HospitalInspections.org

Based upon observation and interview it was determined that facility failed to maintain the two hour fire resistive separation in two instances on two of five floors.

Findings include:

1. On January 23, 2013, at 11:11 a.m., there were penetrations to first floor two hour fire resistive separation by the data cables above door 51091 C-A.
2. On January 24, 2013, at 9:57 a.m., there were penetrations to the ground level two hour fire resistive separation as seen above the ceiling tile on the west wall of respiratory therapy.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed the two hour fire resistive separation issues.

Based upon observation and interview, it was determined the doors protecting corridor openings were not in compliance in one instance on one of five floors:

Findings include:

1. On January 23, 2013, at 11:28 a.m., the door to the second floor isolation room in the ICU 52049A was being held open using a waste container.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed door issues.

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls in four instances on two of five floors.

Findings include:

1. On January 23, 2013, at 11:11 a.m., there were penetrations to the second floor smoke wall above doors 52000 C-A.
2. On January 23, 2013, at 11:15 a.m., there were penetrations to the second floor smoke wall by the chilled water pipe above doors 52017 C-A.
3. On January 23, 2013, at 11:22 a.m., there were penetrations to the second floor smoke wall in the data closet 52022A.
4. On January 24, 2013, at 10:08 a.m., there were penetrations to the ground level smoke wall above door 50045 C-A as seen from the ER side.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed the smoke wall penetrations.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in one instance on one of five floors.

Findings include:

1. On January 23, 2013, at 12:41 p.m., the first floor Biohazard Room 51091A doors were not equipped with an automatic closing device and had a separation of more than 1/8 inch in the closed position.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed the hazardous area issues.

Based on observation and document review, it was determined the automatic sprinkler system was not continuously maintained in reliable operating condition or inspected and tested in accordance with NFPA 101, 19.7.6, NFPA 13, and NFPA 25, 1999 editions.

Findings include:

1. On January 24, 2013, at 9:36 a.m., it was determined that the gauges for the dry sprinkler system in the ground floor ambulance bay were not recalibrated nor replaced within the previous five years.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed sprinkler system issue.

Based on observation and interview, the facility failed to meet the requirements for electrical wiring in two instances on two of five floors.

Findings include:

1. On January 23, 2013, at 11:16 a.m., there was temporary wiring/ lighting above the ceiling tile on the second floor by door 52017 C-A.
Findings include:
1. On January 24, 2013, at 9:30 a.m., it was determined that there was unterminated electrical wires in the two hour rated wall inside the ground floor Environmental Services closet.

Interview with the facility administrator on January 24, 2013, at 1:30 p.m. confirmed the electrical issues.