HospitalInspections.org

Based on observation and staff interview, the facility failed to provide a corridor door that would resist the passage of smoke. This practice would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 8/9/18, at 2:05 pm revealed the Lab Office Door did not fully close or positively latch when self-closed.

In an interview on 8/9/18, at 2:05 pm, Maintenance A confirmed the door did not positively latch.

Based on observation and staff interview, the facility failed to maintain smoke doors so they fully closed within the door frame. This condition would allow smoke to spread between smoke compartments.

Findings are:
Observation on 8/9/18, at 2:27 pm revealed the South Admissions smoke doors did not fully close into the door frame when auto-closed.

In an interview on 8/9/18, at 2:27 pm, Maintenance A confirmed the doors did not fully close.

Based on record review and staff interview, the facility failed to test patient bed receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet.

Findings are:
Record review on 8/9/18, at 1:26 pm revealed documentation of annual patient bed location receptacle testing was not provided for review.

In an interview on 8/9/18, at 1:26 pm, Maintenance A confirmed the testing was not conducted, and was not aware of the requirement.

NFPA 99, 2012, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.