HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 1 of 15 fire zones. The findings were:


Observations on 1/4/11 at 3:30 PM revealed a 1.5 inch diameter circular hole in the ceiling in the medical surgical clean utility room. The director of plant operations verified the above findings at the time of the observation.

Based on observation and staff interview the facility failed to ensure 1 of 14 smoke barrier doors was maintained in optimal operational condition. The findings were:


Observation on 1/4/11 at 2:48 PM revealed the cross corridor smoke barrier doors near the patient care administrator's office could not be opened after it was closed unless considerable pressure (in excess of 10 ft-lbs) was applied to the cross-bar door opener. The director of plant operations verified the above findings at the time of the observation.

Based on observation and staff interview, the facility failed to ensure 3 hazardous areas were separated from patient use areas in 2 of 15 fire zones. The findings were:


Observation on 1/4/11 at 4 PM revealed the doors into three hazardous areas did not close, with three separate attempts. All doors had operational self-closure devices attached.
1. The medical surgical clean utility room door.
2. The medical surgical soiled utility room door.
3. The intensive care unit's soiled utility door.
The director of plant operations verified the above findings at the time of the observation.

Based on record review and staff interview the facility failed to ensure 2 of 2 emergency battery backup light tests were conducted in 11 of the previous 12 months. The findings were:


Review of the emergency battery light testing records revealed the monthly 30 minute battery backup emergency light tests for the generator room and the main electrical room had not been conducted during the previous year, with the exception of the July test (7/27/10). The director of plant operations verified the above findings on 1/4/11 at 2:22 PM.

Based on observation and staff interview, the facility failed to ensure 3 emergency exit signs were fully illuminated. The findings were:


Observation on 1/4/11 between at 3:38 PM and 4 PM revealed burned out light bulbs in the following emergency exit signs:
1. The emergency exit sign leading from the operating room into the hallway was not lit.
2. One of two light bulbs was burned out in the exit sign by the endoscopy room
3. One of two light bulbs was burned out in the exit sign by the x-ray office.
The director of plant operations verified the above findings at the times of the observations.

Based on record review and staff interview, the facility failed to ensure the fire alarm system received an annual inspection during the previous year. The findings were:


Review of facility fire alarm records on 1/4/11 at 2:22 PM revealed the fire alarm system was last inspected on 1/29/09. The director of plant operations stated at the time of the review that the system was inspected in January 2010, but the report of that inspection could not be found.

Based on observation and staff interview the facility failed to ensure two sprinkler heads in 2 of 15 fire zones were installed as required. The findings were:

Observation on 1/4/11 at 3:48 PM revealed the ceiling sprinkler head escutcheons were missing in the mammography room and in the rehabilitative storage room. The director of plant operations verified the above findings at the time of the observations.

Based on record review and staff interview, the facility failed to ensure the fire suppression (sprinkler) system received a quarterly main drain test during three of four quarters in 2010. The findings were:


Record review revealed the fire suppression (sprinkler) system received an annual inspection on 7/20/10 (third quarter). However, further record review revealed the quarterly main drain tests were not conducted during the first, second or fourth quarter of 2010. On 1/4/11 at 2:22 PM the director of plant operations confirmed that the quarterly main drain tests had not been conducted.

Based on record review and staff interview the facility failed to ensure the medical gas master alarm panel operated properly. The findings were:


Review of facility inspection reports for medical gasses revealed "Compliance Plus Inc." (CPI) did an annual inspection on 1/5/10 and then again on 1/3/11. Reports from both inspections revealed the "Master alarm panel in the business office is not functioning properly." CPI also stated in both reports that this was considered a "major condition." CPI further also stated the definition of a major concern was a "condition exists which is a significant risk to patients or staff safety and the potential failure of primary and or secondary equipment." The director of plant operations confirmed at the time of the record review that the master alarm panel needed to be "worked on."

Based on record review and staff interview the facility failed to maintain a log of monthly emergency generator tests during three of the previou twelve months. The findings were:


Record review revealed the annual inspection of the generator was conducted 7/6/10. However, the monthly inspections of the emergency generator were not conducted during the months of June, August and December 2010. On 1/4/11 at 2:22 PM the director of plant operations confirmed that the monthly inspections were probably done; however, they were not logged as being conducted. The director of plant operations confirmed there were no other records to review.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required in 2 of 15 fire zones. The findings were:


Observation on 1/4/11 between 3:38 PM and 4 PM revealed the following concerns:

a. An electrical outlet on the wall over the counter in the operating room clean up room was not ground fault circuit interupt (GFCI) protected. The outlet was within six feet of a water source.
b. One electrical cover plate was missing from an electrical outlet in the operating room scheduling office.
c. An electrical panel in the guest services office room was blocked by a portable file drawer.
The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure an alcohol based hand rub (ABHR) dispenser was not installed over an ignition source in 1 of 15 fire zones. The findings were:


Observation on 1/4/11 at 4:44 PM revealed one ABHR dispenser was attached to the wall directly over an electrical outlet near room #219. The director of plant operations verified the above finding at the time of the observation.

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 1 of 15 fire zones. The findings were:


Observations on 1/4/11 at 3:30 PM revealed a 1.5 inch diameter circular hole in the ceiling in the medical surgical clean utility room. The director of plant operations verified the above findings at the time of the observation.

Based on observation and staff interview the facility failed to ensure 1 of 14 smoke barrier doors was maintained in optimal operational condition. The findings were:


Observation on 1/4/11 at 2:48 PM revealed the cross corridor smoke barrier doors near the patient care administrator's office could not be opened after it was closed unless considerable pressure (in excess of 10 ft-lbs) was applied to the cross-bar door opener. The director of plant operations verified the above findings at the time of the observation.

Based on observation and staff interview, the facility failed to ensure 3 hazardous areas were separated from patient use areas in 2 of 15 fire zones. The findings were:


Observation on 1/4/11 at 4 PM revealed the doors into three hazardous areas did not close, with three separate attempts. All doors had operational self-closure devices attached.
1. The medical surgical clean utility room door.
2. The medical surgical soiled utility room door.
3. The intensive care unit's soiled utility door.
The director of plant operations verified the above findings at the time of the observation.

Based on record review and staff interview the facility failed to ensure 2 of 2 emergency battery backup light tests were conducted in 11 of the previous 12 months. The findings were:


Review of the emergency battery light testing records revealed the monthly 30 minute battery backup emergency light tests for the generator room and the main electrical room had not been conducted during the previous year, with the exception of the July test (7/27/10). The director of plant operations verified the above findings on 1/4/11 at 2:22 PM.

Based on observation and staff interview, the facility failed to ensure 3 emergency exit signs were fully illuminated. The findings were:


Observation on 1/4/11 between at 3:38 PM and 4 PM revealed burned out light bulbs in the following emergency exit signs:
1. The emergency exit sign leading from the operating room into the hallway was not lit.
2. One of two light bulbs was burned out in the exit sign by the endoscopy room
3. One of two light bulbs was burned out in the exit sign by the x-ray office.
The director of plant operations verified the above findings at the times of the observations.

Based on record review and staff interview, the facility failed to ensure the fire alarm system received an annual inspection during the previous year. The findings were:


Review of facility fire alarm records on 1/4/11 at 2:22 PM revealed the fire alarm system was last inspected on 1/29/09. The director of plant operations stated at the time of the review that the system was inspected in January 2010, but the report of that inspection could not be found.

Based on observation and staff interview the facility failed to ensure two sprinkler heads in 2 of 15 fire zones were installed as required. The findings were:

Observation on 1/4/11 at 3:48 PM revealed the ceiling sprinkler head escutcheons were missing in the mammography room and in the rehabilitative storage room. The director of plant operations verified the above findings at the time of the observations.

Based on record review and staff interview, the facility failed to ensure the fire suppression (sprinkler) system received a quarterly main drain test during three of four quarters in 2010. The findings were:


Record review revealed the fire suppression (sprinkler) system received an annual inspection on 7/20/10 (third quarter). However, further record review revealed the quarterly main drain tests were not conducted during the first, second or fourth quarter of 2010. On 1/4/11 at 2:22 PM the director of plant operations confirmed that the quarterly main drain tests had not been conducted.

Based on record review and staff interview the facility failed to ensure the medical gas master alarm panel operated properly. The findings were:


Review of facility inspection reports for medical gasses revealed "Compliance Plus Inc." (CPI) did an annual inspection on 1/5/10 and then again on 1/3/11. Reports from both inspections revealed the "Master alarm panel in the business office is not functioning properly." CPI also stated in both reports that this was considered a "major condition." CPI further also stated the definition of a major concern was a "condition exists which is a significant risk to patients or staff safety and the potential failure of primary and or secondary equipment." The director of plant operations confirmed at the time of the record review that the master alarm panel needed to be "worked on."

Based on record review and staff interview the facility failed to maintain a log of monthly emergency generator tests during three of the previou twelve months. The findings were:


Record review revealed the annual inspection of the generator was conducted 7/6/10. However, the monthly inspections of the emergency generator were not conducted during the months of June, August and December 2010. On 1/4/11 at 2:22 PM the director of plant operations confirmed that the monthly inspections were probably done; however, they were not logged as being conducted. The director of plant operations confirmed there were no other records to review.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required in 2 of 15 fire zones. The findings were:


Observation on 1/4/11 between 3:38 PM and 4 PM revealed the following concerns:

a. An electrical outlet on the wall over the counter in the operating room clean up room was not ground fault circuit interupt (GFCI) protected. The outlet was within six feet of a water source.
b. One electrical cover plate was missing from an electrical outlet in the operating room scheduling office.
c. An electrical panel in the guest services office room was blocked by a portable file drawer.
The director of plant operations verified the above findings at the time of the observations.