HospitalInspections.org

Based on observation and interview, the facility failed to maintain means of egress for one of over ten exit doors.
Findings include:
Observation on February 23, 2022, at 11:29 a.m., revealed the operating room egress corridor to the exit door was obstructed by three tables and a trash can.

Interview with the maintenance supervisor on February 22, 2022, at 11:29 a.m., confirmed the above means of egress deficiency existed.

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas on two of three levels.

Findings include:

Observation on February 22, 2022, between 10:33 a.m. and 12:13 p.m., revealed the following hazardous area deficiencies:
A. (10:33 a.m.) First floor, patient room 120, was being used for clean linen storage and the storage of other various items at the time of the survey. However, the room did not meet the requirements for a hazardous storage room, which should include a fire barrier rating, automatic sprinkler protection, rated self-closing door, etc.
B. (11:42 a.m.) Ground floor, "Elevator B" equipment room, self-closing door failed to positively latch in the frame. Additionally, the door was arranged with a dead bolt/two-step locking arrangement that could delay egress during an emergency;
C. (12:01 p.m.) Ground floor, stereographic room, doors lacked automatic closures necessary to meet the hazardous area safeguard requirements. The provided Life Safety drawings stated that the room was intended to have a one-hour rated fire barrier;
D. (12:13 p.m.) Ground floor, lobby storage, was being used to store various combustible items at the time of the survey. However, the room did not meet the requirements for a hazardous storage room, which should include a fire barrier rating, automatic sprinkler protection, rated self-closing door, etc.

Interview with the maintenance supervisor on February 22, 2022, at 12:13 p.m., confirmed the above hazardous area deficiencies existed.

Based on observation and interview, the facility failed to maintain alcohol-based hand rub dispensers in one of over fifty rooms.
Findings include:
Observation on February 22, 2022, at 10:16 a.m., revealed the second floor, patient room 206 bathroom, had an alcohol-based hand rub dispenser that was mounted within one inch of an ignition source.
Interview with maintenance supervisor on February 22, 2022, at 10:16 a.m., confirmed there was an alcohol-based hand rub dispenser mounted within one inch of an ignition source at the time of the survey.

Based on observation and interview, it was determined that the facility failed to maintain three of over one hundred corridor doors.

Findings include:

Observation on February 22, 2022, between 10:26 a.m. and 10:50 a.m., revealed the following rooms had various items (chairs, wheelchairs, and beds) stored in a manner that prevented the corridor doors from closing within the frames:
A. (10:26 a.m.) First floor, SPU wing, room 122;
B. (10:28 a.m.) First floor, SPU wing, room 124;
C. (10:50 a.m.) First floor, ACU wing, equipment room.

Interview with the maintenance supervisor on February 22, 2022, at 10:50 a.m., confirmed the above rooms had items stored in the door pathway, preventing the doors from being closed.

Based on document review and interview, it was determined that the facility failed to test and inspect the fire, ceiling, and smoke dampers throughout the building within the previous six years, per NFPA 101-8.5.5.4.2 and NFPA 105-6.5.2.

Findings include:

Document review on February 22, 2022, at 11:50 a.m., revealed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Interview with the facility manager on February 22, 2022, at 11:50 a.m., confirmed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Based on observation and interview, it was determined the facility failed to inspect and maintain electrical power cords on two of three levels.

Findings include:

1. Observation on February 22, 2022, between 10:47 a.m. and 11:22 a.m., revealed the following electrical power cord deficiencies:
A. (10:47 a.m.) First floor, nursing/administration wing, pharmacy office, had a coffee pot plugged into a surge protector;
B. (11:22 a.m.) Ground floor, lab supervisor office, had a surge protector plugged into a surge protector.

Interview with the maintenance supervisor on February 22, 2022, at 11:22 a.m., confirmed the above electrical power cord deficiencies.