HospitalInspections.org

K 025

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls on two of six building levels.

Findings include:

Observation on April 26, 2012 between 9:45 am and 11:00 am revealed the following smoke barrier walls have unsealed penetrations:
A. Third floor smoke barrier above soiled utility room door 3330 has multiple unsealed conduits (9:45 am). CORRECTED JUNE 15, 2012.
B. Third floor smoke barrier above East Senior Transitions Unit doors has unsealed P. T. S. Network cable conduit (10:00 am).
C. Second floor smoke barrier above E. R. entrance (near elevator #4) has unsealed P. T. S. Network cable conduit (11:00 am). CORRECTED JUNE 15, 2012.

Interview with Maintenance Manager on April 26, 2012 at 11:00 am confirmed the above smoke barrier walls have unsealed penetrations. Maintenance Manager verified item "B" was not corrected during the time of follow-up inspection.

K 029

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

Findings include:

Observation on April 27, 2012 at 10:50 am revealed zero floor storage room (next to elevator #3) door lacks positive latching with the self-closure.

Interview with Maintenance Manager on April 27, 2012 at 10:50 am confirmed the storage room door lacks positive latching with the self-closure. Maintenance Manager verified the above item was not corrected during the time of follow-up inspection.

K 062

Based on document review and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in all areas of the building.

Findings include:

Document review on April 27, 2012 at 8:30 am revealed the following sprinkler system inspection deficiencies:
1. Quarterly flow test on January 13, 2012 stated approximately 2 1/2" of 1/2" pipe is rusted and leaks when alarm line is activated on system in boiler room in basement. CORRECTED JUNE 15, 2012.
2. Annual back-flow preventer test on July 22, 2011 stated check valve #2 leaked and failed, suggest rebuilding or replacement.

Interview with Maintenance Manager on April 27, 2012 at 8:30 am confirmed the sprinkler system concerns shall be addressed. Maintenance Manager verified item "2" was not corrected during the time of follow-up inspection.

K 147

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 two of four building levels.

Findings include:

Observation on April 27, 2012 between 10:00 am and 11:15 am revealed the following electrical issues:
A. First floor Hane Cancer Center office is utilizing a hubble multiple cord strip (10:00 am). CORRECTED JUNE 15, 2012.
B. Zero floor Campbell wing boiler room has a surge protector plugged into an extension cord (10:30 am). CORRECTED JUNE 15, 2012.
C. Zero floor O. R. has a refrigerator plugged into a hubble "extension cord" mounted to wheeled cart across from fire exit door #8 (11:15 am).

Interview with Maintenance Manager on April 27, 2012 at 11:15 am confirmed the above electrical deficiencies, and the subsequent correction of these items during the time of the survey. Maintenance Manager verified item "C" was not corrected during the time of follow-up inspection.