HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to assure the integrity of the corridor. Janitor closet, near physical therapy, did not latch.


Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire resistance rating of the one-hour rated barrier. The administration door, which was 45 minute rated with fire glazing, was held open by a door stop. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied tot the fire alarm.


Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to stop spread of smoke into central sterile department. Louver existed at mechanical room door.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to provide the direction of the egress path. Exit sign near the X-Ray room was not visible throughout most of the egress path due to hanging signs in the egress corridor.

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the egress corridor. The nursing supply storage room did not latch into its frame. Additionally several doors did not completely latch into frame or were held open by door stop in laundry, storage room over 50 square feet and the soiled utiltiy room.

Based on review of records during the survey of the facility on the afternoon of 05/10/2016, with the Director of Maintenance, the facility failed to explain why certain biomedical equipment failed their inspections. Please explain why and if they were repaired and what policy is in place to ensure biomed equipment gets repaired or replaced.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenancethe facility failed to provide acceptable exiting out the designated exit door. The door required two operations to open in an emergency and was located at old surgery department. Only one operation is allowed to open an exit door per NFPA 101, 2003: 7.2.1.5.9.2 ..... The releasing mechanism shall open the door with not more than one releasing operation

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain a clear and unobstructed egress path. Physical therapy ' s corridor, leading to marked exit door, contained furniture and equipment, which impeded egress path.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire alarm system. Fire sprinkler riser and Fire Alarm Control Panel were yellow tagged. The riser gage expired and should be replaced every 5 years. Explain how this was corrected and when the fire sprinkler system was approved by local Fire Marshall. The fire alarm was tested on site and did function.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to the sprinklered system. The Fire Marshall cited that the CT room ' s sprinkler was inoperable and this must be operational. The flow switch above the CT room was inoperable and the file storage was inoperable.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to ensure the operation of the smoke detection system. Nourishment alcove with a coffee pot, which may be sitting on a burner empty, was opened into the egress corridor in the med surg patient wing with no smoke detector.

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to identify medical gas bottles in med gas area. All medical gas cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.




Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to protect medical gas cylinders in med gas area. Portion of the covering was missing.
NFPA 99, 2002: 5.1.3.5.4 ... ...Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.




Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the medical gas system. Central sterile moved into the existing abandoned surgical suite. Since med gas is not needed in this department, plate over (or remove) medical gas outlets and at a minimum, remove the zone valve handle. Therefore no immediate patient care can occur in this newly created central sterile department. Additionally, med gas outlet was in the nursing supply storage room, which is not a patient care area. Remove or plate over this outlet.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to provide, at emergency generator set location, a light fixture which illuminates the generator that is energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panel board.




Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, patient treatment areas in the outpatient did not have hospital grade receptacles throughout all areas where patients are seen and treated

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, equipment was being stored in the old unoccupied nursing home, directly adjacent to the hospital. Currently there is no separation. However, there is an application with the state to construct a two hour wall. To ensure equipment is not being brought over into the hospital and being used (equipment was out of date and not being maintained), describe hospital policy of what is being done to unmaintained medical equipment and who can gain entry into that nursing home side (which currently is part of the hospital). Hospital shall not store items on this nursing home side due to its physical integrity. It was stated that the nursing home side would be demolished soon. Verify the status of the statment (timeframe).



Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the facility. Construction crews entering the facility kept the exterior door open allowing exterior elements (insects, dirt) into the facility. Additionally gap existed at exterior wall at a few patient walls. Additionally patient treatment areas and work areas were missing lenses at the light fixtures.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the facility. Ceiling tiles had water damage (appearing wet) and sagged in X-Ray.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to clearly identified essential electrical panels. Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Based on review of records during the survey of the facility on the afternoon of 05/10/2016, with the Director of Maintenance, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually and biannual for critical care areas. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to provide acceptable location for alcohol based hand rub dispensers. Dispenser was installed over an ignition source (electrical outlets and light switches) in lab.

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to assure the integrity of the corridor. Janitor closet, near physical therapy, did not latch.


Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire resistance rating of the one-hour rated barrier. The administration door, which was 45 minute rated with fire glazing, was held open by a door stop. This door remained opened at all times and should be closed at all times, unless held open with magnetic hold open tied tot the fire alarm.


Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to stop spread of smoke into central sterile department. Louver existed at mechanical room door.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to provide the direction of the egress path. Exit sign near the X-Ray room was not visible throughout most of the egress path due to hanging signs in the egress corridor.

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the egress corridor. The nursing supply storage room did not latch into its frame. Additionally several doors did not completely latch into frame or were held open by door stop in laundry, storage room over 50 square feet and the soiled utiltiy room.

Based on review of records during the survey of the facility on the afternoon of 05/10/2016, with the Director of Maintenance, the facility failed to explain why certain biomedical equipment failed their inspections. Please explain why and if they were repaired and what policy is in place to ensure biomed equipment gets repaired or replaced.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenancethe facility failed to provide acceptable exiting out the designated exit door. The door required two operations to open in an emergency and was located at old surgery department. Only one operation is allowed to open an exit door per NFPA 101, 2003: 7.2.1.5.9.2 ..... The releasing mechanism shall open the door with not more than one releasing operation

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain a clear and unobstructed egress path. Physical therapy ' s corridor, leading to marked exit door, contained furniture and equipment, which impeded egress path.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the fire alarm system. Fire sprinkler riser and Fire Alarm Control Panel were yellow tagged. The riser gage expired and should be replaced every 5 years. Explain how this was corrected and when the fire sprinkler system was approved by local Fire Marshall. The fire alarm was tested on site and did function.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to the sprinklered system. The Fire Marshall cited that the CT room ' s sprinkler was inoperable and this must be operational. The flow switch above the CT room was inoperable and the file storage was inoperable.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to ensure the operation of the smoke detection system. Nourishment alcove with a coffee pot, which may be sitting on a burner empty, was opened into the egress corridor in the med surg patient wing with no smoke detector.

Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to identify medical gas bottles in med gas area. All medical gas cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.




Based on observations during the survey walk of the facility on the morning of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to protect medical gas cylinders in med gas area. Portion of the covering was missing.
NFPA 99, 2002: 5.1.3.5.4 ... ...Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.




Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the medical gas system. Central sterile moved into the existing abandoned surgical suite. Since med gas is not needed in this department, plate over (or remove) medical gas outlets and at a minimum, remove the zone valve handle. Therefore no immediate patient care can occur in this newly created central sterile department. Additionally, med gas outlet was in the nursing supply storage room, which is not a patient care area. Remove or plate over this outlet.

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to provide, at emergency generator set location, a light fixture which illuminates the generator that is energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panel board.




Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, patient treatment areas in the outpatient did not have hospital grade receptacles throughout all areas where patients are seen and treated

Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, equipment was being stored in the old unoccupied nursing home, directly adjacent to the hospital. Currently there is no separation. However, there is an application with the state to construct a two hour wall. To ensure equipment is not being brought over into the hospital and being used (equipment was out of date and not being maintained), describe hospital policy of what is being done to unmaintained medical equipment and who can gain entry into that nursing home side (which currently is part of the hospital). Hospital shall not store items on this nursing home side due to its physical integrity. It was stated that the nursing home side would be demolished soon. Verify the status of the statment (timeframe).



Based on observations during the survey walk of the facility on the afternoon of 05/09/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the facility. Construction crews entering the facility kept the exterior door open allowing exterior elements (insects, dirt) into the facility. Additionally gap existed at exterior wall at a few patient walls. Additionally patient treatment areas and work areas were missing lenses at the light fixtures.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to maintain the integrity of the facility. Ceiling tiles had water damage (appearing wet) and sagged in X-Ray.

Based on observations during the survey walk of the facility on the afternoon of 05/10/2016, while being accompanied by the Director of Maintenance, the facility failed to clearly identified essential electrical panels. Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Based on review of records during the survey of the facility on the afternoon of 05/10/2016, with the Director of Maintenance, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually and biannual for critical care areas. Facility must initiate a log to retain these records.