HospitalInspections.org

Based on observation and interview, the facility failed to inspect doors with closures for one of over fifty doors.

Findings include:

Observation on January 25, 2024, at 12:30 p.m., revealed door 345, third floor, would not fully close and latch in the frame.

Interview with the maintenance technician on January 25, 2024, at 12:30 p.m., confirmed the door would not close and latch.

Based on observation and interview, the facility failed to install a sprinkler head, per NFPA requirements, in one of over ten corridors.

Findings include:

Observation on January 25, 2024, at 10:17 a.m., revealed the facility did not have a sprinkler head in the x-ray department corridor. The facility lacked sprinkler drawings to verify adequate sprinkler coverage.

Interview with the maintenance supervisor on January 25, 2024, at 10:17 a.m., confirmed the deficiency existed at the time of the survey.

Based on observation and interview, the facility failed to maintain the sprinkler system on one of three building levels.

Findings include:

Observation on January 25, 2024, at 11:14 a.m., revealed the first floor x-ray department had a gap present between the escutcheon plate and the ceiling tile. A gap around the escutcheon plate could cause a delay in sprinkler activation.

Interview with the maintenance technician on January 25, 2024, at 11:14 a.m., confirmed the gap between the escutcheon plate and ceiling tile.

Based on observation and interview, the facility failed to maintain rated corridor fire barriers, per building specifications and NFPA requirements, on one of three building levels.
Findings include:
Observation on January 25, 2024, at 10:43 a.m., revealed an open section of rated wall measuring approximately 21 square feet, between corridor 107 and the security command room. The facility drawings indicated that this was part of the two-hour rated wall assembly that extended throughout the corridor.
Interview with the maintenance technician on January 25, 2024, at 10:43 a.m., confirmed the incomplete fire barrier above the ceiling tile.

Based on observation and interview, the facility failed to maintain electrical receptacles on two of three building levels.

Findings include:

Observation on January 25, 2024, between 9:00 a.m. and 2:00 p.m., revealed the first and second floors had electrical outlets located in multiple areas in close proximity to water sources. The outlets were not protected by ground fault circuit interrupters (GFCI).

Interview with the maintenance supervisor on January 25, 2024, at 2:00 p.m., confirmed the receptacle deficiencies.