HospitalInspections.org

Based on observations the facility failed to maintain corridor doors.

The findings included:

1. Observations on 09/19/2016 at 11:24 AM-12:23 PM, revealed the following doors failed to self-latch within the frame:
a. Front Hall laboratory
b. Medical Surgical nursing services
c. Medical Surgical doctor dictation room
d. Same day surgery hallway nutrition room
e. Same day surgery clean linen room
f. OR environmental services closet
g. Radiology waiting room
National Fire Protection Association (NFPA) 101, 19.3.6.3 (2000 Edition)

2. Observations on 09/19/2016 at 11:46 AM, revealed the door of room 125 had a gap over ½ inch at the top of the door. CMS S&C-07-18-LSC

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations the facility failed to maintain fire/smoke doors.

The findings included:

1. Observation on 09/19/2016 at 12:38 PM, revealed the OR hallway rear cross corridor doors had several penetrations. NFPA 101, 8.2.3.2.1 (2000 Edition) NFPA 80, 15-2.5.4 (1999 Edition)

2. Observation on 09/19/2016 at 12:39 PM, revealed the OR hall way rear cross corridor door did not properly latch within the frame. NFPA 101, 8.2.3.2.1 (2000 Edition) NFPA 80, 15-1.2 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on document review, the facility failed to maintain the smoke detection system.

The findings included:

Document review on 09/29/2016 at 10:15 AM, revealed 29 smoke detectors failed annual testing during the annual fire alarm inspection during 08/2016.

This finding was verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observation and document review, the facility failed to maintain the sprinkler system.

The findings included:

1. Document review on 09/19/2016 at 10:12 AM, revealed the facility failed to conduct quarterly sprinkler inspections during the 1st and 2nd quarters of 2016 and the 4th quarter of 2015. NFPA 101, 19.3.5.1 (2000 Edition) NFPA 101, 9.7.1.1 (2000 Edition) NFPA 13, 12-1 (1999 Edition) NFPA 25, 2-1 (1998 Edition)

2. Observation on 09/19/2016 at 11:47 AM, revealed the medical surgical wing supply closet #2 missing an sprinkler escutcheon plate. NFPA 101, 19.3.5.1 (2000 Edition) NFPA 101, 9.7.1.1 (2000 Edition) NFPA 13, 3-2.7.2 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to comply with smoking regulations.

The findings included:

1. Observation on 09/19/2016 at 11:50 AM, revealed products of smoking in the outside break area while the facility is a smoke-free campus. NFPA 101. 19.7.4 (2000 Edition)

2. Observation on 09/19/2016 at 11:51 AM, revealed cigarette butts improperly disposed on the ground around the outside break area. NFPA 101. 19.7.4 (2000 Edition)

3. Observation on 09/19/2016 at 11:52 AM, revealed no ashtrays in the outside break area. NFPA 101. 19.7.4 (2000 Edition)

4. Observation on 09/19/2016 at 11:53 AM, revealed no metal can with a self-closing lid in the outside break area for ash disposal. NFPA 101. 19.7.4 (2000 Edition)

5. Interview with the risk manager on 09/19/2016 at 1:20 AM, revealed patients sneaking outside to smoke in the outside break area. NFPA 101. 19.7.4 (2000 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to prohibit the use of portable space heaters.

The findings included:

Observation on 09/19/2016 at 11:23 AM-1:00 PM, revealed portable space heaters in use in the following areas:
a. Patient registration office
b. Medical records
c. Sleep study office
d. Dietary office
NFPA 101, 19.7.8 (2000 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to maintain the emergency power generator.

The findings included:

Document review on 09/19/2016 at 10:45 AM, revealed the facility failed to conduct the annual 1 ½ hour generator load bank test. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.3 (2000 Edition) NFPA 110, 6-4.2.2 (1999 Edition)

This finding was verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations the facility failed to maintain the electrical system.

The findings included:

1. Observation on 09/19/2016 at 11:04 AM, revealed an extension cord in the risk managers office. NFPA 99, 3-3.2.1.2 (d) 2 (1999 Edition)

2. Observation on 09/19/2016 at 11:21 AM, revealed a flexible cord run through the lab storage room door. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.2 (2000 Edition) NFPA 70, 400-8 (1999 Edition)

3. Observation on 09/19/2016 at 1:10 PM, revealed the facility failed to provide battery back-up emergency lighting at the transfer switch location. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.3 (2000 Edition) NFPA 110 5.3.1 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations the facility failed to maintain corridor doors.

The findings included:

1. Observations on 09/19/2016 at 11:24 AM-12:23 PM, revealed the following doors failed to self-latch within the frame:
a. Front Hall laboratory
b. Medical Surgical nursing services
c. Medical Surgical doctor dictation room
d. Same day surgery hallway nutrition room
e. Same day surgery clean linen room
f. OR environmental services closet
g. Radiology waiting room
National Fire Protection Association (NFPA) 101, 19.3.6.3 (2000 Edition)

2. Observations on 09/19/2016 at 11:46 AM, revealed the door of room 125 had a gap over ½ inch at the top of the door. CMS S&C-07-18-LSC

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations the facility failed to maintain fire/smoke doors.

The findings included:

1. Observation on 09/19/2016 at 12:38 PM, revealed the OR hallway rear cross corridor doors had several penetrations. NFPA 101, 8.2.3.2.1 (2000 Edition) NFPA 80, 15-2.5.4 (1999 Edition)

2. Observation on 09/19/2016 at 12:39 PM, revealed the OR hall way rear cross corridor door did not properly latch within the frame. NFPA 101, 8.2.3.2.1 (2000 Edition) NFPA 80, 15-1.2 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on document review, the facility failed to maintain the smoke detection system.

The findings included:

Document review on 09/29/2016 at 10:15 AM, revealed 29 smoke detectors failed annual testing during the annual fire alarm inspection during 08/2016.

This finding was verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observation and document review, the facility failed to maintain the sprinkler system.

The findings included:

1. Document review on 09/19/2016 at 10:12 AM, revealed the facility failed to conduct quarterly sprinkler inspections during the 1st and 2nd quarters of 2016 and the 4th quarter of 2015. NFPA 101, 19.3.5.1 (2000 Edition) NFPA 101, 9.7.1.1 (2000 Edition) NFPA 13, 12-1 (1999 Edition) NFPA 25, 2-1 (1998 Edition)

2. Observation on 09/19/2016 at 11:47 AM, revealed the medical surgical wing supply closet #2 missing an sprinkler escutcheon plate. NFPA 101, 19.3.5.1 (2000 Edition) NFPA 101, 9.7.1.1 (2000 Edition) NFPA 13, 3-2.7.2 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to comply with smoking regulations.

The findings included:

1. Observation on 09/19/2016 at 11:50 AM, revealed products of smoking in the outside break area while the facility is a smoke-free campus. NFPA 101. 19.7.4 (2000 Edition)

2. Observation on 09/19/2016 at 11:51 AM, revealed cigarette butts improperly disposed on the ground around the outside break area. NFPA 101. 19.7.4 (2000 Edition)

3. Observation on 09/19/2016 at 11:52 AM, revealed no ashtrays in the outside break area. NFPA 101. 19.7.4 (2000 Edition)

4. Observation on 09/19/2016 at 11:53 AM, revealed no metal can with a self-closing lid in the outside break area for ash disposal. NFPA 101. 19.7.4 (2000 Edition)

5. Interview with the risk manager on 09/19/2016 at 1:20 AM, revealed patients sneaking outside to smoke in the outside break area. NFPA 101. 19.7.4 (2000 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to prohibit the use of portable space heaters.

The findings included:

Observation on 09/19/2016 at 11:23 AM-1:00 PM, revealed portable space heaters in use in the following areas:
a. Patient registration office
b. Medical records
c. Sleep study office
d. Dietary office
NFPA 101, 19.7.8 (2000 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations, the facility failed to maintain the emergency power generator.

The findings included:

Document review on 09/19/2016 at 10:45 AM, revealed the facility failed to conduct the annual 1 ½ hour generator load bank test. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.3 (2000 Edition) NFPA 110, 6-4.2.2 (1999 Edition)

This finding was verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.

Based on observations the facility failed to maintain the electrical system.

The findings included:

1. Observation on 09/19/2016 at 11:04 AM, revealed an extension cord in the risk managers office. NFPA 99, 3-3.2.1.2 (d) 2 (1999 Edition)

2. Observation on 09/19/2016 at 11:21 AM, revealed a flexible cord run through the lab storage room door. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.2 (2000 Edition) NFPA 70, 400-8 (1999 Edition)

3. Observation on 09/19/2016 at 1:10 PM, revealed the facility failed to provide battery back-up emergency lighting at the transfer switch location. NFPA 101, 19.5.1 (2000 Edition) NFPA 101, 9.1.3 (2000 Edition) NFPA 110 5.3.1 (1999 Edition)

These findings were verified by the maintenance director and acknowledged by the risk manager during the exit conference on 09/22/2016.