HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure 5 corridor doors were resistant to the passage of smoke in 4 of 23 smoke compartments. The findings were:

Observations on 7/28/10 between 11 AM and 4 PM revealed the following concerns:
a. A wedge was observed under the door to the Respiratory Treatment Room, preventing the door from closing.
b. The men's locker room in the Operating Room (OR) did not closed completely in its frame after three separate attempts. A self-closure device was attached to the door.
c. The autoclave room in the OR did not close completely in its frame with three separate attempts. A self-closure device was attached to the door.
d. A table was observed in front of the door to the staff locker room near resident room #106, preventing the door from closing. A self-closure device was attached to the door.
e. The door to the audiology room had a self-closure device attached to the door, but the device had been disabled.
Interview with the administrator and plant operations staff manager at the time of the observations confirmed the doors did not seat in their frames and needed adjusting.

Based on observation and staff interview the facility failed to ensure 1 of 24 smoke barrier doors was maintained in optimal operational condition. The findings were:

Observation on 7/28/10 at 2:48 PM revealed the two cross corridor smoke barrier doors near resident room #109 were able to close upon release from their magnetic hold-open devices. However, one of the two doors could not be reopened. Considerable pressure in excess of 10 ft-lbs was applied to the cross-bar door opener, but the door still did not open. After approximate five minutes, however, the door opened. The administrator confirmed the observation and stated the door latch needed to be fixed.

Based on observation and staff interview, the facility failed to ensure 2 hazardous areas were separated from patient use areas in 2 of 23 smoke compartments. The findings were:

Observation on 7/28/10 at 11:30 AM and then again at 1:23 PM revealed neither the soiled utility room in the emergency room, nor the janitor's closet door in the newborn nursery had self-closure devices attached to their doors. The administrator and maintenance staff confirmed the doors did not have self-closures attached.

Based on record review and staff interview the facility failed to inspect 40 portable fire extinguishers during the last 5 months of 2009 in accordance with NFPA 10 Section 4-4.3 & Table 5-2. The findings were:

Review of maintenance records revealed the fire extinguisher inspection log sheet for 2009 was missing from the preventive maintenance log book. The 2010 log was present and up-to-date through July 2010. Interview with maintenance staff confirmed the 2009 log was missing and could not be located.

Based on observation and staff interview the facility failed to ensure the electrical system was properly maintained in 2 of 23 smoke compartments. The findings were:

Observation on 7/28/10 at 11:30 AM and then again at 2:20 PM revealed an electrical outlet cover plate next to a front office staff desk was damaged. The plate was on the wall about ankle high. In addition, a refrigeration unit on the counter in the clean utility room in the obstetrics department was plugged into a "white" electrical outlet. Patient medications were observed to be present in the refrigerator. Interview with the facility's administrator at the above times confirmed the condition of the electrical cover plate. He also stated the electrical outlet with the white coverplate was probably not part of the emergency circuit.

Based on observation and staff interview, the facility failed to ensure 5 corridor doors were resistant to the passage of smoke in 4 of 23 smoke compartments. The findings were:

Observations on 7/28/10 between 11 AM and 4 PM revealed the following concerns:
a. A wedge was observed under the door to the Respiratory Treatment Room, preventing the door from closing.
b. The men's locker room in the Operating Room (OR) did not closed completely in its frame after three separate attempts. A self-closure device was attached to the door.
c. The autoclave room in the OR did not close completely in its frame with three separate attempts. A self-closure device was attached to the door.
d. A table was observed in front of the door to the staff locker room near resident room #106, preventing the door from closing. A self-closure device was attached to the door.
e. The door to the audiology room had a self-closure device attached to the door, but the device had been disabled.
Interview with the administrator and plant operations staff manager at the time of the observations confirmed the doors did not seat in their frames and needed adjusting.

Based on observation and staff interview the facility failed to ensure 1 of 24 smoke barrier doors was maintained in optimal operational condition. The findings were:

Observation on 7/28/10 at 2:48 PM revealed the two cross corridor smoke barrier doors near resident room #109 were able to close upon release from their magnetic hold-open devices. However, one of the two doors could not be reopened. Considerable pressure in excess of 10 ft-lbs was applied to the cross-bar door opener, but the door still did not open. After approximate five minutes, however, the door opened. The administrator confirmed the observation and stated the door latch needed to be fixed.

Based on observation and staff interview, the facility failed to ensure 2 hazardous areas were separated from patient use areas in 2 of 23 smoke compartments. The findings were:

Observation on 7/28/10 at 11:30 AM and then again at 1:23 PM revealed neither the soiled utility room in the emergency room, nor the janitor's closet door in the newborn nursery had self-closure devices attached to their doors. The administrator and maintenance staff confirmed the doors did not have self-closures attached.

Based on record review and staff interview the facility failed to inspect 40 portable fire extinguishers during the last 5 months of 2009 in accordance with NFPA 10 Section 4-4.3 & Table 5-2. The findings were:

Review of maintenance records revealed the fire extinguisher inspection log sheet for 2009 was missing from the preventive maintenance log book. The 2010 log was present and up-to-date through July 2010. Interview with maintenance staff confirmed the 2009 log was missing and could not be located.

Based on observation and staff interview the facility failed to ensure the electrical system was properly maintained in 2 of 23 smoke compartments. The findings were:

Observation on 7/28/10 at 11:30 AM and then again at 2:20 PM revealed an electrical outlet cover plate next to a front office staff desk was damaged. The plate was on the wall about ankle high. In addition, a refrigeration unit on the counter in the clean utility room in the obstetrics department was plugged into a "white" electrical outlet. Patient medications were observed to be present in the refrigerator. Interview with the facility's administrator at the above times confirmed the condition of the electrical cover plate. He also stated the electrical outlet with the white coverplate was probably not part of the emergency circuit.