HospitalInspections.org

Based upon observation and interview, it was determined the building construction type does not meet regulations on one of three floors.

Findings include:

Observation on August 5, 2014, at 11:05 am revealed the first floor storage/electrical room in the Home Health corridor had unsealed penetrations (conduit).

Interview with Director of Maintenance (DOM) on August 5, 2014, at 11:05 am confirmed the unsealed penetrations.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one (1) hour on one of three floors.

Findings include:

Observation on August 5, 2014, at 9:50 am revealed the third floor old elevator stair tower had storage.

Interview with DOM on August 5, 2014, at 9:50 am confirmed the stair tower had storage.

Based on documentation review and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of three floors.

Findings include:

Documentation review on August 6, 2014, at 11:15 am revealed the facility lacked documention that the clean agent fire extinguishing system in the computer room is inspected and tested annually as required by NFPA 2001, 2000 Edition.

Interview with DOM on August 6, 2014, at 11:15 am confirmed the lack of documentation on the clean agent fire extinguishing system.

Based on documentation review and interview, it was determined the cooking equipment/facilities do not comply with regulations on one of three floors.

Findings include:

Documentation review on August 6, 2014, at 10:45 am revealed the facility lacks documentation that the snack bar hood fire suppression system is being inspected and tested semi-annually.

Interview with DOM on August 6, 2014, at 10:45 am confirmed the facility lacks documentation that the snack bar hood fire suppression system is being inspected and tested semi-annually.

Based upon observation and interview, the facility failed to maintain means of egress free of all obstructions or impediments to full and instant use in case of fire or other emergency on three of three floors.

Findings include:

1. Observation on August 5, 2014, at 9:40 am revealed the facility is charging computers on wheels in the second floor cardiac-pulmonary exit corridor.

Interview with DOM on August 5, 2014, at 9:40 am confirmed the computers on wheels were being charged in the exit corridor and the subsequent correction during the time of the survey.

2. Observation on August 5, 2014, between 10:10 am and 12:40 pm revealed the facility has storage in the exit corridor which impedes on the clear and unobstructed corridor width at the following locations:
A. Second floor ICU exit corridor (bed).
B. Ground floor SPU/OR back exit corridor (beds and equipment).

Interview with DOM on August 5, 2014, at 12:40 pm confirmed the storage in the exit corridor at the above listed locations.

Based upon documentation review and interview it was determined that the facility failed to comply with regulations for generators in one area of the entire building.

Findings include:

Documentation review on August 6, 2014, at 11:00 am revealed the facility lacks documentation of an annual inspection and test of the emergency generator by an outside vendor.

Interview with DOM on August 6, 2014, at 11:00 am confirmed the emergency generator is not inspected and tested annually by an outside vendor.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on two of three floors.

Findings include:

1. Observation on August 5, 2014, at 11:00 am revealed the first floor patient services had a microwave oven cord stretched and the plug was bent at the electrical outlet.

Interview with DOM on August 5, 2014, at 11:00 am confirmed the plug was bent and the subsequent correction during the time of the survey.

2. Observation on August 5, 2014, at 11:10 am revealed the first floor chart review room had a coffee pot and toaster plugged into a surge protector.

Interview with DOM on August 5, 2014, at 11:10 am confirmed the devices plugged into a surge protector and the subsequent correction during the time of the survey.

3. Observation on August 5, 2014, at 1:30 pm revealed the kitchen electrical panels were blocked from access by carts.

Interview with DOM on August 5, 2014, at 1:30 pm confirmed the electrical panels were blocked and the subsequent correction during the time of the survey.