HospitalInspections.org

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain patient room doors to latch as required by:
2000 NFPA 101 Sections 19.3.6.3.1; 19.3.6.3.2
The deficiency affected patient room number 4.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the door for patient room number 4 would not latch due to the privacy curtain getting caught between the door and door frame preventing it from latching.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain self-closing doors to hazardous rooms as required by:
2000 NFPA 101 Section: 19.3.2.1; 4.6.12.1
The deficiency affected the corridor where the health information records room is located.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the health information records room does not have a self-closing device, the device has been removed.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to as maintain exits readily accessible at all times required by:
2000 NFPA 101 Sections 19.2.1; 7.1; 7.1.7.1; 7.1.7.2; 7.2.1.3; 7.2.1.4.4; 7.2.2; 7.2.2.2; 7.2.2.4.2; 7.2.2.4.5
The deficiency affected the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the modular CT building does not have a landing or steps for the rear exit door, this door does not exit a grade level.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain emergency lights as required by:
2000 NFPA 101 Sections 19.2.9.1; 7.9; 7.9.2.1; 7.9.2.2; 7.9.3; 4.6.12.1
The deficiency affected the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the emergency light in the modular CT building does not work on battery power when manually tested. The light indicating normal power is not illuminated.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to provide complete sprinkler coverage as required by:
2000 NFPA 101 Sections 19.3.5.1; 19.1.6; 9.7; 9.7.1.1
1999 NFPA 13 Sections 1-6.1; Chapter 5; Chapter 6; Chapter 7
CMS S&C-13-55-LSC dated August 16, 2013

The deficiency affected the area between the main hospital building and the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM there is an awning greater than 4 foot of combustible construction attached the main hospital building at the modular CT building that provides a covered walkway from the main hospital to the modular CT building that does not have sprinkler protection.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain patient room doors to latch as required by:
2000 NFPA 101 Sections 19.3.6.3.1; 19.3.6.3.2
The deficiency affected patient room number 4.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the door for patient room number 4 would not latch due to the privacy curtain getting caught between the door and door frame preventing it from latching.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain self-closing doors to hazardous rooms as required by:
2000 NFPA 101 Section: 19.3.2.1; 4.6.12.1
The deficiency affected the corridor where the health information records room is located.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the health information records room does not have a self-closing device, the device has been removed.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to as maintain exits readily accessible at all times required by:
2000 NFPA 101 Sections 19.2.1; 7.1; 7.1.7.1; 7.1.7.2; 7.2.1.3; 7.2.1.4.4; 7.2.2; 7.2.2.2; 7.2.2.4.2; 7.2.2.4.5
The deficiency affected the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the modular CT building does not have a landing or steps for the rear exit door, this door does not exit a grade level.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to maintain emergency lights as required by:
2000 NFPA 101 Sections 19.2.9.1; 7.9; 7.9.2.1; 7.9.2.2; 7.9.3; 4.6.12.1
The deficiency affected the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM the emergency light in the modular CT building does not work on battery power when manually tested. The light indicating normal power is not illuminated.
The maintenance director was present when the deficiency was identified.

This STANDARD is not met evidenced by:
Surveyor: 35818
Based on observation and staff interview, the facility failed to provide complete sprinkler coverage as required by:
2000 NFPA 101 Sections 19.3.5.1; 19.1.6; 9.7; 9.7.1.1
1999 NFPA 13 Sections 1-6.1; Chapter 5; Chapter 6; Chapter 7
CMS S&C-13-55-LSC dated August 16, 2013

The deficiency affected the area between the main hospital building and the modular CT building.
Findings include:
On 03/15/2016 between 9:00 AM and 11:30 AM there is an awning greater than 4 foot of combustible construction attached the main hospital building at the modular CT building that provides a covered walkway from the main hospital to the modular CT building that does not have sprinkler protection.
The maintenance director was present when the deficiency was identified.