HospitalInspections.org

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Based on observation and staff interview, the facility did not ensure that access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is readily apparent to the occupants.

Findings are:

1- On 11/28/11, during a tour of the Kitchen, it was observed that the washing area did not have a readily visible exit sign to direct the staff to the exit door.

Also, the second mean of egress to the Kitchen near the dish washing area lacked an illuminated exit sign.

2- No exit sign was provided in the CT scan and MRI suite.

3- No illuminated exit signs were provided in the paint shop area.

4- No exit signs were provided at the space of the mechanical area in 3B Mechanical Floor.

All the above findings were brought to the attention of the facility's Associative Executive Director of Environmental Care, Engineering and Safety.
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Based on record review and staff interview, the facility failed to ensure that the fire and smoke dampers are tested and maintained as per the manufacturer's recommendation and to ensure that they are working properly.

Findings include:

Review of the fire dampers testing of November 3-6, 2010 showed the following:

1- Nine (9) of the fire dampers on the fifth, fifteenth, sixteenth and seventeenth floors were not tested due to lack of access. Those dampers are: 5-FD-032, 5-FD-035, 5-FD-047, 5-FD-048, 5-FD-049, 5-FD-084, 5-FD-284, 5-FD-313, 5-FD-254.

2- The smoke damper of second floor, 2B-SD-433, had failed the test due to inoperable actuator and there was no documented evidence to ensure its repair.

3- The fire damper, 5-FD-002, at the fifth floor failed the test of November, 2010 because of a broken spring on one side.

4- The fire damper, 5-FD-051, at the fifth floor failed the test of November, 2010 because of no fusible link.

5- The fire damper, 5-FD-088, at the fifth floor failed the test of November, 2010 because of no fusible link.

6- The fire damper, 5-FD-151, at the fifth floor failed the test of November, 2010 because of no fusible link.

All the above findings were brought to the attention of the facility's Associative Executive Director of Environmental Care, Engineering and Safety.