HospitalInspections.org

Based on observation and interview, the hospital failed to arrange readily accessible exits at all times. Failure to maintain exits risks the life and safety of all building occupants in the event of a fire requiring exiting the building.

Findings:

During a tour of the hospital on 5/24/11, the exit door from the corridor near Physical Therapy was found on a mag hold close device which would not allow exiting from the hospital. On this same tour, a delayed egress door was found without sign.

Staff #6 stated that the door was not delayed egress and would only open when the alarm sounded.

CORRECTED DURING SURVEY

Based on observation, the hospital failed to continuously maintain the automatic sprinkler system.. Failure to continuously maintain the automatic sprinkler systems places all building occupants at risk should the system fail to operate during a fire.

Findings:

During a tour of the hospital on 5/24/11, an escutcheon was missing on the sprinkler in the lobby outside the entrance to the laboratory.

CORRECTED DURING SURVEY.

Based on interview and examination of hospital records, the hospital failed to protect anesthetizing locations in accordance with NFPA 99. [Relative humidity in the operating rooms is maintained equal to or greater than 35%]. Failure to maintain relative humidity of at least 35% in operating rooms increases the risk of fire due to static or other ignition sources in he oxygen enriched environment.

Findings:

During a tour of the operating room on 5/24/11, Staff Member #6 stated that the humidity is monitored, but often falls below 35% and surgery is notified.

Hospital operating room relative humidity monitoring logs showed over 113 surgery days with a relative humidity below 35%.

Based on observation, the hospital failed to maintain electrical equipment in accordance with NFPA 70. Failure to maintain electrical equipment in accordance with NFPA 70 increases the risk of fire and places all building occupants at risk.

Findings:

During a tour of the gift shop on 5/24/11, "piggybacked" electrical power strips were found in use.

CORRECTED DURING SURVEY

Based on observation, the hospital failed to install alcohol based hand rub (ABHR) dispensers such that they were not installed over or adjacent to an ignition source. Failure to place ABHR dispensers such that they are not over or adjacent to an ignition source in increases the risk of fire should the flammable liquid be ignited by the source.

Findings:

During a tour of the hospital, ABHR dispensers were found installed over or within 6 inches of electrical light switched through out the hospital.

Based on observation and interview, the hospital failed to arrange readily accessible exits at all times. Failure to maintain exits risks the life and safety of all building occupants in the event of a fire requiring exiting the building.

Findings:

During a tour of the hospital on 5/24/11, the exit door from the corridor near Physical Therapy was found on a mag hold close device which would not allow exiting from the hospital. On this same tour, a delayed egress door was found without sign.

Staff #6 stated that the door was not delayed egress and would only open when the alarm sounded.

CORRECTED DURING SURVEY

Based on observation, the hospital failed to continuously maintain the automatic sprinkler system.. Failure to continuously maintain the automatic sprinkler systems places all building occupants at risk should the system fail to operate during a fire.

Findings:

During a tour of the hospital on 5/24/11, an escutcheon was missing on the sprinkler in the lobby outside the entrance to the laboratory.

CORRECTED DURING SURVEY.

Based on interview and examination of hospital records, the hospital failed to protect anesthetizing locations in accordance with NFPA 99. [Relative humidity in the operating rooms is maintained equal to or greater than 35%]. Failure to maintain relative humidity of at least 35% in operating rooms increases the risk of fire due to static or other ignition sources in he oxygen enriched environment.

Findings:

During a tour of the operating room on 5/24/11, Staff Member #6 stated that the humidity is monitored, but often falls below 35% and surgery is notified.

Hospital operating room relative humidity monitoring logs showed over 113 surgery days with a relative humidity below 35%.

Based on observation, the hospital failed to maintain electrical equipment in accordance with NFPA 70. Failure to maintain electrical equipment in accordance with NFPA 70 increases the risk of fire and places all building occupants at risk.

Findings:

During a tour of the gift shop on 5/24/11, "piggybacked" electrical power strips were found in use.

CORRECTED DURING SURVEY