HospitalInspections.org

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

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there was a penetration by a pipe in the smoke barrier that had not been properly sealed. This was located in the main east/west corridor just inside the west entrance, high on the northern wall.

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

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there were several problems with enclosures at hazardous areas. A penetration in a 1 hour wall was found at central receiving above the ceiling grid on the south wall of the vestibule. There were several locations were hazardous areas did not have a 45 minute door. They were: 1) the biohazard room near the east entry, 2) the soiled utility room #107, 3) the soiled utility room #113, 4) the biohazard room # 209, and 5) the entry door to the sterile core.

Also, there was a clean linen storage room that was rated 1 hour on the plan that had 4 walls that extended up to the deck. This room was adjacent to the kitchen. Within the " 4 walls " of the clean linens storage there was a gas fired, hot water heater room that had two walls extending into the space created by the 1 hour enclosure of the clean linen storage room. The two walls of the water heater closet did not extend up to deck. The top of the water heater closet was visible from above the ceiling in the clean linen storage room above 10 feet from the finished floor. The ceiling of the water heater room was not a 1 hour enclosure and had several penetrations. Neither the door to the clean linen storage room or the water heater room were 45 minute doors as required for a hazardous area enclosure. The door to the water heater room also had grills in the door high and low even though the water heater room did have a fresh air duct bringing in combustion air. These two spaces could be combined into one hazardous area with 45 minute doors without penetrations.

Based on observation the facility failed to maintain the fire sprinkler system.

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there were two locations where bundles of wire were bearing down on drops of the sprinkler piping. The two locations were: 1) the main east/west corridor where corridor 141 intersects, and 2) in the vestibule for central receiving #11.

Based on observation the facility failed to provide an acceptable curtain in one location.

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there was a curtain in the anesthesia work room #303 that was not tested and rated relative to NFPA 701.

Based on observation the facility failed to provide acceptable storage of the medical gas bottles.

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there were medical gas bottles inside the enclosure that were not individually chained to the wall.

Based on observation the facility failed to provide acceptable lighting at the emergency generator.

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there was not a light with battery backup on the life safety branch at the emergency generator re. NFPA 99, 1999, 3-4.2.2.2 (b) 5.

Based on observation the facility failed to provide an acceptable preferred customer agreement with a vendor to supply water in emergency situations.

The inspector observed while accompanied by the Safety Director and the Facility Manager during the hours of the inspection from 9:00 am to 2:30 pm that there was not an agreement for preferred customer status for water re. NFPA 99, 1999, 11-5.3.2.