HospitalInspections.org

Bringing transparency to federal inspections

500 BURLINGTON ROAD

JACKSON, OH 45640

No Description Available

Tag No.: K0018

Based on observations and staff interviews, the facility failed to ensure the doors of four of eight patient sleeping rooms in the critical care unit were equipped with latching hardware to resist the passage of smoke, as required by the code at 19.3.6.3.2. This could affect all patients in the in-patient unit.

Findings include:

On 03/14/11 at 1:25-1:35 PM, a tour was conducted on the 2 North in-patient unit with Staff E, F, and G on 03/14/11. The critical care unit was observed with four critical care unit rooms in this same corridor. The doors to these patient rooms (Rooms 1, 2, 3, and 4) were constructed of sliding glass doors, and lacked any type of positive latching hardware. Due to the lack of latching hardware, these doors could be forced open in the event of a fire or products of combustion, allowing smoke to enter into the patient rooms. According to Staff E and G, these doors were equipped to breakaway with pushing pressure of approximately 5 pounds. The cross corridor doors located in this unit were not equipped with positive latching hardware. Staff E and G verified the patient room doors, and cross corridor doors, do not latch.

No Description Available

Tag No.: K0021

Based on observations and staff interviews, the facility failed to ensure one of one set of latching fire doors, located in the administrative wing, latched when released from the automatic hold open device, in accordance with the code at 7.2.1.8.2. This could place the facility's 21 patients, staff and visitors at risk in the event of a fire.

Findings include:

A tour was conducted on 03/15/11 at 7:52 AM, with Staff E, F, and G. The fire doors located by the bathrooms leading into the administrative wing on the first floor were tested for closure. When released from the automatic hold open device, one of the two doors failed to latch into the frame. The doors were equipped with positive latching hardware, and were observed with a fire rating label of Class B (1 hour fire resistance rating). These doors were located in a one hour fire rated wall.
This was verified by Staff E, F, and G at the time of the tour.

No Description Available

Tag No.: K0022

Based on observations, staff interviews, and review of the facility life safety floor plan, the facility failed to ensure one of ten exits was identified with an approved, readily visible sign. The way to reach this exit, directional guidance, was not readily apparent to visitors and staff. The code at 7.10.1.4 requires access to exits be marked with approved, readily visible signs in all cases where the exit or the way to reach the exit is not readily apparent. This would place all patients, staff and visitors present in the emergency/triage area waiting room at risk in the event of a fire.

Findings include:

A tour was conducted on 03/14/11, at 2:00 PM, with Staff E, F, and G. When standing at the triage area/emergency room waiting room, an exit sign was observed at the cross corridor (long curving corridor with a wall of glass). The exit sign lacked directional arrows to direct persons to the exit discharge. The curving corridor was located to the right of the exit sign (when facing the sign). Approximately 8-10 feet, to the left, and beyond the exit sign, were two sets of double sliding doors which led to an exit discharge. The inner set of doors lacked a directional exit sign. Although an exit sign was located just inside the outer sliding doors, it could only be viewed when standing at the inner set of doors, and not at the cross corridor intersection. This would require extra time for the staff, visitors, and patients to make a decision between the two different directions possible to go to find the correct exit in the event of a fire, instead of the correct direction distinctly designated for them to exit. The long curved hallway was not designated as an exit access corridor according to the floor plan and staff interviews.

This was verified with Staff E and G at the time of the tour.

No Description Available

Tag No.: K0029

Based on observations and staff interviews, the facility failed to ensure the door to one of one soiled utility rooms, located in the critical care in-patient unit, resisted the passage of smoke, in accordance with the code at 19.3.2.1. This could affect all patients in the in-patient unit.

Findings include:

On 03/14/11 at 1:28 PM, a tour was conducted on the 2 North in-patient unit with Staff E, F, and G on 03/14/11. The critical care unit was observed with a soiled utility room which contained trash containers. This soiled utility room was observed with an automatic sprinkler head, and two positive latching doors. One of the two doors would not resist the passage of smoke as it was observed with two holes that had been drilled into the door directly above the door handle. These holes were measured and verified with Staff G as 3/4 inch in diameter, and 5/8 inch in diameter. Four critical care unit rooms were located in this same corridor. The doors to these patient rooms lacked any type of positive latching hardware in order to keep the patient rooms free from smoke in the event of a fire.
This was verified with all three staff (E, F, and G) at the time of the tour.

No Description Available

Tag No.: K0038

Based on observations and staff interviews, the facility failed to ensure one of ten exits lacked a hard or paved continuous surface from the exit discharge to a common way, in accordance with Chapter 7. This affected all patients in the facility. The facility census was 21 at the time of the survey.

Findings include:

Observations during tour on 03/15/11 at 8:40 AM, and staff interviews, revealed the exit from the stairwell located in the 2 North in-patient unit did not have a hard or paved continuous surface from the exit discharge to the common way, which was approximately 65 feet in length. The concrete pad outside the exit discharge did not allow for the placement of wheelchairs or gurneys due to the size of the concrete pad (4 feet wide by 5 feet long), and due to the way the exit discharge door swung open. When the door was open, it swung in the direction of the path of travel from this exit discharge. Staff G verified the open door would force staff to step off the concrete pad, and into the grass, in order to place a patient into a wheelchair or onto a gurney. Staff G stated the facility needs to enlarge the concrete pad in order to accommodate safe transfers of patients.

This was verified with Staff E, F, and G at the time of the tour.

No Description Available

Tag No.: K0045

Based on observations and staff interviews, the facility failed to ensure five of ten exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness in accordance with the code at 7.8.1.4.

Findings include:

Observations made on 03/15/11 in the dark, between 6:50 AM and 6:55 AM, revealed five exit discharges were either left in darkness, or had electrical light fixtures with burned out light bulbs. These exit discharges are as follows:

a) The emergency department outside driveway canopy was observed with only one of six recessed lights illuminated. Five of the recessed light bulbs were not working at that time.

b) The generator room exit was observed with a light fixture at the exit discharge on the outside of the building; however, the light fixture was not working, leaving the area in darkness.

c) The exit discharge from the mechanical corridor (at the northeast area of the building) was observed in darkness. The light fixture at the exit was observed not working at the time of the tour.

d) The exit discharge from the stairwell in the 2 North in-patient unit was observed with a light fixture; however, the fixture was not working, resulting in darkness at the exit discharge.

e) The South stairwell, near physical therapy, lacked lighting at the exit discharge and along the approximately 25 feet of sidewalk leading to the public way.


Interviews conducted with Staff E, F, and G, on 03/15/11 at 7:20 AM, verified the lack of the required illumination at the aforementioned exit discharges. When questioned about a preventative maintenance program for checking these lights, Staff E and G replied the facility security staff are to inform the maintenance department when the lights are not working; however, the maintenance department could not provide documented evidence of any notifications. Staff G stated the facility hires an outside service company to change the outside light bulbs when 5 or 6 are burned out, that this is costly due to needing a bucket truck.

No Description Available

Tag No.: K0050

Based on review of fire drill reports, and staff interviews, the facility failed to conduct fire drills in the second quarter on the third shift, did not ensure fire drills were held at unexpected times and days, and did not ensure the operating room and in-patient care units participated consistently in fire drills, in accordance with the code at 19.7.1.2. This affected all patients in the facility.

Findings include:

During this survey on 03/14/11 between 9:00 AM and 11:00 AM, a review of fire drills for 2010 was conducted with Staff E, F, and G.
The following concerns with fire drills were verified with Staff E and G:
a) There was no evidence of a fire drill conducted for the second quarter third shift.

b) The facility did not vary the days when fire drills were conducted each quarter as the fire drills for 2010 were all conducted either on/or close to last day of each quarter (03/31/10, 06/30/10, 09/30/10, and 12/29/30, and 12/29/10).

c) Fire drills times were not varied for the first and second shifts on 03/30/10 at 2:55 PM 3:51 PM, on 06/30/10 at 2:53 PM and 3:55 PM, and on 09/30/10 both were conducted at 3:15 PM.

d) There was no documented evidence of a fire drill for the in-patient unit on the 2nd floor on the first shift of the first quarter, or for the operating room staff on 06/30/10. It was verified with Staff G, at the time of the review, 06/30/10 was a Wednesday, and stated operating staff were on duty that day.

e) The fire drills for 2010 lacked documentation of staff who participated in the drills.

No Description Available

Tag No.: K0078

Based on observations, a review of humidity logs, and staff interviews, the facility failed to ensure relative humidity was maintained at equal to or greater than 35% in three of three operating rooms, failed to ensure the facility's documented acceptable parameters for humidity in the operating room met the requirement of 35% or greater. These operating rooms were equipped with piped-in oxygen. The code requirements at 19.3.2.3. and NFPA 99, 4.3.1.2.3 (n) states the relative humidity should be maintained equal to or greater than 35%. This could affect all staff and patients in the operating rooms.

Findings include:

A tour of the operating room suite was conducted on 03/14/11, between 3:40 PM and 4:02 PM, with Staff E and G. Three operating rooms were observed with piped-in oxygen during tour. On 03/16/11, at 4:30 PM, the humidity logs for December 2010 through March 2011 were reviewed with Staff E. Staff E verified the facility's acceptable parameters for humidity in the ORs is between 30-60 %. The humidity dropped below 35% in the three ORs as follows:

OR #1: 1 time during the week of 11/29/10 to 12/07/10 (34%),
5 times during the week of 12/08/10 to 12/14/10 (30 to 32%),
6 times during the week of 12/20/10 to 12/20/10 (30 to 32%),
7 times during the week of 01/10/11 to 01/17/11 (27 to 31%),
3 times during the week of 01/18/11 to 01/24/11 (25 to 29%),
3 times during the week of 01/31/11 to 02/08/11 (30 to 31%),

OR #2: 4 times during the week of 12/08/10 and 12/14/10 (33 to 34 %),
4 times during the week of 12/20/10 to 12/20/10 (33 to 34%),
7 times during the week of 01/10/11 to 01/17/11 (2 to 34%),
3 times during the week of 01/18/11 to 01/24/11 (26 to 32%),
3 times during the week of 01/31/11 to 02/08/11 (32 to 34%),

OR #3: 4 times during the week of 12/08/10 and 12/14/10 (33 to 34 %),
6 times during the week of 12/20/10 to 12/20/10 (32 to 33%),
1 time during the week of 01/10/11 to 01/17/11 (34%),
1 time during the week of 01/18/11 to 01/24/11 (30% ),
1 times during the week of 01/31/11 to 02/08/11 (33%).

An interview conducted with Staff E on 03/16 11 at 4:30 PM verified the documented relative humidity levels. Staff E stated the OR staff monitor the humidity levels and inform maintenance to make adjustments to the heating and air system if the levels are outside of the acceptable parameters

The facility's OR humidity logs included the statement the facility's acceptable range of relative humidity was between 30% to 60%. As of 03/17/11, at 11:30 AM, there was no documented evidence presented that maintenance was notified of these low levels in order to adjust the humidity levels.

No Description Available

Tag No.: K0144

Based on review of generator logs, and staff interviews, the facility lacked documented evidence of weekly generator checks between 07/07/10 through 03/01/11. This affected all patients in the facility. The NFPA 110 code, 8.4.2 requires weekly inspections of the generator.

Findings include:

A review of the generator logs on 03/16/11, at 2:30 PM, with Staff E revealed there was no documented evidence of weekly testing of the generator between 07/07/10 and 03/01/11.. The only testing logs available were for monthly load tests of the generator between 07/07/10 and 03/01/11. Staff E stated it was discovered in July 2010 the generator had been tested weekly under load, resulting in an increase in the usage of diesel fuel. Staff E stated the facility began running the generator under load monthly in July 2010; and verified the lack of documentation the generator had been tested and inspected on a weekly basis between 07/07/10 and 03/01/11.

No Description Available

Tag No.: K0154

Based on review of the fire watch plan, and interviews with staff, the facility lacked evidence the fire watch plan included the frequency of, and the person responsible for conducting the fire watch rounds, in accordance with the code at 9.7.6.1, in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. This affected all patients in the facility.

Findings include:

During this survey on 03/14/11 between 9:00 AM and 11:00 AM, a review of the fire watch plan, related to the required automatic sprinkler system, was conducted with Staff E, F, and G. The fire watch plan lacked identification of the person responsible for conducting the fire watch rounds, and lacked the frequency the fire watch rounds are to be conducted.

This was verified with Staff G at the time of the review.

No Description Available

Tag No.: K0155

Based on review of the fire watch plan, and interviews with staff, the facility lacked evidence the fire watch plan included the frequency of, and the person responsible for, conducting the fire watch rounds, in accordance with the code at 9.6.1.8, in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period. This affected all patients in the facility.

Findings include:

During this survey on 03/14/11 between 9:00 AM and 11:00 AM, a review of the fire watch plan, related to the fire alarm system, was conducted with Staff E, F, and G. The fire watch plan lacked identification of the person responsible for conducting the fire watch rounds, and lacked the frequency the fire watch rounds are to be conducted.

This was verified with Staff G at the time of the review.