HospitalInspections.org

Based on observation and staff interview, the hospital failed to ensure that the exit doors were provided with a means suitable for keeping the exit door closed as per NFPA 101, 2000 edition.
Finding includes:
During a tour of the Emergency Department and other areas of the hospital, on 11/18/2013 from 11:00 am to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

The exit door next to the ambulance entrance was not working properly and did not have a positive latch.

Based on observation and staff interview, the hospital failed to ensure that exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

findings include:

During a tour of the Emergency Department, Intensive Care Unit and Coronary Care Unit and Endoscopy Suite on 11/18/2013 from 11:00 am to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

1- There were two beds blocking the corridor and the exit way of the CCU unit next to the two smoke doors of the unit.
2- The corridor and the exit way of the endoscopy suite was observed to be blocked by two (2) supply carts , a garbage container, a bed side unit and a bronchoscopy cart.
3- During a tour of the hospital on 11/19/2013 at approximately 11:00 AM, the corridor of the outpatient clinics especially outside the surgical clinic was partly obstructed by at least 12 chairs and that the corridor (Exit passageway) was used as a waiting room.

Based on observation and staff interview, the hospital failed to ensure that exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Findings include:

During a tour of the Emergency Department and other areas of the hospital, on 11/18/2013 from 11:00 AM to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

Exit signs in the Emergency Department areas were not lit. Examples included but were not limited to the Exit sign outside the trauma room and outside the ambulance entrance door.

Based on observation and staff interview, the hospital failed to ensure that required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Finding includes:

During review of the records of sprinkler system tests on 11/21/2013, it was revealed that the tests of the main drain were not done during the years of 2012 and 2013.

based on observation and staff interview, the hospital failed to ensure that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

Finding include:

Review of the documentation of the Emergency Generator's monthly testing on 11/19/2013 revealed that the hospital failed to record the time of the transfer switch as required per NFPA 99 requirement.

Based on observation and staff interview, the hospital failed to ensure that the exit doors were provided with a means suitable for keeping the exit door closed as per NFPA 101, 2000 edition.
Finding includes:
During a tour of the Emergency Department and other areas of the hospital, on 11/18/2013 from 11:00 am to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

The exit door next to the ambulance entrance was not working properly and did not have a positive latch.

Based on observation and staff interview, the hospital failed to ensure that exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

findings include:

During a tour of the Emergency Department, Intensive Care Unit and Coronary Care Unit and Endoscopy Suite on 11/18/2013 from 11:00 am to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

1- There were two beds blocking the corridor and the exit way of the CCU unit next to the two smoke doors of the unit.
2- The corridor and the exit way of the endoscopy suite was observed to be blocked by two (2) supply carts , a garbage container, a bed side unit and a bronchoscopy cart.
3- During a tour of the hospital on 11/19/2013 at approximately 11:00 AM, the corridor of the outpatient clinics especially outside the surgical clinic was partly obstructed by at least 12 chairs and that the corridor (Exit passageway) was used as a waiting room.

Based on observation and staff interview, the hospital failed to ensure that exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Findings include:

During a tour of the Emergency Department and other areas of the hospital, on 11/18/2013 from 11:00 AM to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.

Exit signs in the Emergency Department areas were not lit. Examples included but were not limited to the Exit sign outside the trauma room and outside the ambulance entrance door.

Based on observation and staff interview, the hospital failed to ensure that required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Finding includes:

During review of the records of sprinkler system tests on 11/21/2013, it was revealed that the tests of the main drain were not done during the years of 2012 and 2013.

based on observation and staff interview, the hospital failed to ensure that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

Finding include:

Review of the documentation of the Emergency Generator's monthly testing on 11/19/2013 revealed that the hospital failed to record the time of the transfer switch as required per NFPA 99 requirement.