HospitalInspections.org

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 16:30 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
The Obstetrics and Gynecology waiting room fire door leading into the corridor failed to close and latch properly. The Maintenance Director states that he see the problem and points to a part of door lock. He states that he will have repaired. At the conclusion of the inspection a reinspection was preformed on the door and the door was placed back in compliance

The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 16:00 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
A deadbolt lock was found on the Medical Records door that leads into the corridor. This is the only door that exits out of the Medical Records office area. The Maintenance Director states that this lock was added so that a staff member could lock themselves in the office at night time since no other staff would be around. The Maintenance Director states that he understand exit door shall consist of single motion.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 10:30 and 12:00 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to residents, staff and/or visitors.

The findings include, but are not limited to:
The facility failed to maintain records of annual emergence light testing on site. The Maintenance Director stated that the computer prompted a monthly 30 second test instead of an annual 90 minute test.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 14:00 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain fire sprinkler esutcheon ring in downstairs laundry room. The Maintenance Director states that he see's that the it is missing and that he will get it repaired. At the conclusion of the inspection the esutcheon ring was re-inspected and found to be back in compliance.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 15:30 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Infection Prevention Employee Heath Safety Directors office had powerstrip plugged into powerstrip. Maintenance Director stated that see's the powerstrip plugged into another powerstrip. Maintenance Director educated staff about the rules associated with powerstrips and one powerstrip was removed immediately placing a single powerstrip back in compliance.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 16:30 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
The Obstetrics and Gynecology waiting room fire door leading into the corridor failed to close and latch properly. The Maintenance Director states that he see the problem and points to a part of door lock. He states that he will have repaired. At the conclusion of the inspection a reinspection was preformed on the door and the door was placed back in compliance

The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 16:00 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
A deadbolt lock was found on the Medical Records door that leads into the corridor. This is the only door that exits out of the Medical Records office area. The Maintenance Director states that this lock was added so that a staff member could lock themselves in the office at night time since no other staff would be around. The Maintenance Director states that he understand exit door shall consist of single motion.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 10:30 and 12:00 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to residents, staff and/or visitors.

The findings include, but are not limited to:
The facility failed to maintain records of annual emergence light testing on site. The Maintenance Director stated that the computer prompted a monthly 30 second test instead of an annual 90 minute test.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 14:00 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility failed to maintain fire sprinkler esutcheon ring in downstairs laundry room. The Maintenance Director states that he see's that the it is missing and that he will get it repaired. At the conclusion of the inspection the esutcheon ring was re-inspected and found to be back in compliance.
The above was discussed and acknowledged by the CEO.

Based upon observations and staff interviews on 01/19/2016 between approximately 13:00 and 15:30 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Infection Prevention Employee Heath Safety Directors office had powerstrip plugged into powerstrip. Maintenance Director stated that see's the powerstrip plugged into another powerstrip. Maintenance Director educated staff about the rules associated with powerstrips and one powerstrip was removed immediately placing a single powerstrip back in compliance.
The above was discussed and acknowledged by the CEO.