved electrical practices.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations on two of three floors.

Findings include:

1. Observation on June 4, 2013 between 10:00 am and 1:00 pm revealed the facility had corridor doors that were being held open with unapproved hold open devices at the following locations:
A. First floor Therapy room double doors were being held open with weights.
B. Ground floor Surgical Waiting room was held open with a wooden wedge.

Interview with the Director of Maintenance on June 4, 2013 at 1:00 pm confirmed the corridors were held open with unapproved hold-open devices.

2. Observation on June 4, 2013 at 11:30 am revealed the Radiology Suite corridor failed to close and latch consistently.

Interview with the Director of Maintenance on June 4, 2013 at 11:30 am confirmed the corridor door lacked positive latching.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one (1) hour on two of three floors.

Findings include:

Observation on June 4, 2013 between 10:05 am and 11:20 am revealed the facility had unsealed floor ceiling penetrations at the following locations:
A. Second floor West housekeeping closet.
B. First floor West housekeeping closet.

Interview with the Director of Maintenance on June 4, 2013 at 11:20 am confirmed the vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of three floors.

Findings include:

Observation on June 4, 2013 at 10:00 am revealed the second floor storage room 215 corridor door was being held open with an unapproved hold-open device (wooden wedge).

Interview with the Director of Maintenance on June 4, 2013 at 10:00 am confirmed the storage room corridor door was held-open with a wooden wedge.

Based on documentation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulation on one of three floors.

Findings include:

1. Observation on June 4, 2013 at 11:30 am revealed the fire extinguisher in the ground floor electrical room was blocked from immediate access by items stored within the room.

Interview with the Director of Maintenance on June 4, 2013 at 11:30 am confirmed the fire extinguisher was blocked from immediate use.

2. Observation on June 4, 2013 at 11:50 am revealed the fire extinguisher in the PACS room was not inspected for the months of April and May 2013.

Interview with the Director of Maintenance on June 4, 2013 at 11:50 am confirmed the fire extinguisher in the PACS room was not inspected for the months of April and May 2013.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of three floors.

Findings include:

Observation on June 4, 2013 between 9:50 am and 11:20 am revealed the facility was utilizing unapproved electrical practices at the following locations:
A. An extension cord was being utilized in the second floor Cardiac Rehab office.
B. First floor Respiratory office had a refrigerator plugged into a surge protector.
C. Ground floor O.R. break room had a microwave oven plugged into a surge protector.

Interview with the Director of Maintenance on June 4, 2013 at 11:20 am confirmed the facility was utilizing unapproved electrical practices.