HospitalInspections.org

Based upon observation an interview, it was determined that the facility failed to maintain two (2) hour common walls and/or doors with a non-conforming building, on three of four building levels.

Findings include:

1. Observation on August 26, 2015, at 11:20 am revealed first floor fire barrier door at the end of the O.R. lacks positive latching (right side).

Interview with Maintenance Supervisor (MS) on August 26, 2015, at 11:20 am confirmed the fire barrier door lacks positive latching.

2. Observation on August 26, 2015, at 12:45 pm revealed ground floor Cafeteria fire barrier wall had an unsealed black wire penetration above doors inside the Cafeteria.

Interview with MS on August 26, 2015, at 12:45 pm confirmed the unsealed penetration in the fire barrier wall.

3. Observation on August 27, 2015, at 9:39 am revealed basement tunnel fire barrier door between the Hospital and Nursing Home lacks positive latching (right side).

Interview with MS on August 27, 2015, at 9:39 am confirmed the fire barrier door lacks positive latching.

Based upon observation an interview, it was determined that the facility failed to maintain two (2) hour common walls and/or doors with a non-conforming building, on three of four building levels.

Findings include:

1. Observation on August 26, 2015, at 11:20 am revealed first floor fire barrier door at the end of the O.R. lacks positive latching (right side).

Interview with Maintenance Supervisor (MS) on August 26, 2015, at 11:20 am confirmed the fire barrier door lacks positive latching.

2. Observation on August 26, 2015, at 12:45 pm revealed ground floor Cafeteria fire barrier wall had an unsealed black wire penetration above doors inside the Cafeteria.

Interview with MS on August 26, 2015, at 12:45 pm confirmed the unsealed penetration in the fire barrier wall.

3. Observation on August 27, 2015, at 9:39 am revealed basement tunnel fire barrier door between the Hospital and Nursing Home lacks positive latching (right side).

Interview with MS on August 27, 2015, at 9:39 am confirmed the fire barrier door lacks positive latching.

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

Findings include:

1. Observation on August 26, 2015, at 9:35 am revealed second floor smoke barrier near room 27 had an inadequately-sealed sprinkler pipe penetration above the cross-corridor doors (original fire sealant had shrunk since the time of installation).

Interview with MS on August 26, 2015, at 9:35 am confirmed the smoke barrier penetration was inadequately-sealed.

2. Observation on August 27, 2015, at 9:07 am revealed ground floor smoke barrier between registration and mechanical equipment room had an unsealed 4" conduit above the cross-corridor doors.

Interview with MS on August 27, 2015, at 9:07 am confirmed the unsealed smoke barrier penetration.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas on two of four floors.

Findings include:

1. Observation on August 26, 2015, at 11:35 am revealed first floor P.A.C.U. soiled utility room door lacks positive latching with the self-closure.

Interview with MS on August 26, 2015, at 11:35 am confirmed the soiled utility room door lacks positive latching.

2. Observation on August 27, 2015, at 9:30 am revealed ground floor E.D. cardiology office has a large amount of files in open cabinets, and the door lacks a self-closure.

Interview with MS on August 27, 2015, at 9:30 am confirmed the file storage room door lacks a self-closure.

Based upon observation and interview, the facility failed to maintain exit egress components on one of four building levels.

Findings include:

Observation on August 26, 2015, at 10:20 am revealed second floor generations stair tower has a duct penetration that is not adequately sealed (original fire sealant had shrunk since the time of installation).

Interview with MS on August 26, 2015, at 10:20 am confirmed the unsealed stair tower penetration.

Based upon observation and interview, the facility failed to maintain horizontal exit doors on one of four building levels.

Findings include:

Observation on August 26, 2015, at 1:00 pm revealed ground floor fire barrier doors near elevator #7 lack positive latching.

Interview with MS on August 26, 2015, at 1:00 pm confirmed the fire barrier doors lack positive latching.

Based upon observation and interview, the facility failed to maintain emergency lighting in one of five anesthetizing locations.

Findings include:

Observation on August 26, 2015, at 10:45 am revealed first floor maternity C-section room lacks battery back-up lighting.

Interview with MS on August 26, 2015, at 10:45 am confirmed the anesthetizing location lacks emergency battery back-up lighting.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations in one of one main medical gas storage room.

Findings include:

Observation on August 26, 2015, at 9:05 am revealed ground floor main medical gas room had five unsecured carbon dioxide cylinders.

Interview with MS on August 26, 2015, at 9:05 am confirmed the unsecured carbon dioxide cylinders.