HospitalInspections.org

Based on observation of exit signage and corridor areas serving patient rooms, the facility failed to maintain corridors required for exit access to a minimum of eight feet in width in accordance with 18.2.3.3, free of obstructions or impediments and available at all times to full instant use in the case of fire of other emergency for two of two exits available to staff, visitors and patients on the Patient Wing. The facility census was 16.

Findings included:

1. Observation on 03/26/12 at 1:55 PM showed a wheeled metal cabinet in the corridor outside of patient room 36. The cabinet measured four feet tall by three feet wide by two feet deep. A patient in a wheelchair could not see over the cabinet without standing up and it reduced the corridor to a width of less than six feet; or less than two wheelchair widths or two patient bed widths, which could potentially prevent the simultaneous evacuation of two patient beds side by side, or two wheel chairs at a time. At 2:38 PM, the metal cabinet was observed still parked at patient room 36.

During an interview, Staff GG., Activities Director stated the music cabinet is in use daily and is used for storage of activity related supplies and different musical instruments she uses as she visits residents. She stated that it is generally parked in the corridor outside of a room and is moved periodically. She stated that she was aware its bulky size could pose a potential obstruction and always tried to park it along the wall, and admitted it sometimes sat at the same location in the corridor for over one hour.

2. Observation on 03/27/12 at 10:20 AM through 1:00 PM showed the following items reduced the corridor required for exit access to less than six feet wide:
-Med or treatment cart in the corridor outside of room 23.
-Food tray cabinet in the corridor next to nurses' station, between rooms 36 and 37.
-Isolation cart in the corridor outside of room 32.
-Med or treatment cart parked in the corridor between rooms 34 and 35.
-Wheeled stand with a computer and separate wheeled desk chair in the corridor outside of room 35.
-Wheeled metal music cabinet in the corridor outside of room 38.
-Wheeled housekeeping cart in the corridor outside of room 40.
-Wheeled EKG (electrocardiograph-instrument used in the detection and diagnosis of heart abnormalities) parked in the corridor outside of Consultation room 908.

3. Observation on 03/28/12 at 12:40 AM through 1:00 PM showed the following items reduced the corridor required for exit access to less than six feet wide:
-Food tray cabinet in the corridor outside of room 36.
-Wheeled stand with a computer and separate wheeled desk chair in the corridor outside of room 35.
-Wheeled metal music cabinet in the corridor outside of room 32.
-Wheeled stand with a computer and separate wheeled desk chair in the corridor outside of room 26.
-Activity cart in the corridor outside of room 24.

4. Observation on 03/28/12 at 3:05 PM showed the following items reduced the corridor required for exit access to less than six feet wide:
-Blood Pressure/vitals monitor in the corridor between rooms 21 and 22.
-Isolation or Med cart in the corridor outside of room 23.
-Wheeled metal music cabinet and wheeled stand with a computer and separate wheeled desk chair in the corridor between rooms 25 and 26.
-Wheeled stand with a computer and separate wheeled desk chair in the corridor outside of room 35.

5. Observation on 03/26/12 at 1:55 PM through 03/29/12 at 3:00 PM showed that two exits serve the 25-bed Patient Wing; one exit to grade at the northwest end of the north corridor, and the other exit to grade through a north door, along the back wall of surgical recovery suite. The cumulative amount of equipment in the corridors, especially before mid-day, with medications being passed and treatments administered to patients, combined with the additional load of at least two housekeeping carts on the floor creates an obstacle course of wheeled impediments to any staff or patients who may have to quickly evacuate to a safe area in a fire or weather emergency.

During an interview on 03/29/12 at 10:30 AM, Staff W, QA/Risk Manager, stated that there was no formal facility policy or procedure to address impediments to the exit egress. She stated that it had been a subject regularly discussed in several safety committee meetings over the past two years, from 08-12-10 through 06-30-11. She said more wall outlets were added and department heads agreed to monitor themselves to limit and reduce the number of obstructions in the corridor by putting everything along the same wall. She stated that they did not review, discuss or establish parameters for the amount of time each item was attended or unattended before it was moved or relocated to another corridor.

Based on observations and interviews, the facility failed to maintain the sprinkler system in accordance with NFPA 13, 8.5.6.1, by ensuring a minimum clearance of 18 inches between sprinkler deflectors and the top of storage around the perimeter edges of at storage room in Pharmacy, potentially affecting, staff, visitors and 16 patients. The facility census was 16.

Findings included:

1. Observation on 03/26/12 at 3:00 PM showed a clearance of less than three inches between the plane of pendant type sprinklers and cardboard boxed items stored on top shelves around the perimeter of the room.

During an interview on 3/26/12 at 3:08 PM Staff QQ, Plant Operations Manager stated that there was no formal policy or procedure regarding items stored above the 18 inch plane in sprinklered rooms. He stated that he usually just treats each situation case by case and monitors clearance to storage during his normal rounds.

During an interview on 03/26/12 at Staff R, Pharmacy Director stated that she would rearrange the storage and remove items from the top shelf and re-locate them to onto some additional shelves that Maintenance had offered to put up in the open center area of the room.