HospitalInspections.org

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the smoke partitions of the hospital were incomplete at the following locations:

? The cross corridor door on the fourth floor did not close smoke tight as there were gaps more that 1/8th of an inch.
? The smoke wall near room 3236 is not complete and needs to be verified by the facility.
? Unsealed penetrations above the door near room 5222. Corridor side between rooms 5240 and 5242.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the following hazardous areas were found to be in compliance in the following locations:
? The old CT room was being used as storage on that floor.
? The door to the soiled linen room in the dialysis suite was blocked from closing with equipment that was stored in the room.
? The two hour protected elevator room door could not be verified as having a rating.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the facilities special locking doors still have the magnets and the strikes on them giving the facility the ability to energize them. The facility noted that these devices were no long in use.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010, documentation review noted the following fire drills were noncompliant: Specific findings include, the fire drill records did not indicate that drills were being conducted on the weekend shifts for the 1st and 4th quarter of 2009.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the facility had:
? a large amount of dust and lint on the sprinkler heads above the air handlers in the fourth floor mechanical room.
? sprinkler heads in rooms 3245 and 3251 were green in color with oxidation.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 there were no access doors for servicing or maintained Smoke Dampers and Duct detectors at the following locations:
? Corridor side near room 4212 (Smoke Damper)
? Mechanical room within the dining room (Duct Detector)

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the small in-wall cabinets and larger wall Cabinets on the old labor and delivery wing open into the corridors more than seven inches and did not retract when opened.

Based on the observations and staff interview during the tour between 2/22/2010 and 2/25/2010 the oxygen cylinders full and empty mixed and not labeled properly at these locations:
? At the nurses station on the 5th floor.
? At Radiology
? Oxygen storage in the basement storage area on the right hand side as you go down the corridor did not have proper signs noting oxygen storage.
? Oxygen cylinders not individually chained in the bulk storage area near facilities office main medical gas room has its cylinders were not individually chained.

By observation, oxygen cylinders were not properly chained or supported in a proper cylinder stand or cart.[NFPA 99 Sections 4-3.5.2.1b(27) and 4-5.1.1.1 ]

Provisions shall be made for racks or fastenings to protect cylinders form accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]