HospitalInspections.org

Stratford Division - Sleep Center

Based on observation, it was determined that the facility failed to ensure that access to exits are marked by visible signs.

Findings include:

On 1/13/15 at 2:05 PM, in the presence of Staff #S10 and Staff #S16, no exit sign was readily visible in the corridor indicating the second means of egress in the Nourishment Room.

Stratford Division - Family Health Services

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure that staff are familiar with procedures in the case of an emergency.

Findings include:

1. On 1/13/15 at 11:45 AM, in the presence of Staff #S5 and Staff #S13, the "Emergency Preparedness Guide" at the Medication Preparation Area states, "Call X 2222 for emergencies."

a. The policy, "Medical Emergency" #324, revised 3/2102 states, "... policy is to call 9-911..."

(i) Staff #S5 and #S13 confirmed this finding.

b. A review of the facility's Disaster Plan indicates, "...Will set up procedures for the prompt transfer of casualties to the local hospital by the dialing of 911..."

(i) Staff #S5 and #S13 confirmed this finding.

c. The policy, "Medical Emergency (#324)," the "Emergency Preparedness Guide" and the "Disaster Plan," all for the same procedure in the event of emergency, contain different content. This is a possible source of confusion and could lead to the procedure not being done properly in the event of an emergency.

Stratford Division - Family Health Services

Based on document review and staff interview, it was determined that the facility failed to ensure that the automatic sprinkler systems are maintained in accordance with NFPA 13 and NFPA 25.

Finding include:

Reference: The Fire Sprinkler Report from --- Fire Protection & Security dated 4/16/14. Deficiency indicated on report stated, "No access to sprinkler room. Telecommunication office closed. Suite empty. Visual of sprinkler heads in Kennedy Space Only."

1. On 1/13/15 at 12:00 PM, a review of the sprinkler inspection reports in the presence of Staff #S5 and Staff #S13 indicated that access to the Sprinkler Room could not be made.

a. Staff #S5 and Staff #S13 could not provide evidence of a follow up inspection of the sprinkler system with access to the Sprinkler Room

Based on observation and staff interview, it was determined the facility failed to ensure that all means of egress are maintained free of all obstruction and impediments.

Findings include:

Washington Township

1. On 1/13/15 at approximately 1:30 PM, in the presence of Staff #W75, the lower level exit passageway, located outside of the Pavilion E Building, was congested with food tray racks and medical equipment stands that would inhibit occupant exit.

a. This finding was confirmed by Staff #W75.

2. On 1/15/15 at 10:50 AM, in the presence of Staff #W10, the exit stairs leading from the building to Parking Lot B, were cracked and loose.




Stratford Campus

1. On 1/14/15 at approximately 2:15 PM, in the presence of Staff #S94, the door knob on the exterior door, located at Exit #13 on the ground level, was broken and would not allow occupant passage of any kind.

a. This finding was confirmed by Staff #S94.






33557

2. On 1/13/15 at 2:30 PM, in the presence of Staff #S21, the following items were stored in the Operating Room Suite corridor, reducing the egress width to less then three feet:

a. 3 storage carts

b. 1 anesthesia machine

c. 1 supply cart with monitor

d. 1 rolling storage cabinet

e. 1 patient transfer board

f. 1 flammable liquid cabinet

Stratford Division - Family Health Services at Somerdale

Based on observation, it was determined that the facility failed to ensure that compressed medical gas tanks are stored properly.

Findings include:

1. On 1/13/15 at 11:00 AM, in the presence of Staff #S5 and Staff #S13, two "E" size medical oxygen tanks were unsecured in the Medication Preparation area. These tanks were removed by staff immediately.

a. At 11:30 AM, in the presence of Staff #S5 and Staff #S13, the same two "E" size medical oxygen tanks were found to be relocated to the Nurse Manager's office and remained unsecured.

Stratford Division - Sleep Center

Based on observation, it was determined that the facility failed to ensure that access to exits are marked by visible signs.

Findings include:

On 1/13/15 at 2:05 PM, in the presence of Staff #S10 and Staff #S16, no exit sign was readily visible in the corridor indicating the second means of egress in the Nourishment Room.

Stratford Division - Family Health Services

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure that staff are familiar with procedures in the case of an emergency.

Findings include:

1. On 1/13/15 at 11:45 AM, in the presence of Staff #S5 and Staff #S13, the "Emergency Preparedness Guide" at the Medication Preparation Area states, "Call X 2222 for emergencies."

a. The policy, "Medical Emergency" #324, revised 3/2102 states, "... policy is to call 9-911..."

(i) Staff #S5 and #S13 confirmed this finding.

b. A review of the facility's Disaster Plan indicates, "...Will set up procedures for the prompt transfer of casualties to the local hospital by the dialing of 911..."

(i) Staff #S5 and #S13 confirmed this finding.

c. The policy, "Medical Emergency (#324)," the "Emergency Preparedness Guide" and the "Disaster Plan," all for the same procedure in the event of emergency, contain different content. This is a possible source of confusion and could lead to the procedure not being done properly in the event of an emergency.

Stratford Division - Family Health Services

Based on document review and staff interview, it was determined that the facility failed to ensure that the automatic sprinkler systems are maintained in accordance with NFPA 13 and NFPA 25.

Finding include:

Reference: The Fire Sprinkler Report from --- Fire Protection & Security dated 4/16/14. Deficiency indicated on report stated, "No access to sprinkler room. Telecommunication office closed. Suite empty. Visual of sprinkler heads in Kennedy Space Only."

1. On 1/13/15 at 12:00 PM, a review of the sprinkler inspection reports in the presence of Staff #S5 and Staff #S13 indicated that access to the Sprinkler Room could not be made.

a. Staff #S5 and Staff #S13 could not provide evidence of a follow up inspection of the sprinkler system with access to the Sprinkler Room

Based on observation and staff interview, it was determined the facility failed to ensure that all means of egress are maintained free of all obstruction and impediments.

Findings include:

Washington Township

1. On 1/13/15 at approximately 1:30 PM, in the presence of Staff #W75, the lower level exit passageway, located outside of the Pavilion E Building, was congested with food tray racks and medical equipment stands that would inhibit occupant exit.

a. This finding was confirmed by Staff #W75.

2. On 1/15/15 at 10:50 AM, in the presence of Staff #W10, the exit stairs leading from the building to Parking Lot B, were cracked and loose.




Stratford Campus

1. On 1/14/15 at approximately 2:15 PM, in the presence of Staff #S94, the door knob on the exterior door, located at Exit #13 on the ground level, was broken and would not allow occupant passage of any kind.

a. This finding was confirmed by Staff #S94.






33557

2. On 1/13/15 at 2:30 PM, in the presence of Staff #S21, the following items were stored in the Operating Room Suite corridor, reducing the egress width to less then three feet:

a. 3 storage carts

b. 1 anesthesia machine

c. 1 supply cart with monitor

d. 1 rolling storage cabinet

e. 1 patient transfer board

f. 1 flammable liquid cabinet

Stratford Division - Family Health Services at Somerdale

Based on observation, it was determined that the facility failed to ensure that compressed medical gas tanks are stored properly.

Findings include:

1. On 1/13/15 at 11:00 AM, in the presence of Staff #S5 and Staff #S13, two "E" size medical oxygen tanks were unsecured in the Medication Preparation area. These tanks were removed by staff immediately.

a. At 11:30 AM, in the presence of Staff #S5 and Staff #S13, the same two "E" size medical oxygen tanks were found to be relocated to the Nurse Manager's office and remained unsecured.