HospitalInspections.org

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide hazardous areas with separation from other portions of the building as required.

Findings:

1. The door closing device on the rear access door to the autoclaves was observed to be disconnected.

2. Four unsealed ceiling penetrations were observed in the autoclave room.

3. The autoclave room main door did not close to positive latch when allowed to self-close.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide unimpeded egress from all portions of the building as required.

Findings:

Deadbolt hooklatch devices were observed installed on the two main entrance power sliding doors.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not conduct fire drill at one per quarter per shift as required.

Findings:

The hospital could not provide documentation that 6 of 8 required fire drills were conducted during the previous twelve month period.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide remote generator annunciation as required.

Findings:

The hospital emergency generator did not provide control panel information to a constantly staffed location as required per NFPA 99 and NFPA 110.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide hazardous areas with separation from other portions of the building as required.

Findings:

1. The door closing device on the rear access door to the autoclaves was observed to be disconnected.

2. Four unsealed ceiling penetrations were observed in the autoclave room.

3. The autoclave room main door did not close to positive latch when allowed to self-close.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide unimpeded egress from all portions of the building as required.

Findings:

Deadbolt hooklatch devices were observed installed on the two main entrance power sliding doors.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not conduct fire drill at one per quarter per shift as required.

Findings:

The hospital could not provide documentation that 6 of 8 required fire drills were conducted during the previous twelve month period.

Based on observation during the life safety survey completed on 08/23/2011, the hospital did not provide remote generator annunciation as required.

Findings:

The hospital emergency generator did not provide control panel information to a constantly staffed location as required per NFPA 99 and NFPA 110.

This observation was made in the presence of the maintenance supervisor.