HospitalInspections.org

Based upon observation and interview, it was determined that facility failed to maintain the two (2) hour common wall doors as directed by regulations on one of four building levels.

Findings include:

Observation on March 9, 2015 at 11:45 am revealed ground floor fire barrier double doors, components 01/03 (Mary Evans Ramp), lacked positive latching.

Interview with Director of Plant Services (DPS) on March 9, 2015 at 11:45 am confirmed the fire barrier doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to provide building construction type and height to meet regulations in all areas of the building.

Findings include:

Observation on March 9, 2015 at 8:30 am revealed the building construction type exceeds the height requirements for this type of construction. This condition is acceptable per FSES conducted on June 28, 2005.

Interview with DPS on March 9, 2015 at 8:30 am confirmed the above condition exists and is acceptable per FSES.

Based on observation and interview, it was determined that the facility failed to maintain doors protecting the corridor opening in other than hazardous areas to be substantial, or smoke resistant, in accordance with regulations on one of three building levels.

Findings include:

Observation on March 9, 2015 at 9:10 am revealed third floor I.C.U. door 336 lacked positive latching.

Interview with Director of Plant Services (DPS) on March 9, 2015 at 9:10 am confirmed the corridor door lacked positive latching.

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

Findings include:

Observation on March 9, 2015 at 12:55 pm revealed ground floor O.R. Post Recovery soiled utility room door lacked positive latching.

Interview with DPS on March 9, 2015 at 12:55 pm confirmed the soiled utility room door lacked positive latching.

Based upon observation and interview, the facility failed to maintain exit egress components to provide a continuous path of egress as per regulations on one of four building levels.

Findings include:

Observation on March 9, 2015 at 11:35 am revealed ground floor rear exit (Mary Evans) stair tower door to the outside exit discharge would not open without excessive force.

Interview with DPS on March 9, 2015 at 11:35 am confirmed the stair tower door to the outside was difficult to open.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of four building levels.

Findings include:

Observation on March 10, 2015 at 10:00 am revealed one of the fire sprinkler heads in the basement kitchen dietary food storage room (toward back wall) showed evidence of "impact" (plastic material attached to the sprinkler head).

Interview with DPS on March 10, 2015 at 10:00 am confirmed the plastic on the fire sprinkler head, and the need to protect the sprinkler heads from possible future damage.

Based on interview, it was determined the cooking equipment/facilities failed to comply with regulations in one of one kitchen.

Findings include:

Interview on March 10, 2015 at 9:50 am revealed four of four kitchen staff (in the basement kitchen) was unfamiliar with procedures for manual activation of the extinguishing system over the cooking surface.

Interview with DPS on March 10, 2015 at 9:50 am confirmed the staff shall be re-inserviced as to the location of the manual activation of the extinguishing system.

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 one of three building levels.

Findings include:

Observation on March 9, 2015 at 9:15 am revealed third floor RNAC office had a surge protector plugged into another surge protector for a computer on a cart.

Interview with DPS on March 9, 2015 at 9:15 am confirmed the surge protector was plugged into another surge protector in the RNAC office.