HospitalInspections.org

K21

Based on observation and staff interview, the facility failed to demonstrate that door assemblies in stairwells and smoke compartments are of an approved type with appropriate fire protection rating.

The findings are:

During a tour of the facility on 2/2/16, between 1:00pm and 2:00pm, it was observed that the fire protection rating labels on doors separating the smoke compartments on the second and third floors were painted over, rendering them illegible.
The fire protection rating labels on the doors in two stairwells on the second and third floors were also painted over and were not legible.
Failure to provide approved type fire rated doors will compromise the safety of occupants exiting the facility during a fire emergency.

These findings were confirmed during interview with the Senior Director of Facilities Management at the time of observation.

K46

Based on observation and staff interview, emergency lighting of 1½ hour duration is not provided throughout the facility.

The findings are:
During a tour of the facility on 2/4/16 at 10:30 am, the fire pump room in the basement was observed to be lacking a battery operated emergency light.
Failure to provide this emergency lighting can compromise the safety of staff and patients during a power outage.

These findings were confirmed during interview with the Senior Director of Facilities Management at the time of observation.

K62

Based on observation and staff interview, the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition.

The findings are:

During a tour of the facility on 2/2/16 at 11:45 am, a sprinkler escutcheon was noted missing from the sprinkler head in the second floor laundry chute room (room C-202).

Failure to maintain the automatic sprinkler system in reliable operating condition can negatively impact facility occupants in the event of a fire emergency.

These findings were confirmed during interview with the Senior Director of Facilities Management at the time of observation.

K147

Based on observation and staff interview, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 99, National Electrical Code.

The findings are:
During a tour of the facility on 2/3/16, between 11:00am and 12:00pm, it was observed that the electrical circuit panels on both the second and third floors were lacking directories describing what equipment is wired to each circuit panel.

Failure to maintain the electrical wiring correctly can impair the functioning of equipment and compromise the safety of facility occupants.

These findings were confirmed during interview with the Senior Director of Facilities Management at the time of observation.