HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain doors protecting corridor openings to close and positively latch into their frames on two of three levels within this facility.

Findings include:

1. Observation made on December 21, 2015, between 11:30 am and 1:25 pm, revealed that the following corridor doors failed to positively latch into their corresponding door frame assemblies when tested.

a. 11:30 am, second floor north hall, court waiting room.
b. 1:25 pm, first floor east wing, map waiting room.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the doors requires and adjustment.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier walls on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015, at 1:35 pm, revealed that above the basement smoke barrier doors, there were unsealed horizontal penetrations with blue data wiring that was filled with mineral wool only.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain doors to hazardous areas to be capable of self-closing and positively latching into the door frame without impediments, on two of three levels within this facility.

Findings include:

1. Observation made on December 21, 2015 between 11:25 am and 1:40 pm, revealed that the following hazardous area corridor doors failed to close completely and positively latch when tested:

a. 11:25 am, second floor center, medical records remote storage room #220.
b. 1:30 pm, basement mechanical room # 3, corridor door failed to latch.
c. 1:40 pm, basement filter room, corridor door failed to latch.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the doors require an adjustment.

2. Observation made on December 21, 2015, at 11:28 am, revealed the second floor center medical records chart room, corridor door was blocked open by a rubber wedge.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the hazardous area door was blocked open.

3. Observation made on December 21, 2015 at 11:45 am, revealed that the second floor west wing storage room lacked an automatic closing device on the door. The room was greater than fifty square feet and was used to store combustibles, such as paper, cardboard and plastics.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the door lacked self-closing hardware.

Based on observation and interview, it was determined that the facility failed to ensure portable fire extinguishers were inspected required intervals on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015 at 11:10 am, revealed the second floor reception area, the ABC portable fire extinguisher's inspection tag had not been noted with the date of the extinguisher's monthly inspection and the initials of the person performing the inspection.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the monthly inspections were not documented on the fire extinguisher tag.

Based on observation, document review and interview, it was determined that the
facility failed to maintain inspection and testing of heating, ventilation, and air conditioning equipment at required intervals within this building component.

Findings include:

Document review on December 21, 2015 between 9:00 am and 10:15 pm., revealed that documentation verifying that the inspection and exercising of fusible link fire dampers was not available. The facility failed to verify with documentation that all dampers were inspected/tested.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed that documentation was unavailable.

Based on observation and interview, it was determined that the facility failed to maintain the use of authorized portable space heating devices on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015, at 11:40 am, revealed the second floor west wing Nurse practitioner's office, had a portable space heater in use that was not equipped with an automatic shut off device.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the unauthorized use of a space heater.

Based on observation and interview, it was determined that the facility failed to maintain continuous monitoring of the emergecy generator within this facility.

Findings Include:

Observation made on December 21, 2015, at 1:45 p.m., revealed that the facility did not have an audible and visual remote annunciator panel for the facility diesel generator, located at a work site continuously monitored by personnel.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed that the emergency generator was not remotely monitored.

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical equipment and prevent the unauthorized use of electrical devices on three of three levels within this facility.

Findings Include:

1. Observation made on December 21, 2015, between 11:00 am and 11:15 am, revealed that the following locations had unauthorized electrical devices in use:

a. 11:00 am, second floor east wing room #211, had a refrigerator, microwave and toaster oven powered by a power strip.
b. 11:15 am, second floor east wing, inside the PA coordinator's office, an outlet multiplier was plugged into a power strip.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the unauthorized use of electrical devices.


2. Observation made on December 21, 2015, at 1:45 p.m., revealed that the basement generator room lacked a rated corridor door and self-closing hardware in order to maintain the rated enclosure.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the enclosure was incomplete.

Based on observation and interview, it was determined that the facility failed to maintain doors protecting corridor openings to close and positively latch into their frames on two of three levels within this facility.

Findings include:

1. Observation made on December 21, 2015, between 11:30 am and 1:25 pm, revealed that the following corridor doors failed to positively latch into their corresponding door frame assemblies when tested.

a. 11:30 am, second floor north hall, court waiting room.
b. 1:25 pm, first floor east wing, map waiting room.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the doors requires and adjustment.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier walls on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015, at 1:35 pm, revealed that above the basement smoke barrier doors, there were unsealed horizontal penetrations with blue data wiring that was filled with mineral wool only.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the penetration.

Based on observation and interview, it was determined that the facility failed to maintain doors to hazardous areas to be capable of self-closing and positively latching into the door frame without impediments, on two of three levels within this facility.

Findings include:

1. Observation made on December 21, 2015 between 11:25 am and 1:40 pm, revealed that the following hazardous area corridor doors failed to close completely and positively latch when tested:

a. 11:25 am, second floor center, medical records remote storage room #220.
b. 1:30 pm, basement mechanical room # 3, corridor door failed to latch.
c. 1:40 pm, basement filter room, corridor door failed to latch.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the doors require an adjustment.

2. Observation made on December 21, 2015, at 11:28 am, revealed the second floor center medical records chart room, corridor door was blocked open by a rubber wedge.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the hazardous area door was blocked open.

3. Observation made on December 21, 2015 at 11:45 am, revealed that the second floor west wing storage room lacked an automatic closing device on the door. The room was greater than fifty square feet and was used to store combustibles, such as paper, cardboard and plastics.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the door lacked self-closing hardware.

Based on observation and interview, it was determined that the facility failed to ensure portable fire extinguishers were inspected required intervals on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015 at 11:10 am, revealed the second floor reception area, the ABC portable fire extinguisher's inspection tag had not been noted with the date of the extinguisher's monthly inspection and the initials of the person performing the inspection.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the monthly inspections were not documented on the fire extinguisher tag.

Based on observation, document review and interview, it was determined that the
facility failed to maintain inspection and testing of heating, ventilation, and air conditioning equipment at required intervals within this building component.

Findings include:

Document review on December 21, 2015 between 9:00 am and 10:15 pm., revealed that documentation verifying that the inspection and exercising of fusible link fire dampers was not available. The facility failed to verify with documentation that all dampers were inspected/tested.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed that documentation was unavailable.

Based on observation and interview, it was determined that the facility failed to maintain the use of authorized portable space heating devices on one of three levels within this facility.

Findings include:

Observation made on December 21, 2015, at 11:40 am, revealed the second floor west wing Nurse practitioner's office, had a portable space heater in use that was not equipped with an automatic shut off device.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the unauthorized use of a space heater.

Based on observation and interview, it was determined that the facility failed to maintain continuous monitoring of the emergecy generator within this facility.

Findings Include:

Observation made on December 21, 2015, at 1:45 p.m., revealed that the facility did not have an audible and visual remote annunciator panel for the facility diesel generator, located at a work site continuously monitored by personnel.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed that the emergency generator was not remotely monitored.

Based on observation and interview, it was determined that the facility failed to maintain protection of electrical equipment and prevent the unauthorized use of electrical devices on three of three levels within this facility.

Findings Include:

1. Observation made on December 21, 2015, between 11:00 am and 11:15 am, revealed that the following locations had unauthorized electrical devices in use:

a. 11:00 am, second floor east wing room #211, had a refrigerator, microwave and toaster oven powered by a power strip.
b. 11:15 am, second floor east wing, inside the PA coordinator's office, an outlet multiplier was plugged into a power strip.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the unauthorized use of electrical devices.


2. Observation made on December 21, 2015, at 1:45 p.m., revealed that the basement generator room lacked a rated corridor door and self-closing hardware in order to maintain the rated enclosure.

Interview at the exit conference on December 21, 2015 at 2:00 pm, with the CEO Medical Director, Chief Operating Officer and Maintenance Director, confirmed the enclosure was incomplete.