HospitalInspections.org

Based on observation it was determined the facility failed to ensure all doors would close and latch.

The findings included:

On 11/12/2014 the procedure area equipment clean up room has card board under the door keeping it from closing. The latch to the door was missing and would not latch.

Based on observation, it was determined the facility failed to maintain the fire rating in the ceiling/floor and walls in hazardous areas.

The findings included:

Observations on 11/12/2014 revealed penetrations in the file room in the basement around the piping in the floor/ceiling rating and also in the wall above the door.

These findings were verified by the maintenance director during the survey and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the staff failed to perform their assigned duties during the fire drill.

The findings included:

Observations during the fire drill conducted on 11/12/2014 at 1:55 P.M. revealed a staff member brought a patient out of the operating room area through the fire doors and down the hall to the CT scan room and entered it through a set of smoke doors. A construction worker held the fire doors open during the fire drill.

The finding was verified by the maintenance supervisor and acknowledged by the Administrator during the exit conference on 11/12/2014.

Based on observation, it was determined the facility failed to prohibit the use of portable space heaters.

The findings included:

Observation on 11/12/2014 revealed space heaters were found in these locations that when checked with a Raytek temperature gage went over the 212 degrees: IT room, Assistance Executive Director office, Director of Education Affairs office, Health information Management office, QA/infection control office,

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the facility failed to maintain the soiled linen chute.

The findings included:

Observation of the soiled linen chute on 11/12/14 revealed the soiled linen door would not latch due to 3 bags of linen backed up into chutes.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the facility failed to install ground fault circuit interrupter (GFCI) receptacles for water contained medical equipment. NFPA 70, 210-8

The findings included:

Observation of the Occupational Therapy and the Physical Therapy rooms on 11/12/14 revealed the hydroculator was not connected to a GFCI receptacle.

This finding was verified by the maintenance director and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation it was determined the facility failed to ensure all doors would close and latch.

The findings included:

On 11/12/2014 the procedure area equipment clean up room has card board under the door keeping it from closing. The latch to the door was missing and would not latch.

Based on observation, it was determined the facility failed to maintain the fire rating in the ceiling/floor and walls in hazardous areas.

The findings included:

Observations on 11/12/2014 revealed penetrations in the file room in the basement around the piping in the floor/ceiling rating and also in the wall above the door.

These findings were verified by the maintenance director during the survey and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the staff failed to perform their assigned duties during the fire drill.

The findings included:

Observations during the fire drill conducted on 11/12/2014 at 1:55 P.M. revealed a staff member brought a patient out of the operating room area through the fire doors and down the hall to the CT scan room and entered it through a set of smoke doors. A construction worker held the fire doors open during the fire drill.

The finding was verified by the maintenance supervisor and acknowledged by the Administrator during the exit conference on 11/12/2014.

Based on observation, it was determined the facility failed to prohibit the use of portable space heaters.

The findings included:

Observation on 11/12/2014 revealed space heaters were found in these locations that when checked with a Raytek temperature gage went over the 212 degrees: IT room, Assistance Executive Director office, Director of Education Affairs office, Health information Management office, QA/infection control office,

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the facility failed to maintain the soiled linen chute.

The findings included:

Observation of the soiled linen chute on 11/12/14 revealed the soiled linen door would not latch due to 3 bags of linen backed up into chutes.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/12/14.

Based on observation, it was determined the facility failed to install ground fault circuit interrupter (GFCI) receptacles for water contained medical equipment. NFPA 70, 210-8

The findings included:

Observation of the Occupational Therapy and the Physical Therapy rooms on 11/12/14 revealed the hydroculator was not connected to a GFCI receptacle.

This finding was verified by the maintenance director and acknowledged by the administrator during the exit conference on 11/12/14.