HospitalInspections.org

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews December 9, 2015 doors were observed to not be able to close and latch properly in the following locations:
1. At 10:05am, I observed that the Surgery Out Patient fire doors did not close and latch properly when tested.
2. At 11:14am, I observed the door to the mail/copy room was obstructed by a trash can on a step ladder. If the fire alarm was to activate and release the magnetic hold device on this door, the door would not close and latch.
3. At 2:55pm, I observed that the door to Imaging Tech Control did not close and latch when tested.
These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the requirements for humidity levels in Anesthetizing locations are properly addressed in the facility policies for Operating Rooms. This could allow for a static electricity fire to start and thus place the patient and staff at risk of and exposure to threat of fire.
The findings include, but are not limited to:
Survey and document review of the facility Operating Rooms on December 09, 2015 between the hours of 10:05am and 11:30am, revealed the following:
1. Document review of the Operating Room reports of recorded humidity levels in each of the rooms, revealed that the facility operating rooms and the C-Section room all stayed well above the 20% humidity levels.
2. Written documentation of the Operating Room policy indicates steps to take if humidity levels fall below 20%. The code requires that they stay above 35%, unless they have a Categorical Waiver for the 20%. The facility currently does not have a Categorical Waiver in place for 20% humidity levels.
3. Interview with Maintenance Director revealed that the facility's mechanical upgrades does allow for the rooms to stay above 35%. If the facility decides to change their policy to take action when the humidity levels fall below 35%, then they must change their written policy to read as such.
These findings were observed and discussed with the Maintenance Director.

The facility has failed to provide a required emergency stop button for the existing generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Maintenance Director December 09, 2015 between the hours of 8:30am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

At approximately 10:50am, I observed that the generators do not have emergency shut off buttons as required.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on December 09, 2015, between the hours of 10:30 and 3:30pm, I observed electrical hazards in the following locations:

1. At 11:15am, I observed that the data room by the mail/copy room has a power strip dangling in mid air.
2. At 1:48pm, I observed that patient room 108 had a power strip in place for computer and other electronics.
3. At 1:57pm, I observed that the Hospitalist Sleeping room had a refrigerator on a power strip.
4. At 2:00pm, I observed that patient room 115 had a power strip in place for computer and other electronics.
5. At 2:10pm, I observed that Pharmacy had a power strip dangling under a desk.

Interview with Maintenance Director revealed that he was under the impression that he had no power strips in patient use areas. The facility was made aware of the Categorical Waiver process for power strips.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on December 09, 2015, between the hours of 10:30 and 3:30pm, I observed electrical hazards in the following locations:

The Emergency Department equipment storage room by ER1 was observed to have several miscellaneous items directly in front of the electrical panels.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews December 9, 2015 doors were observed to not be able to close and latch properly in the following locations:
1. At 10:05am, I observed that the Surgery Out Patient fire doors did not close and latch properly when tested.
2. At 11:14am, I observed the door to the mail/copy room was obstructed by a trash can on a step ladder. If the fire alarm was to activate and release the magnetic hold device on this door, the door would not close and latch.
3. At 2:55pm, I observed that the door to Imaging Tech Control did not close and latch when tested.
These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the requirements for humidity levels in Anesthetizing locations are properly addressed in the facility policies for Operating Rooms. This could allow for a static electricity fire to start and thus place the patient and staff at risk of and exposure to threat of fire.
The findings include, but are not limited to:
Survey and document review of the facility Operating Rooms on December 09, 2015 between the hours of 10:05am and 11:30am, revealed the following:
1. Document review of the Operating Room reports of recorded humidity levels in each of the rooms, revealed that the facility operating rooms and the C-Section room all stayed well above the 20% humidity levels.
2. Written documentation of the Operating Room policy indicates steps to take if humidity levels fall below 20%. The code requires that they stay above 35%, unless they have a Categorical Waiver for the 20%. The facility currently does not have a Categorical Waiver in place for 20% humidity levels.
3. Interview with Maintenance Director revealed that the facility's mechanical upgrades does allow for the rooms to stay above 35%. If the facility decides to change their policy to take action when the humidity levels fall below 35%, then they must change their written policy to read as such.
These findings were observed and discussed with the Maintenance Director.

The facility has failed to provide a required emergency stop button for the existing generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Maintenance Director December 09, 2015 between the hours of 8:30am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

At approximately 10:50am, I observed that the generators do not have emergency shut off buttons as required.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on December 09, 2015, between the hours of 10:30 and 3:30pm, I observed electrical hazards in the following locations:

1. At 11:15am, I observed that the data room by the mail/copy room has a power strip dangling in mid air.
2. At 1:48pm, I observed that patient room 108 had a power strip in place for computer and other electronics.
3. At 1:57pm, I observed that the Hospitalist Sleeping room had a refrigerator on a power strip.
4. At 2:00pm, I observed that patient room 115 had a power strip in place for computer and other electronics.
5. At 2:10pm, I observed that Pharmacy had a power strip dangling under a desk.

Interview with Maintenance Director revealed that he was under the impression that he had no power strips in patient use areas. The facility was made aware of the Categorical Waiver process for power strips.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on December 09, 2015, between the hours of 10:30 and 3:30pm, I observed electrical hazards in the following locations:

The Emergency Department equipment storage room by ER1 was observed to have several miscellaneous items directly in front of the electrical panels.

These findings were observed and discussed with the Maintenance Director.