HospitalInspections.org

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One random door was provided with double-action latching hardware (CT control/bioterorisim room). Findings include:

1. Observation and interview beginning at 3:00 p.m. revealed the door to the CT control/bioterorisim room had double-action latching hardware. That door was provided with a deadbolt and a coded latching lock. The two devices together provided the possible need for two actions to exit that room. Interview with the maintenace supervisor at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed set of 90 minute doors between the hospital and the independent living apartments did not properly latch into the floor strike plates. Findings include:

1. Observation at 11:50 a.m. on 4/12/11 revealed the north leaf of the cross-corridor horizontal exit doors between the hospital and the independent living apartments would not fully close and latch into the frame. The 90 minute fire resistance rating of that assembly was not being maintained. That door leaf was not correctly latching into the floor strike plate. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated those doors had worked properly during his last preventative maintenance inspection the day prior to the survey.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at three randomly observed patient rooms (21, 22, 26, and 31). Findings include:

1. Observation from 10:30 a.m. to 10:45 a.m. revealed ABHR containers were installed adjacent to an electrical source (light switches) in patient rooms 21, 22, 26, and 31. Interview with the maintenance supervisor at the time of the observations revealed he believed every patient room was probably deficient in the installation of the ABHR due to similar room layouts. He further stated he would relocate the ABHR containers to acceptable locations as soon as possible.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One random door was provided with double-action latching hardware (CT control/bioterorisim room). Findings include:

1. Observation and interview beginning at 3:00 p.m. revealed the door to the CT control/bioterorisim room had double-action latching hardware. That door was provided with a deadbolt and a coded latching lock. The two devices together provided the possible need for two actions to exit that room. Interview with the maintenace supervisor at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. One randomly observed set of 90 minute doors between the hospital and the independent living apartments did not properly latch into the floor strike plates. Findings include:

1. Observation at 11:50 a.m. on 4/12/11 revealed the north leaf of the cross-corridor horizontal exit doors between the hospital and the independent living apartments would not fully close and latch into the frame. The 90 minute fire resistance rating of that assembly was not being maintained. That door leaf was not correctly latching into the floor strike plate. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated those doors had worked properly during his last preventative maintenance inspection the day prior to the survey.