HospitalInspections.org

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Based on observation and interview, the facility failed to ensure an exit sign was properly displayed in an area for means of egress. This deficient practice had the potential to delay egress for patients, staff and visitors during an emergency situation. Findings:


Observation on 12/17/15 at 10:30 am revealed there was no exit sign above corridor door B-123 leading from X-ray to the ED exit.


During an interview on 12/17/15 the Facilities Director acknowledged the findings.



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Based on observation and interview the facility failed to ensure protection from the spread of fire in both corridors and high hazards areas. Specifically, the facility failed to ensure penetrations were sealed in the generator room and doors in high hazard areas were not wedged open. These failed practices prevented complete protection of hazardous areas and had the potential to expose residents, staff, and visitors to a smoke environment and loss of services. Findings:


Observation on 12/17/15 between 8:30 am and 12:00 pm revealed multiple doors with self-closures in the exit corridors that were wedged open with a variety of items. The wedging of the doors prevented the doors from automatically closing in the event of a fire alarm.

Additionally, the clean laundry room door accessing the corridor was wedged open.

Observation in the oxygen storage and filling rooms revealed the door connecting the two rooms was wedged open.


During an interview on 12/17/15 the Facilities Director acknowledged the findings.




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Based on observation and interview the facility failed to ensure exit access was readily accessible at all times and free of impediments. This deficiency had the potential to delay access to an exit which could expose staff to a smoke and or fire environment. Findings:


Observation on 12/17/15 at 9:10 pm revealed the exit door located in the generator room had a large piece of plywood obstructing the door from fully opening.


During an interview on tour on 12/17/15 at 9:10 am the Facilities Director acknowledged the finding.



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Based on record review and interview the facility failed to conduct 2 quarterly night shift fire drills. Failure to conduct fire drills on all shifts quarterly had the potential of untrained staff responding to fire or smoke alarms, exposing residents, staff, and visitors to a smoke or fire environment. Findings:


Record review of fire drill records on 12/17/15 between 8:30 am and 12:00 pm revealed there was no documentation of the night shift participating in a fire drill for the 1st and 3rd quarter of 2015.

During an interview on 12/17/15 at 12:00 pm, the Director of Facilities confirmed the findings.


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Based on observation and interview, the facility failed to maintain sprinkler heads and ceiling tiles in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficiency had the potential to cause a delay or failure in the sprinkler heads operational function and expose patients, staff, and visitors to a smoke or fire environment. Findings:

Observations on 12/17/15 between 8:30 am - 12:15 pm revealed 2 sprinkler heads in the kitchen walk-in cooler and freezer, C-110, had no eschusion plates.

In addition, further observations on tour revealed 3 sprinkler heads in the clean laundry room with significant accumulation of dust and lint.

Additionally, 2 ceiling tiles above the compounding hood in the NW wing pharmacy, and 1 tile in the OR storage area were soiled.



During an interview on tour on 12/17/15 the Facilities Director acknowledged the findings.



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Based on observation and interview the facility failed to ensure a maintenance schedule in the clean laundry room to prevent excessive lint build up. This had the potential to expose all staff, patients, and visitors to a fire environment and loss of services. Findings:


Observations on 12/17/15 between 8:30 am - 12:00 pm revealed a significant layer of lint within the hood over 3 commercial dryers and on the dryer ducts. In addition, each dryer in the lint collection tray had a very thick layer of lint.

During an interview with the staff working in the clean laundry, each stated the lint trays were only cleaned twice a week. When asked who cleaned the dryer vent hood and ducts they stated they thought it was maintenance staff.

During an interview on tour on 12/17/15 the Facilities Director acknowledged the findings and also stated he was not sure who was to clean the hood and ducts.


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Based on observations and interview, the facility failed to ensure power strips were safely used. This had the potential to expose patients and staff to a potential smoke or fire environment, electrocution and loss of services. Findings:

Observation on 12/14/15 at 9:45 am and again on 12/15/15 at 10:08 am revealed 2 medical devices plugged into a power strip in OR room #1. The power strip cord was lying on its side on the floor.

During an interview on 12/17/15 the Facilities Director acknowledged the finding and stated there were to be no power strips used.




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Based on observation and interview, the facility failed to ensure an exit sign was properly displayed in an area for means of egress. This deficient practice had the potential to delay egress for patients, staff and visitors during an emergency situation. Findings:


Observation on 12/17/15 at 10:30 am revealed there was no exit sign above corridor door B-123 leading from X-ray to the ED exit.


During an interview on 12/17/15 the Facilities Director acknowledged the findings.



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.
Based on observation and interview the facility failed to ensure protection from the spread of fire in both corridors and high hazards areas. Specifically, the facility failed to ensure penetrations were sealed in the generator room and doors in high hazard areas were not wedged open. These failed practices prevented complete protection of hazardous areas and had the potential to expose residents, staff, and visitors to a smoke environment and loss of services. Findings:


Observation on 12/17/15 between 8:30 am and 12:00 pm revealed multiple doors with self-closures in the exit corridors that were wedged open with a variety of items. The wedging of the doors prevented the doors from automatically closing in the event of a fire alarm.

Additionally, the clean laundry room door accessing the corridor was wedged open.

Observation in the oxygen storage and filling rooms revealed the door connecting the two rooms was wedged open.


During an interview on 12/17/15 the Facilities Director acknowledged the findings.




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Based on observation and interview the facility failed to ensure exit access was readily accessible at all times and free of impediments. This deficiency had the potential to delay access to an exit which could expose staff to a smoke and or fire environment. Findings:


Observation on 12/17/15 at 9:10 pm revealed the exit door located in the generator room had a large piece of plywood obstructing the door from fully opening.


During an interview on tour on 12/17/15 at 9:10 am the Facilities Director acknowledged the finding.



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Based on record review and interview the facility failed to conduct 2 quarterly night shift fire drills. Failure to conduct fire drills on all shifts quarterly had the potential of untrained staff responding to fire or smoke alarms, exposing residents, staff, and visitors to a smoke or fire environment. Findings:


Record review of fire drill records on 12/17/15 between 8:30 am and 12:00 pm revealed there was no documentation of the night shift participating in a fire drill for the 1st and 3rd quarter of 2015.

During an interview on 12/17/15 at 12:00 pm, the Director of Facilities confirmed the findings.


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Based on observation and interview, the facility failed to maintain sprinkler heads and ceiling tiles in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficiency had the potential to cause a delay or failure in the sprinkler heads operational function and expose patients, staff, and visitors to a smoke or fire environment. Findings:

Observations on 12/17/15 between 8:30 am - 12:15 pm revealed 2 sprinkler heads in the kitchen walk-in cooler and freezer, C-110, had no eschusion plates.

In addition, further observations on tour revealed 3 sprinkler heads in the clean laundry room with significant accumulation of dust and lint.

Additionally, 2 ceiling tiles above the compounding hood in the NW wing pharmacy, and 1 tile in the OR storage area were soiled.



During an interview on tour on 12/17/15 the Facilities Director acknowledged the findings.



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.
Based on observation and interview the facility failed to ensure a maintenance schedule in the clean laundry room to prevent excessive lint build up. This had the potential to expose all staff, patients, and visitors to a fire environment and loss of services. Findings:


Observations on 12/17/15 between 8:30 am - 12:00 pm revealed a significant layer of lint within the hood over 3 commercial dryers and on the dryer ducts. In addition, each dryer in the lint collection tray had a very thick layer of lint.

During an interview with the staff working in the clean laundry, each stated the lint trays were only cleaned twice a week. When asked who cleaned the dryer vent hood and ducts they stated they thought it was maintenance staff.

During an interview on tour on 12/17/15 the Facilities Director acknowledged the findings and also stated he was not sure who was to clean the hood and ducts.


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.
Based on observations and interview, the facility failed to ensure power strips were safely used. This had the potential to expose patients and staff to a potential smoke or fire environment, electrocution and loss of services. Findings:

Observation on 12/14/15 at 9:45 am and again on 12/15/15 at 10:08 am revealed 2 medical devices plugged into a power strip in OR room #1. The power strip cord was lying on its side on the floor.

During an interview on 12/17/15 the Facilities Director acknowledged the finding and stated there were to be no power strips used.




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