HospitalInspections.org

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain doors that are not protecting hazardous areas so that they close and latch and are without obstructions or impediments to the closing of the doors. This could result in the toxic products of combustion moving from one room into the corridor or from the corridor into the room.


The findings include:

1. At approximately 1132 hours on Tuesday November 27 observed that the door to the ICU waiting room failed to close and latch.

2. At approximately 0851 hours on November 28, 2012 observed that the door into the Dialysis area failed to close and latch. This was discussed with and acknowledged by the Director of Maintenance

3. At approximately 0908 hours on November 28, 2012 observed that the door to the medication room across from the med-surgical nurses station was prevented from closing by a rope looped around the door handle and then tied to the handles of cabinet doors. This door is equipped with a self closing device. The Director of Maintenance immediately cut the rope with a knife.

4. At approximately 0909 hours on November 28, 2012 observed that the door to patient room 111 failed to close in the frame. The door latching mechanism would not retract to allow the door to close. This was noted by the Director of Maintenanceand discussed with him.

5..At approximately 0910 hours on November 28, 2012 observed that the door to patient room 108 failed to close for the same reason as room 111. This was also discussed with the Director of Maintenance.

Based upon observations and staff interviews Tri-State Memorial Hospital has failed to maintain doors so that they will close and latch so as to resist the passage of smoke. This could result in the movement of the toxic products of combustion from one room into the exit access corridor or from the exit access corridor into a patient room. These observations were made during survey rounds with the Director of Maintenance.

The findings include:

1. At approximately 1400 hours on Tuesday November 27, 2012 observed unsealed holes in the door to the Triage Room. This was acknowledged by the Director of Maintenance.

2. At approximately 1435 on Tuesday November 27, 2012 observed that the door to the staff lounge located directly behind the nurses station in the Emergency Department was blocked open by a wedge. Interviews with staff indicated that the wedge was used during low staffing at night so that nursing staff could observe the nurses station and respond if needed. This was acknowledged by the Director of Maintenance.

3.. At approximately 1444 on Tuesday November 27, 2012 observed that the door to the patient admissions office Failed to close. This was acknowledged by Director of Maintenance

Based upon observations and staff interviews during survey rounds Tri State Memorial Hospital has failed to maintain the required separation between Hazardous Areas and other areas in the hospital. This could result in the toxic products of combustion passing from the Hazardous area to other areas of the hospital in the event of a fire.


The findings include:

1. Observed on Tuesday November 27 at approximately 1440 that the latching device on the door to the Soiled Utility Room had been disabled preventing the door latching. In addition evidence on the door indicated that at a previous time tape had been used to keep the latching device from being able to engage the door frame. This was acknowledged by the Director of Maintenance who repaired the door and also was acknowledged by the Director of the Emergency Department.

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain the required separation of Hazardous Areas from other portions of the building. This could result in the toxic products of combustion spreading from the hazardous area into other areas of the Hospital.


The findings include:

1. At approximately 0847 hours on November 28, 2012 observed that the door separating the Clean Linen Supply room behind the nurses station had a rope tied to the interior door handle and then secured to conduit which prevented the door closing. This condition was observed by the Director of Maintenance who removed the rope by cutting it free.


2. At approximately 0904 hours on November 28, 2012 observed unsealed pipe penetrations in the wall separating the Boiler Room from the Dialysis service room. This was acknowledged by the Director of Maintenance

Based upon a record review, observations and staff interviews Tri State Memorial Hospital has failed to maintain the fire sprinkler system as required. This could result in an inaccurate test procedure that is unable to determine the status of the fire sprinkler system. This could possibly result in the system not being able to perform as designed.

The specific standard from NFPA 13 "Standard for the Installation of Sprinkler Systems" 1999 edition." states:

10-5* Hydraulic Design Information Sign.
The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, pre-action valve, or deluge valve supplying the corresponding hydraulically designed area. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand


This standard is not met:

The findings include:

1. Based upon observations and interviews with the director of maintenance there is no Hydraulic Design Information on the Risers that supply the fire sprinkler system in the Emergency Department or Imaging Departments. Without that information available it is difficult if not impossible to determine if the system when tested is performing as it was designed.

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain the means of egress free of obstructions or impediments to the full and instant use in the event of a fire or other emergency that would require the evacuation of a compartment or the building. This could result in a delay in moving patients from one compartment into another.


The findings include:

1. On November 27, 2012 at the time of entry into Tri State Memorial Hospital at approximately 0815 hours observed a number of Computer on Wheels (COW's) which were plugged into wall electrical outlets and other wheeled items in the exit access corridor of the medical surgical care care area.

2. On November 28, 2012 at approximately 0845 observed several COW's plugged into wall outlets in the
exit access corridor near room 125.

3. Interviews with staff indicated that they are normally plugged into outlets in the corridor. This was discussed with the Director of Maintenance and acknowledged.

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain doors that are not protecting hazardous areas so that they close and latch and are without obstructions or impediments to the closing of the doors. This could result in the toxic products of combustion moving from one room into the corridor or from the corridor into the room.


The findings include:

1. At approximately 1132 hours on Tuesday November 27 observed that the door to the ICU waiting room failed to close and latch.

2. At approximately 0851 hours on November 28, 2012 observed that the door into the Dialysis area failed to close and latch. This was discussed with and acknowledged by the Director of Maintenance

3. At approximately 0908 hours on November 28, 2012 observed that the door to the medication room across from the med-surgical nurses station was prevented from closing by a rope looped around the door handle and then tied to the handles of cabinet doors. This door is equipped with a self closing device. The Director of Maintenance immediately cut the rope with a knife.

4. At approximately 0909 hours on November 28, 2012 observed that the door to patient room 111 failed to close in the frame. The door latching mechanism would not retract to allow the door to close. This was noted by the Director of Maintenanceand discussed with him.

5..At approximately 0910 hours on November 28, 2012 observed that the door to patient room 108 failed to close for the same reason as room 111. This was also discussed with the Director of Maintenance.

Based upon observations and staff interviews Tri-State Memorial Hospital has failed to maintain doors so that they will close and latch so as to resist the passage of smoke. This could result in the movement of the toxic products of combustion from one room into the exit access corridor or from the exit access corridor into a patient room. These observations were made during survey rounds with the Director of Maintenance.

The findings include:

1. At approximately 1400 hours on Tuesday November 27, 2012 observed unsealed holes in the door to the Triage Room. This was acknowledged by the Director of Maintenance.

2. At approximately 1435 on Tuesday November 27, 2012 observed that the door to the staff lounge located directly behind the nurses station in the Emergency Department was blocked open by a wedge. Interviews with staff indicated that the wedge was used during low staffing at night so that nursing staff could observe the nurses station and respond if needed. This was acknowledged by the Director of Maintenance.

3.. At approximately 1444 on Tuesday November 27, 2012 observed that the door to the patient admissions office Failed to close. This was acknowledged by Director of Maintenance

Based upon observations and staff interviews during survey rounds Tri State Memorial Hospital has failed to maintain the required separation between Hazardous Areas and other areas in the hospital. This could result in the toxic products of combustion passing from the Hazardous area to other areas of the hospital in the event of a fire.


The findings include:

1. Observed on Tuesday November 27 at approximately 1440 that the latching device on the door to the Soiled Utility Room had been disabled preventing the door latching. In addition evidence on the door indicated that at a previous time tape had been used to keep the latching device from being able to engage the door frame. This was acknowledged by the Director of Maintenance who repaired the door and also was acknowledged by the Director of the Emergency Department.

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain the required separation of Hazardous Areas from other portions of the building. This could result in the toxic products of combustion spreading from the hazardous area into other areas of the Hospital.


The findings include:

1. At approximately 0847 hours on November 28, 2012 observed that the door separating the Clean Linen Supply room behind the nurses station had a rope tied to the interior door handle and then secured to conduit which prevented the door closing. This condition was observed by the Director of Maintenance who removed the rope by cutting it free.


2. At approximately 0904 hours on November 28, 2012 observed unsealed pipe penetrations in the wall separating the Boiler Room from the Dialysis service room. This was acknowledged by the Director of Maintenance

Based upon a record review, observations and staff interviews Tri State Memorial Hospital has failed to maintain the fire sprinkler system as required. This could result in an inaccurate test procedure that is unable to determine the status of the fire sprinkler system. This could possibly result in the system not being able to perform as designed.

The specific standard from NFPA 13 "Standard for the Installation of Sprinkler Systems" 1999 edition." states:

10-5* Hydraulic Design Information Sign.
The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, pre-action valve, or deluge valve supplying the corresponding hydraulically designed area. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand


This standard is not met:

The findings include:

1. Based upon observations and interviews with the director of maintenance there is no Hydraulic Design Information on the Risers that supply the fire sprinkler system in the Emergency Department or Imaging Departments. Without that information available it is difficult if not impossible to determine if the system when tested is performing as it was designed.

Based upon observations and staff interviews Tri State Memorial Hospital has failed to maintain the means of egress free of obstructions or impediments to the full and instant use in the event of a fire or other emergency that would require the evacuation of a compartment or the building. This could result in a delay in moving patients from one compartment into another.


The findings include:

1. On November 27, 2012 at the time of entry into Tri State Memorial Hospital at approximately 0815 hours observed a number of Computer on Wheels (COW's) which were plugged into wall electrical outlets and other wheeled items in the exit access corridor of the medical surgical care care area.

2. On November 28, 2012 at approximately 0845 observed several COW's plugged into wall outlets in the
exit access corridor near room 125.

3. Interviews with staff indicated that they are normally plugged into outlets in the corridor. This was discussed with the Director of Maintenance and acknowledged.