HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain the proper fire resistance rating of smoke barrier walls in two areas within the entire facility.

Findings include:

1. Observation on August 9, 2011, at 10:57 AM revealed that there was a 3-inch square unsealed smoke barrier penetration in the corridor between the Kitchen Delivery Room and the Exit doors above the Press to Operate door release.

Interview with the Maintenance Man on August 9, 2011, at 10:57 AM confirmed that there was an unsealed smoke barrier penetration in the corridor near the kitchen.

2. Observation on August 9, 2011, at 12:15 PM revealed that there were unsealed smoke barrier penetrations around conduits above the corridor doors near the ICU Waiting Room.

Interview with the Maintenance Man on August 9, 2011, at 12:15 PM confirmed that there were unsealed smoke barrier penetrations above the corridor doors.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance ratings of two hazardous areas throughout the facility.

Findings include:

1. Observation on August 9, 2011, at 1:11 PM revealed the Kitchen food storage room door lacks a self-closing device.

Interview with the Maintenance Man on August 9, 2011, at 1:11 PM confirmed the door was missing a closer.

2. Observation on August 9, 2011, at 2:01 PM revealed the OR Equipment Storage corridor doors do not close and latch into the frame.

Interview with the Maintenance Man on August 9, 2011, at 2:01 PM confirmed the door was would not close and latch.

Based on documentation review and interview, the facility failed to maintain required fire alarm system or smoke detectors throughout the entire facility.

Findings include:

Documentation review on August 10, 2011, between 8:30 AM and 11:00 AM revealed that the facility had no documentation reflecting that the smoke detectors had a sensitivity check within the past two years.

Interview with the Maintenance Man on August 10, 2011, at 11:00 AM confirmed that the facility had no documentation reflecting the smoke detectors had a sensitivity check within the past two years.

Based on observation and interview, the facility failed to provide adequate sprinkler coverage for one area throughout the facility

Findings include:

Observation on August 9, 2011, at 12:57 AM revealed the Pharmacy Chemo Room lacks sprinkler coverage.

Interview with the Maintenance Man on August 9, 2011, at 12:57 PM confirmed the Pharmacy Chemo Room lacked sprinkler coverage.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in reliable operating condition in one location throughout the facility.

Findings include:

Observation on August 9, 2011, at 11:37 AM revealed there were wire bundles and MC cable resting on sprinkler pipe in the corridor between the SPU Registration and Out Patient Waiting Room.

Interview with the Maintenance Man on August 9, 2011, at 11:37 AM confirmed the wires were on the sprinkler pipe.

Based on documentation review, the facility failed to properly maintain the humidity levels in anesthetizing locations in all two (2) of two (2) operating rooms.

Findings include:

Review of documentation on October 28, 2009, between 8:45 AM and 10:15 AM, revealed that the humidity levels were less than 35% in two (2) procedure rooms on numerous occasions during the entire months of November (10.9%) and December (20.9%) 2010, and January (18.5%), February (0%), March (6.0%), and April (25.3%) 2011.

Interview with the Maintenance Man on August 10, 2011, at 11:00 AM confirmed the humidity levels were below 35%.

Based on documentation review and interview, the facility failed to maintain the emergency generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on August 10, 2011, between 08:30 AM and 11:00 AM revealed the facility lacked documentation verifying that the generator showed no evidence of wet stacking during the 7/21/09 generator inspection/servicing.

Interview with the Maintenance Man on August 10, 2011, at 11:00 AM confirmed the facility lacked documentation verifying the generator showed no evidence of wet stacking or verification that the generator could pull 30% of its nameplate under load during the past year. The generator did not have a load bank test during this time.

Based on observation and interview, the facility failed to maintain electrical wiring and equipment for four areas throughout the facility.

Findings include:

Observation on August 9, 2011, revealed the following:
a. At 12:39 PM, Respiratory Therapy has a coffee pot and microwave plugged into a surge protector.
b. At 12:45 PM, Lab Storage Break room has a coffee pot and a toaster plugged into a surge protector.
c. At 1:05 PM, Materials Management Section, Materials Directors/Supply Room has an extension cord powering a coffee pot and an extension cord powering a microwave.
d. At 2:11 PM, Nursing Administration Kitchen has two refrigerators and a toaster plugged into a surge protector.

Interview with the Maintenance Man on August 10, 2011, at the above times confirmed the above electrical issues.