HospitalInspections.org

Based on observation the facility failed to provide an acceptable floor/ceiling assembly for the required construction type.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there was scrap wood inserted in the floor/ceiling assembly in the bulk storage room that would negate the fire rating of the assembly.

Based on observation the facility failed to provide acceptable flame spread documentation.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there was a board room at one end of the building that contained wood paneling but there was no flame spread documentation.

Based on observation the facility failed to provide an acceptable latch on the corridor doors.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there was a waiting room in the special clinic that did not have latching doors.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there were penetrations in smoke barriers in the following locations: 1) the fourth floor, 2) the 3rd floor, 3) the basement, 4) the barrier to the special clinic, 5) the barrier to surgery, 6) the barrier to the O.R. hallway, and 7) at the H.R. department.

Based on observation the facility failed to provide acceptable enclosures at hazardous areas.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there were hazardous areas that were not properly separated with a 45 minute rated fire door, closer, and latch such that the door will latch on its own. This occurred in the following locations: 1) the door to the boiler room from the control room was not a 45 minute labeled door, 2) the doors from the boiler room to the main electrical room were not 45 minute rated doors, 3) the door at the clean utility room 114 did not latch, 4) the biomedical storage room in the O.B. department did not have a latch, 5) the door to the soiled utility in the O.B. department did not latch on its own, 6) the door on the 3rd floor soiled utility room did not latch on its own, and 7) the door at the old boiler room was not a 45 minute fire rated door.

Based on observation the facility failed to provide an acceptable fire escape route.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there was an unlabeled door on the stair at med #2 stairwell. All doors in your hospital for stair wells 4 stories and less shall be 45 minute labeled doors with closers and latches.

Based on observation the facility failed to provide an acceptable stair.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there was a large amount of storage in the maintenance shop stair well. This must be removed.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that the breaker supplying power to the FACP was not identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2 and was not colored red as required. In addition, this life safety panel must be identified with a label on the front of the panel that says " LIFE SAFETY " .

Based on observation the facility failed to provide an acceptable medical gas installation.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there were the following issues with the medical gases: 1) the chiller yard had oxygen bottles that were not individually chained and could fall over, 2) the 4th floor meds room had loose oxygen bottles, 3) the bulk oxygen tank did not have no parking signage on all sides of the enclosure, and 4) the trama room had an oxygen bottle that was not properly stored in a rack.

Based on observation the facility failed to provide an acceptable emergency generator space.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there were flammable objects stored near the east emergency generator. The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an acceptable electrical installation.

The inspector observed while accompanied by the Director of Maintenance, the Ancillary Service Director, and the Maintenance Technologist during the hours of the inspection from 1:00 pm to 6:00 pm that there were the following issues: 1) the ATS in the basement did not have a label indicating the branch of the EES that it serves, 2) the ATS in the old boiler room mechanical closet did not have a label indicating the branch of the EES that it serves, 3) there were not hospital grade receptacles in the 4th floor patient rooms.