HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to be in accordance with building rehabilitation requirements on one of three floors.

Findings include:

1. Observation on December 11, 2019, at 1:00 p.m., revealed an operating room had been converted to a storage location that contained combustible materials, and did not meet the requirements of a hazardous area. The facility changed the use of the above operating room to a storage room, without the approval of State Plan Review, and a granted occupancy from the Division of Life Safety.

Interview with the MS on December 11, 2019, at 1:00 p.m., confirmed the first floor, operating room, had been converted to a storage location that contained combustible materials, and the facility had not submitted plans to designate the room as a storage area.

Based on observation and interview the facility failed to maintain construction type on three of three levels.

Findings include:

1. Observation on December 11 and 12, 2019, revealed that all levels of the facility had an insulation type of material sprayed on the heating, ventilation and air conditioning (HVAC) duct work. The facility was unable to provide documentation of flammability of insulation at the time of the survey.

Interview with the maintenance supervisor (MS) on December 12, 2019, confirmed the insulation on the HVAC duct work.

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Based on observation and interview, it was determined that the facility failed to maintain an unobstructed means of egress on one of three floors.

Findings include:

1. Observation on December 11, 2019, at 12:15 p.m., revealed the second floor, across from the radio pulmonary room, had ventilator equipment being stored in the aisle way.

Interview with the MS on December 11, 2019, at 12:15 p.m., confirmed the facility failed to maintain an unobstructed means of egress on the second floor.

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

Findings include:

1. Observation on December 12, 2019, at 9:02 a.m., revealed the first floor, rural health clinic door #1062, was equipped with a lock that requires the use of a key.

Interview with the MS on December 11, 2019, at 9:02 a.m., confirmed the facility failed to maintain egress door #1062.

Based on observation and interview, the facility failed to remain in accordance with rated stairwell door requirements on one of three floors.

Findings include:

1. Observation on December 12, 2019, between 10:30 a.m. and 10:35 a.m., revealed the following stairwell door deficiencies for the rated corridor to the outside:
a. (10:30 a.m.) Ground floor, stairwell #G48, would not allow door closure;
b. (10:35 a.m.) Ground floor, stairwell #G93, would not allow door closure.

Interview with the maintenance supervisor on December 12, 2019, at 10:35 a.m., confirmed the above corridor door deficiences.

Based on observation and interview, the facility failed to maintain exit discharge requirements.

Findings include:

1. Observation on December 12, 2019, at 9:10 a.m., revealed the exit, near door #810, was not maintained with a hard-packed, all weather travel surface, to a public way.

Interview with the MS on December 12, 2019, at 9:10 a.m., confirmed the above exit discharge was not a hard pack surface, to a public way.

Based on observation and interview, the facility failed to remain in accordance with emergency lighting systems.

Findings include:

1. Observation on December 12, 2019, at 11:16 a.m., revealed the ground floor, outside of switch board room, had a missing illuminated exit sign.

Interview with MS on December 12, 2019, at 11:16 a.m., confirmed the outside of switch board room, requires an illuminated exit sign directing exit travel.

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

Findings include:

1. Observation on December 12, 2019, at 9:41 a.m., revealed on the first floor, soiled utility room, door #1024, had no self closure.

2. Observation on December 12, 2019, at 10:15 a.m., revealed on the ground floor, G-28 door, to the mechanical room, has louvers in it.

Interview with the MS on December 12, 2019, at the above time, confirmed the hazardous area lacked a self closure device.

Based on observation and interview, it was determined that the facility failed to remain in accordance with alcohol based hand rub dispenser requirements on two of three floors.

Findings include:

1. Observation on December 11, 2019, and December 12, 2019, between 10:55 a.m. and 1:35 p.m., revealed the following alcohol based hand rub dispenser deficiencies:
a. December 11, 2019, 1:55 p.m, second floor treatment room, across from the kitchen, had an alcohol based hand rub dispenser over an electrical outlet;
b. December 12, 2019, 10:55 a.m., ground floor, emergency room nurse station, had an alcohol based hand rub dispenser over an electrical strip.

Interview with the MS on December 12, 2019, at 10:55a.m., confirmed the above alcohol based hand rub dispenser deficiences.

Based on document review and interview, it was determined the facility failed to remain in accordance with smoke detection system maintenance and testing regulations for one of one smoke detection system.

Findings include:

1. Document review on December 11, 2019, at 10:06 a.m., revealed there was no documentation to confirm nine inspection deficiences for the smoke detector system (testing completed on September 24, 2019) were corrected at the time of the survey.

Interview with the MS on December 11, 2019, at 10:06 a.m., confirmed the above smoke detector system inspection deficiences, and the lack of documentation that the deficiences were corrected.

Based on document review and interview, it was determined the facility failed to remain in accordance with smoke detection system maintenance and testing regulations for one of one smoke detection system.

Findings include:

1. Document review on December 11, 2019, at 10:06 a.m., revealed there was no documentation to confirm nine inspection deficiences for the smoke detector system (testing completed on September 24, 2019), were corrected at the time of the survey.

Interview with the MS on December 11, 2019 at 10:06 a.m., confirmed the above smoke detector system inspection deficiences, and the lack of documentation that the deficiences were corrected.

Based on observation and interview it was determined that the facility failed to maintain the sprinkler system on one of three levels.

Findings include:

1. Observation on December 11, 2019, at 12:50 p.m., revealed the first floor, electrical room, had a loose sprinkler escutcheon.

Interview with the MS on December 11, 2019, at 12:50 p.m., confirmed the sprinkler system loose escutcheon.

Based on observation and interview the facility failed to seal one pentration in the corridor wall, above the ceiling tile in one of three floors.

Findings include

1. Observation on December 12, 2019, at 9:30 a.m., revealed that there was a wall penetration, by a blue data cable, near door 1046, that the facility only partially spinklered.

Interview with the MS on December 12, 2019, at 9:35 a.m., confirmed the above corridor door deficiences.

Based on observation and interview it was determined that the facility failed to maintain smoke partitions to resist the passage of smoke, on one of three floors.

Findings include:

1. Observation on December 11, 2019, at 1:30 p.m., revealed the ground floor, cardiac rehab storage, had an unsealed penetration allowing passage of smoke to the above level.

Interview with the MS on December 11, 2019, at 1:30 p.m., confirmed the facility failed to maintain smoke partitions to resist the passage of smoke.

Based on observation and interview it was determined that the facility failed to maintain smoke partitions to resist the passage of smoke, on two of three floors.

Findings include:

1. Observation on December 12, 2019, between 9:26 a.m and 10:55 a.m., revealed the following:
a. (9:26 a.m.) First floor, door #1046, had an unsealed blue data cord penetration;
b. (10:15 a.m.) Ground floor, mechanical room door #G28, had a vent allowing the passage of smoke;
c.(10:55 a.m.) Ground floor, x-ray station, had a one inch hole in the wall not resisting the passage of smoke.

Interview with the MS on December 12, 2019, at 10:55 a.m., confirmed the facility failed to maintain smoke partitions to resist the passage of smoke.

Based on document review and interview, it was determined the facility failed to remain in accordance with gas and vacuum piped system maintenance and testing regulations, for one of one medical gas system.

Findings include:

1. Document review on December 11, 2019, at 10:31 a.m., revealed there was no documentation to confirm the below inspection deficiences for the medical gas and vacuum piped system (testing completed on August 18, 2019) were corrected at the time of the survey:
a. (10:27 a.m.) Master alarms;
b. (10:28 a.m.) Outlets/inlets;
c. (10:31 a.m.) Central supply systems.

Interview with the MS on December 11, 2019, at 10:31 a.m., confirmed the above medical gas and vacuum system inspection deficiences, and the lack of documentation that the deficiences were corrected.

Based on document review and interview, it was determined the facility failed to remain in accordance with gas and vacuum piped system maintenance and testing regulations, for one of one medical gas system.

Findings include:

1. Document review on December 11, 2019, at 10:31 a.m., revealed there was no documentation to confirm the below inspection deficiences for the medical gas and vacuum piped system (testing completed on August 18, 2019), were corrected at the time of the survey:
a. (10:27 a.m.) Master alarms;
b. (10:28 a.m.) Outlets/inlets;
c. (10:31 a.m.) Central supply systems.

Interview with the MS on December 11, 2019, at 10:31 a.m., confirmed the above medical gas and vacuum system inspection deficiences, and the lack of documentation that the deficiences were corrected.

Based on observation and interview, the facility failed to maintain electrical system requirements on two of three floors.

Findings include:

1. Observation on December 11, 2019, at 2:06 p.m., and December 12, 2019, at 10:35 a.m., revealed the following electrical system deficiences:
a. December 11, 2019, 2:06 p.m., second floor, near room #213, had an old call system junction box open;
b. December 12, 2019, 10:35 a.m., ground floor, near corridor G 93, had an open junction box.

Interview with the MS on December 12, 2019, at 10:35 a.m., confirmed the above electrical system deficiencies.

Based on observation and interview, the facility failed to maintain electrical system power cords on one of three floors.

Findings include:

1. Observation on December 12, 2019, between 10:54 a.m. and 10:59 a.m., revealed the following electrical system power cords were deficient:
a. (10:54 a.m.), Ground floor, x-ray staff lounge, had multiple kitchen appliances plugged into a surge protector;
b. (10:59 a.m.), Ground floor, in lab, had a power strip mounted behind two sinks with no GFCI.

Interview with MS on December 12, 2019, at 10:59 a.m., confirmed the electrical system power cords were not in compliance.

Based on observation and interview, the facility failed to remain in accordance with gas equipment storage requirements on one of three floors.

Findings include:

1. Observation on December 11, 2019, at 1:40 p.m., revealed the second floor, across from inpatient therapy, oxygen tanks were being stored in the corridor inlet.

Interview with MS on December 11, 2019, at 1:40 p.m., confirmed the oxygen tanks were not meeting the requirements of gas equipment storage.