HospitalInspections.org

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations above the cross corridor doors that had penetrations in the smoke barrier walls. They were: 1) at the administrative/human resources rooms, 2) at the E.D., and 3) at the lab/pharmacy.

Based on observation the facility failed to provide acceptable enclosures for hazardous areas.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations where hazardous areas were not protected by closers on the doors. They were: 1) the medical records, 2) a storage closet in the N.E. corner of the building, 3) the holding storage, 4) the lab storage, and 5) the kitchen storage.

Based on observation the facility failed to provide an acceptable source of illumination at one exit.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was an exit at the exterior smoking area/out patient entrance that only one source of illumination. All exits must have two sources of illumination either in the same or in different light fixtures.

Based on observation the facility failed to provide an acceptable separation of the medical gas lines.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was a copper oxygen line contacting a steel conduit in the mechanical room on the north wall. The electrolytic action between the two dissimilar metals will corrode the oxygen lines causing a leak and a highly hazardous situation.

Based on observation the facility failed to provide an acceptable interval of disaster drills.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were only two recent disaster drills. One was held on 5/3/10 and another on 5/13/2008. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.


Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was no letter from a vendor for either fuel or water indicating that the hospital has preferred customer status re. NPFA 99, 11-5.3.2.

Based on observation the facility failed to provide a complete fire sprinkler system.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were two spaces where the fire sprinkler system was not complete. They were: 1) the communication room, and 2) the electrical room. For a sprinkler system to be considered to be complete there must be protection in all rooms.

Based on observation the facility was considering an unacceptable electrical system configuration.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there had been a request to change the swing of a door such that the door would now swing into the front of an electrical panel. This space must be kept clear of door swings in the event that an electrician is working on an energize panel in this position.

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations above the cross corridor doors that had penetrations in the smoke barrier walls. They were: 1) at the administrative/human resources rooms, 2) at the E.D., and 3) at the lab/pharmacy.

Based on observation the facility failed to provide acceptable enclosures for hazardous areas.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were several locations where hazardous areas were not protected by closers on the doors. They were: 1) the medical records, 2) a storage closet in the N.E. corner of the building, 3) the holding storage, 4) the lab storage, and 5) the kitchen storage.

Based on observation the facility failed to provide an acceptable source of illumination at one exit.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was an exit at the exterior smoking area/out patient entrance that only one source of illumination. All exits must have two sources of illumination either in the same or in different light fixtures.

Based on observation the facility failed to provide an acceptable separation of the medical gas lines.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was a copper oxygen line contacting a steel conduit in the mechanical room on the north wall. The electrolytic action between the two dissimilar metals will corrode the oxygen lines causing a leak and a highly hazardous situation.

Based on observation the facility failed to provide an acceptable interval of disaster drills.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were only two recent disaster drills. One was held on 5/3/10 and another on 5/13/2008. NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise.


Based on observation the facility failed to provide a letter from a vendor for emergency fuel and water indicating that they have a preferred customer status.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there was no letter from a vendor for either fuel or water indicating that the hospital has preferred customer status re. NPFA 99, 11-5.3.2.

Based on observation the facility failed to provide a complete fire sprinkler system.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there were two spaces where the fire sprinkler system was not complete. They were: 1) the communication room, and 2) the electrical room. For a sprinkler system to be considered to be complete there must be protection in all rooms.

Based on observation the facility was considering an unacceptable electrical system configuration.

The inspector observed while accompanied by the Assistant Administrator during the hours of the inspection from 9:00 am to 1:00 pm that there had been a request to change the swing of a door such that the door would now swing into the front of an electrical panel. This space must be kept clear of door swings in the event that an electrician is working on an energize panel in this position.