HospitalInspections.org

Based on observation during the afternoon of 12/27/2012, the following door latches were not in compliance:

(a) the doors to the following patient rooms had roller latches: "101 thru 116; #201 thru 222. These roller latches must be replaced with postive latching hardware.

(b) the doors to the following room did not latch at the door frame when closed: patient rooms 409, 414, 415; soiled-utility room near patient room 403. These doors must be repaired so the doors close and latch to prevent the passage of smoke.

Based on observation during the morning of 12/28/2012, the cross-corridor smoke-barrier doors, near the radilogy suite, did not close tightly against each other to form a smoke-tight seal when closed by the automatic closers.

Based on observation during the afternoon of 12/27/2012, the fire alarm system did not comply with NFPA 72 as follows:

(a) The main fire alarm control panel electical supervisory signal indicated there was a malfunction with the fire alarm system.

(b) The key-operated lock was broken on the front of fire alarm control panel at the unoccupied rear wing nurse station. The lock must be repaired so the inside of the panel is not accessible to unauthorized people.

Based on observation during the afternoon of 12/27/2013, the fire sprinkler system protecting the entire building did not have sprinklers installed in the following rooms as required by NFPA 13: operating room #1; operating room #2; operating room #3; operating room #4; cysto room; main entry vestibule; former gift shop (adjacent to main entry); electrical panel closet near the medical records suite.

Based on observation during the afternoon of 12/27/2012, the majority of the portable fire extinguishers in the hospital had inspection tags dated September 2011. The portable fire extinguishers must be inspected and tagged by a licensed contractor every 12 months.

Based on observation during the morning of 12/28/2012, the medical gas alarm panel, at the wall behind the main entry reception desk, indicated the following conditions:

(a) "Oxygen Level Low"

(b) "Nitrous Oxide Line Pressure High"