HospitalInspections.org

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed the following doors to not latch and close when tested:

1. At 11:52am, I observed that the door to the Quiet Room did not close and latch when tested.
2. At 12:06pm, I observed that the west fire doors to the Clinic did not close and latch when tested. These doors are being replaced and have been ordered.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff and/or visitors during an emergency.

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed that the exit in the PT area, by the existing admin building did not have an exit sign.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on January 07, 2015 between approximately 10:00am and 11:00am, the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include, but are not limited to:

Record review of the facility's fire drill reports from the date of survey to one year prior revealed that the following fire drills were not conducted:

1. Records reflect that no fire drills were conducted in day or night during the second quarter of 2014.
2. Records reflect that a night shift fire drill was not conducted during third quarter of 2014.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to provide a required emergency stop button for each of the generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator or inside the weatherproof cabinet to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Maintenance Director, on January 07, 2015 between the hours of 11:00am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to ensure that power strips were being used correctly when in use. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed improper use of power strips in the following locations:

1. At 11:22am, I observed that the Surgery breakroom has a refrigerator on a power strip. This power strip was not mounted correctly on the wall, and was dangling, causing stress on the cords.
2. At 11:31am, I observed that Recovery has 2 small refrigerators on a power strip.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed the following doors to not latch and close when tested:

1. At 11:52am, I observed that the door to the Quiet Room did not close and latch when tested.
2. At 12:06pm, I observed that the west fire doors to the Clinic did not close and latch when tested. These doors are being replaced and have been ordered.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff and/or visitors during an emergency.

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed that the exit in the PT area, by the existing admin building did not have an exit sign.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on January 07, 2015 between approximately 10:00am and 11:00am, the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include, but are not limited to:

Record review of the facility's fire drill reports from the date of survey to one year prior revealed that the following fire drills were not conducted:

1. Records reflect that no fire drills were conducted in day or night during the second quarter of 2014.
2. Records reflect that a night shift fire drill was not conducted during third quarter of 2014.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to provide a required emergency stop button for each of the generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator or inside the weatherproof cabinet to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Maintenance Director, on January 07, 2015 between the hours of 11:00am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to ensure that power strips were being used correctly when in use. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

Based upon observations and staff interviews on January 07, 2015 between approximately 11:00am and 4:30pm, I observed improper use of power strips in the following locations:

1. At 11:22am, I observed that the Surgery breakroom has a refrigerator on a power strip. This power strip was not mounted correctly on the wall, and was dangling, causing stress on the cords.
2. At 11:31am, I observed that Recovery has 2 small refrigerators on a power strip.

The above was discussed and acknowledged by the Maintenance Director.