HospitalInspections.org

Based on observations the facility failed to maintain barriers that resist the passage of smoke.

At 12:30 PM on April 22, 2014 it is observed on the first floor corridor near the entrance to the cafeteria and administration that the corridor walls terminate just above the acoustical ceiling grid. This is allowable so long as the acoustical ceiling resist the passage of smoke. However, it is observed that there is several non-ducted registers and grills in the ceiling, in this area that do not resist the passage of smoke.

This finding has the potential to effect 100% of the occupants in this smoke compartment.

Based on observations the facility failed to ensure that illuminated exit signs were continuously maintained operable.

Findings Include:

At 12:10 PM on April 22 2014 it is observed on the third floor at the elevator lobby that the illuminated exit light (#8) is not illuminated.

Based on observations the facility failed to maintain the fire detection/notification system in accordance with NFPA 72.

Findings Include:

1. At 11:30 AM on April 22, 2014 it is observed on the third floor near the lab entrance door in the corridor the smoke detector is not within 5' of the a smoke barrier doors and is within three feet of a supply register.

2. At 11:35 AM on April 22, 2014 is observed on the third floor at the fire and smoke double doors located near the stairs there is no smoke detector within 5 feet of the doors on the telecom electrical room side.

3. At 12:00 PM on April 22, 2014 third floor room 302 there is a smoke detector within 3 feet of a supply air register.

4. At 12:05 PM on April 22, 2014 on the third floor in the physicians lounge on-call sleeping room there is a smoke detector within 3 feet of air supply register.

5. At 12:20 PM on April 22, 2014 it is observed on the first floor in the kitchen there is a smoke detector located near the hoods that is within 3 feet of the supply return vents.

6. At 12:40 PM on April 22, 2014 it is observed on the first floor near the main lobby double fire smoke doors that the smoke detector is not within 5 feet of the doors.

7. At 1:10 PM on April 22, 2014 it is observed on the first floor rear loading dock that the fire alarm control panel door is not designated by signage, nor is the electrical panel serving the fire alarm control panel.

These findings have the potential to effect 100% of the buildings occupants.

Based on observations the facility failed to ensure that the sprinkler system was maintained in reliable operating condition.

Findings Include:

1. At 11:28 AM on April 22, 2014 it is observed on the 2nd floor East med room there is a missing escutcheon ring on the sprinkler head.

2. At 11:44 AM on April 22, 2014 it is observed that there is a item hanging from the sprinkler head on the 2nd floor West nurses station.

3. At 11:46 AM on April 22, 2014 it is observed that there is an Item hanging from the sprinkler head on the 2nd floor in West soiled utility room.

4. At 1:00 PM on April 22, 2014 it is observed in the main storage room on the 1st floor that storage exceed the height limitation of 18 inches from the underside of the sprinkler head.

These findings have the potential to effect 100% of the occupants in the facility.

Its is observed that the facility failed to ensure that the means of egress was continuously maintained free of obstructions and impediments.

Findings Include:

1. At 12:15 PM on April 22, 2014 it is observed on the first floor in the cafeteria dining area that the secondary means of egress exit door leading to the public way has a thumb turn lock that requires special knowledge.

2. At 1:15 PM on April 22, 2014 it is observed that there is a thumb turn lock on the exit door in the main hallway of the 1st floor leading to the public way.

These findings have the potential to effect 50% of the occupants in each of these smoke compartments.

It is observed that the facility failed to ensure that all combustible decorations are flame retardant.

Findings Include:

At 11:40 AM on April 22, 2014 it is observed that there is an artificial Christmas tree located in the 2nd floor storage room. The facility was unable to produce the tag or documentation that the item is flame retardant in accordance with the NFPA standard.

This finding has the potential to effect 50% of the occupants in this smoke compartment.

Based on observations and interviews with staff, draperies and curtains are not flame resistant in accordance with NFPA 701.

Findings Include:

At 11:55 AM on April 22, 2014 it is observed on the third floor room 306 that the cubicle curtains are not NFPA fire resistant compliant. No tag or paperwork certifying that the curtains are compliant could be provided by the facility. Furthermore it is observed that many cubicle curtains throughout the facility also do not comply with NFPA 701.

This finding has the potential to affect 100% of the buildings occupants.

Based on observations the facility failed to ensure that the proper precautionary signage regarding oxygen use and storage was maintained.

Findings Include:

1. At 11:31 AM on April 22, 2014 it is observed on the 2nd floor equipment storage room that oxygen is being stored without proper precautionary signage.

2. At 9:30 AM on April 22, 2014 it is observed while conducting an exterior walk around of the building that the fenced and gated bulk liquid oxygen storage tank enclosure area does not have proper precautionary signage.

Finding #1 has the potential to effect 100% of the occupants in the smoke compartment.

Unable to determine the potential impact of Finding #2.

Based on observations the facility failed to ensure that electrical equipment and wiring were continuously maintained operable and compliant.

Findings Include:

1. At 11:35 AM on April 22, 2014 it is observed on the third floor above the ceiling in the corridor at the double fire and smoke doors located near the telecom electrical room there is an open junction box exposed wiring.

2. At 11:51 AM on April 22, 2014 it is observed on the 2nd floor room L-2 that the electrical panels are not properly labeled.

3. At 12:20 PM on April 22, 2014 it is observed on the 1st floor computer room that the electrical panels are not properly labeled.

4. At 12:21 PM on April 22, 2014 it is observed on the 1st floor computer room that there is a non listed multiple plug adapter in use.

5. At 1:10 PM on April 22, 2014 it is observed on the 1st floor main storage room that the electrical service panels blocked are obstructed.

These findings have the potential to effect 50% of the buildings occupants.