HospitalInspections.org

Based on observation and interview the facility failed to ensure all smoke barriers were maintained in a manner to resist smoke. The hospital census was one Acute Care Patients, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of five.

Findings included:

1. During observation on 04/03/24 of the area above the ceiling the smoke wall near the emergency department was noted to have three open areas around joists and the wall near the laboratory entrance had a 12 inch by 18 inch area which were open.

During interview upon the observation Staff D, Maintenance Director, confirmed the open areas in the smoke wall.

Based on observation, record review, and interview, the facility failed to ensure areas where medical gasses were stored were maintained as required by code. The hospital census was one Acute Care Patients, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of five.

Findings included:

1. Observation on 04/03/24 at 8:50 AM showed an outdoor enclosure for liquid oxygen and oxygen tanks. There was no overhead protection for the tanks. The containers were on a concrete pad.

During an interview upon the observation Staff D, Mainteance Director, stated they had contacted the inspection company to provide the needed protection but had not heard back from them.

2. Review of a report on the medical gas system dated 06/20/22 showed the following conditions needed to be addressed, cylinders stored outside must be protected as follows, from the ground beneath to prevent rusting, from the accumulation of snow and ice in winter, and from exosure to direct sunlight during the summer.