HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls, on one of four floors within the facility.

Findings include:

1. Observation on August 17, 2016, at 9:30 AM revealed a 3/4 inch unsealed penetration in the smoke barrier wall, above the double doors by Resident Room #C32.

Interview with Maintenance Representative 1 on August 17, 2016, at 9:30 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain doors of hazardous areas to close and latch, on one of four floors within the facility.

Findings include:

1. Observation on August 17, 2016, at 11:50 AM revealed the door to Level A Soiled-Utility failed to latch in the frame.

Interview at the time of the exit conference with the Director of Plant Operations and the Director of Quality and Risk on August 17, 2016, at 2:00 PM confirmed the door lacked positive latching.

Based on documentation review and interview, it was determined the facility failed to perform required inspection and testing of the fire alarm system, for four of four floors within the facility.

Findings include:

1. Review of documentation on August 17, 2016, between 9:30 AM and 11:00 AM, revealed the facility lacked documentation verifying the fire alarm components were visually inspected between the functional testings, dated May 2015 and May 2016.

Interview at the time of the exit conference with the Director of Plant Operations and the Director of Quality and Risk on August 17, 2016, at 2:00 PM confirmed a semi-annual inspection was not completed.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system to support itself only, affecting the entire facility.

Findings include:

1. Observation on August 17, 2016, at 11:40 AM revealed J hooks attached to the sprinkler system were used to support data wires.

Interview with Maintenance Representative 1 on August 17, 2016, at 11:40 AM confirmed the J hooks were on the sprinkler system.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting one of four floors within the facility.

Findings include:

1. Observation on August 17, 2016, at 11:35 AM revealed there was an electrical junction box that lacked a cover plate, above the ceiling on the "A" floor corridor, outside of the Case Manager's Office.

Interview with Maintenance Representative 1 on August 17, 2016, at 11:35 AM confirmed the missing box cover.

Based on observation and interview, it was determined the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers away from an ignition source, on one of four floors within the facility.

Findings include:

1. Observation on August 17, 2016, at 1:15 PM revealed an ABHR was installed directly over a light switch, in the employee lounge on Level-B.

Interview at the time of the exit conference with the Director of Plant Operations and the Director of Quality and Risk on August 17, 2016, at 2:00 PM confirmed the ABHR was installed directly over the light switch.