HospitalInspections.org

Based on staff interview and tour of the dietary department with the Dietary Director staff F, on 01/24/13 at 10:40 AM it was determined the director failed to ensure dietary staff followed policies and procedures in regard to dating opened products being stored and maintaining disinfectant at the appropriate and safe concentration in the three compartment sink. The hospital census was 98.

Findings include:

Tour of the dietary department on 01/24/13 at 10:40 AM with the staff F revealed the water in the three compartment sink tested at 150 - 170 parts per million in stead of the required 200 parts per million as required for adequate dish sanitation. Interview of the pot washer employee G, revealed the sink was filled at 9:30 AM and the level should be 200 parts per million. The policy called for changing the water at least every two hours. This was confirmed by the Dietary Director during the tour.

Further tour of the kitchen revealed improper storage of refrigerated items. It was noted that four of five gallon containers of salad dressing had been opened, however staff failed to place the date the salad dressing had been opened. One container of sour cream had also been opened and stored without being dated. Dietary policy calls for food products to be disposed of five days after opening. During the tour the Dietary Manager confirmed the salad dressing and sour cream had been opened and staff had failed to date the products.

Based on observation and interview during the life safety code tour on 1/22/13 through 1/28/13 it was determined the facilty failed to maintain a safe environment for the protection of patients. The facility failed to maintain a two hour fire resistive rating in its fire barriers, failed to ensure each space that opened onto a corridor was properly protected, failed to ensure that doors in sprinklered buildings were only required to resist the passage of smoke, that each path of egress was clearly marked with exit signs, that each smoke barrier was free of penetrations, that each hazardous area was properly protected, that the automatic sprinkler system was maintained in a reliable operating condition, that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1 and 19.2, and failed to ensure each portable fire extinguisher was in compliance with NFPA 10. The cumulative effect of these systemic practices resulted in the facility's inability to maintain a safe environment to protect the health and safety of patients, staff and visitors. The hospital census at the time of the survey was 98 patients.
Findings include:
Observation revealed the facility failed to maintain a two-hour fire resistive fire rating in fire barriers. Please refer to A710 for more detailed findings.

Observation of waiting area 4194 in the D building and 324A in the A building revealed the facility failed to ensure each space that opened onto a corridor was properly protected.
Observation of the laboratory area located on the ground floor failed to ensure that doors in sprinklered buildings were only required to resist the passage of smoke. The wood Dutch doors revealed there was no closing device on either the top or bottom portions of the door.
Observation of the sixth, second and ground floor of the D building revealed the facility failed to ensure each exit was marked with approved readily visible exit signs.
Observation of the smoke wall in cafeteria, the sixth and fifth floor of the D building, fourth floor of the C building and the ground floor of the heart center revealed the facility failed to ensure each smoke barrier was free of penetrations.
Tour of the psychiatric occupational therapy corridor and building C revealed the facility failed to ensure each hazardous area was properly protected.
The facility failed to ensure that exit access on locked behavioral units, including the sixth floor of the D building was arranged so that exits were readily accessible at all times in accordance with section 7.1 and 19.2.
The facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key on two of five locked patient care units and one patient surgical area.
Observation of an exit stairwell to courtyard, on the second floor of the C building revealed the facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.
Tour of the facility revealed areas that failed to ensure the automatic sprinkler system was maintained in reliable operating condition. This included sprinkler heads on the D building, C building, and A building.
Observation of the paint room and the sixth floor of the D building revealed the facility failed to ensure each portable fire extinguisher was in compliance with NFPA 10.
Space heaters were observed in office 1252 during tour of the operating room area on first floor of building D and in a medical records room in the Health Center.The facility failed to ensure each patient care area was free of space heaters.
The facility failed to ensure piped gas complied with NFPA 99 on the fourth floor of the A building in the four procedure room area used as a pain clinic.
The facility failed to ensure compliance with NFPA 70 in regards to the use of a power strip and extension cord plugged into it located in the case management office on the second floor of the A building.
Please refer to A710 for more detailed findings.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The census at the time of the survey was 98 patients and the capacity was 203 beds.
Findings include:
Please refer to K11 of the Life Safety Code findings for further detail regarding fhe facility's failed to maintain a two-hour fire resistive fire rating in a fire barrier.
The facility failed to ensure each space that opened onto a corridor was properly protected. Please refer to K17.
The facility failed to ensure that doors in sprinklered buildings were only required to resist the passage of smoke. Please refer to K18.
The facility failed to ensure each exit was marked with approved readily visible exit signs. Please refer to K22.
The facility failed to ensure each smoke barrier was free of penetrations. Please refer to K25.
The facility failed to ensure each hazardous area was properly protected. Please refer to K29.
The facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1 and 19.2. Please refer to K38.
The facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. Please refer to K43.
The facility failed to ensure that illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. Please refer to K45.
The facility failed to ensure the automatic sprinkler system was maintained in reliable operating condition. Please refer to K62.
The facility failed to ensure each portable fire extinguisher was in compliance with NFPA 10. Please refer to K64
The facility failed to ensure each patient care area was free of space heaters. Please refer to K70.
The facility failed to ensure piped gas complied with NFPA 99. Please refer to K77.
The facility failed to ensure compliance with NFPA 70 in regards to the use of power strip and extension cord. Please refer to K147.