HospitalInspections.org

The facility has failed to ensure that fire protection systems are installed, tested, and maintained as required. This could allow for the system to become inoperable and place patients, visitors, and staff at risk of no protection in a fire event.

The findings include, but are not limited to:

1. During document review of the facility's servicing records on October 3, 2017 between the hours of 9am and 12pm, a record could not be produced for the testing of the kitchen roll up fire door. Observation made during the facility tour between the hours of 1pm and 3:30pm revealed that the tag on the system indicated that the last servicing was done by Simplex/Grinnel on 02/2015.

2. During the facility tour on October 3, 2017 between the hours of 1pm and 3:30pm, I observed that the new dr sleeping room was not equipped with a smoke/alarm. Interview with maintenance staff revealed that this was a newly converted room into a dr sleeping room and the smoke/alarm was overlooked.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that fire protection systems are installed, tested, and maintained as required. This could allow for the system to become inoperable and place patients, visitors, and staff at risk of no protection in a fire event.

The findings include, but are not limited to:

During document review of the facility's servicing records on October 3, 2017 between the hours of 9am and 12pm, it was observed that the sprinkler system did not receive its quarterly testing during 2nd quarter of 2017.

Interview with maintenance staff revealed that they thought it had been done. There was evidence that the 3rd quarter received both a quarterly test and an annual test for the system. However, the 2nd quarter was still missed.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure that fire doors opening into the corridors come to a complete close and latch. Doors that fail to close and latch properly could allow for patients, visitors, and staff to be at risk of smoke, fire, heat spread.

The findings include, but are not limited to:

During the facility tour on October 3, 2017 between the hours of 1:00pm and 3:30pm, I observed that fire doors did not close and latch in the following locations:

1. Clinic Office door sticks on plastic flooring and was blocked by chair. This door is on a magnetic hold open device and should not be obstructed from coming to a full close at any time.
2. Recovery Room #2 did not close and latch when tested. This was fixed on site.
3. Patient Room #9 had laundry cart obstructing the door.
4. Emergency Room soiled utility door did not close and latch when tested.

Interview with maintenance staff revealed that they were unaware of these doors not operating properly. Maintenance Staff was quick to repair and correct as we were going along with the survey tour.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the premises is free of electrical hazards. Improper use of power strips could allow for an electrical fire to start and place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

During the facility tour on October 03, 2017, between the hours of 1:00pm and 3:30pm, I observed the following electrical hazards and/or improper use of power strips.

1. Cafeteria lunch room had a a microwave and a toaster using an extension cord as a permanent source of power. This was corrected on site.
2. Surgery office has a power strip that is not mounted to the wall or laying on a flat service like a table or floor. The power strip is dangling causing stress on cords that could eventually cause shorts.
3. Old payroll office has a power strip that is not mounted to the wall or laying on a flat surface.

Interview with maintenance staff revealed that they were unaware of these electrical hazards.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that fire dampers are receiving the required servicing, testing, and maintenance. This could allow for the dampers to become non-functional and allow smoke to spread to next smoke compartment, placing patients, visitors, and staff at risk of smoke spread.

The findings include, but are not limited to:

Record review of the facility's servicing documents on October 03, 2017, between the hours of 9:00am and 12:00pm, revealed that the fire dampers have not been serviced, tested, and maintained as required.

Interview with maintenance staff revealed that they had not been made aware of this requirement.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure that hospital grade receptacles are receiving additional testing performed at intervals defined by documented performance data and that non-hospital grade receptacles are tested annually. Failure to test electrical receptacles could allow for an electrical fire to start and place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

Document review on October 03, 2017 between the hours of 9:00am and 12:00pm, revealed that staff has not been testing the electrical receptacles as required. There were no records maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
Interview with maintenance staff revealed that they were unaware of this requirement.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure that oxygen cylinder storage is maintained and stored as required. This could allow for errors to be made when obtaining an oxygen cylinder for use and place patients, visitors, and staff at risk of delay in providing oxygen.

The findings include, but are not limited to;

During the facility tour on October 03, 2017 between the hours of 1:00pm and 3:30pm, I observed that the facility did not segregate the empty cylinders from the full cylinders. The practice is to place a tag on the empty cylinder that reads "EMPTY", however, this does not meet the intent of the code to have empty cylinders segregated from full cylinders to avoid confusion.

Interview with maintenance staff revealed that they thought they were marking them correctly, but were not aware that the code specifically requires segregation.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to provide continuing education to all personnel concerned with the application, maintenance, and handling of the medical gases and cylinders. This could allow for staff to be unaware and cause an oxygen release or mishap that could place patients, visitors, and staff at risk of an oxygen explosion/rapid release.

The findings include, but are not limited to:

Document review of facility training records on October 03, 2017 between the hours of 9:00am and 12:00pm, revealed that employees are not receiving continuing education of medical gases and cylinders on the risks involved, safety guidelines, and usage requirements.

Interview with staff revealed that they were unaware of this requirement.

This finding was observed and discussed with the Maintenance Director.