HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Roller latches are prohibited by CMS regulations in all health care facilities. Findings

Doors through out the facility in patient rooms and treatment rooms opening to the corridor have roller latches.

Based on review of the Fire Drill Report form dated 1-12-2011 for the drill conducted at 0830 in the East Wing, the facility failed to ensure staff is familiar with procedures. Finding:

The report documented that Laboratory and X-Ray failed to participate in the drill. There was no documentation that corrective action was taken.

Based on observation and interview with staff, the facility failed to provide a fire alarm system maintained in accordance with NFPA 72. Finding:

The fire alarm annual inspection completed on 6-22-2010 failed to list all devices connected to the fire alarm system. Devices not listed were the smoke evacuation system for the OR and the combination fire and smoke dampers located at the combination fire and smoke walls.

Based on observation and interview with staff, the facility failed to provide means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

The corridor on the wing on the south east side of the building by the boiler room was obstructed by 3 recyclable trash collectors and equipment carts.

Based on observation, record review and interview with staff, the facility failed to inspected the generator weekly and exercise it under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Finding:

The Generator Log did not record a test run of the emergency generator since February 18, 2011.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Roller latches are prohibited by CMS regulations in all health care facilities. Findings

Doors through out the facility in patient rooms and treatment rooms opening to the corridor have roller latches.

Based on review of the Fire Drill Report form dated 1-12-2011 for the drill conducted at 0830 in the East Wing, the facility failed to ensure staff is familiar with procedures. Finding:

The report documented that Laboratory and X-Ray failed to participate in the drill. There was no documentation that corrective action was taken.

Based on observation and interview with staff, the facility failed to provide a fire alarm system maintained in accordance with NFPA 72. Finding:

The fire alarm annual inspection completed on 6-22-2010 failed to list all devices connected to the fire alarm system. Devices not listed were the smoke evacuation system for the OR and the combination fire and smoke dampers located at the combination fire and smoke walls.

Based on observation and interview with staff, the facility failed to provide means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

The corridor on the wing on the south east side of the building by the boiler room was obstructed by 3 recyclable trash collectors and equipment carts.

Based on observation, record review and interview with staff, the facility failed to inspected the generator weekly and exercise it under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Finding:

The Generator Log did not record a test run of the emergency generator since February 18, 2011.