HospitalInspections.org

Based on facility tour, and staff verification it was determined this facility failed to ensure all exit accesses and discharges were arranged in a manner to provide a safe access for patients, visitors and staff to a paved public way. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 21.

Findings include:

A facility tour of the main building took place on 01/07/13 through 01/08/13 with staff members A1 and B2. During tour of the exits discharge from the first floor finance area, observation was made of two exits discharges located approximately twenty feet apart which were identical to each other. Each exit discharge had a cement stoop measuring approximately eight foot by seven foot just outside of each door. From the cement stoop to the nearest paved common way was approximately 150 feet of grass.

During tour of the basement level exit discharge located at the south end of the pharmacy corridor, observation was made of and exit discharge which had a cement walk way which lead to approximately 15 feet of patio stones. From the end of the patio stones to the nearest paved public way was approximately 15 feet of grass.

These findings were verified by the staff members present during tour.

Based on interview and record review, the facility failed to hold fire drills under varying conditions at random, unexpected times. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 21 patients.

Findings include:

Review of the facility's 2012 fire drill reports revealed the fire drills were conducted quarterly on each shift. The review revealed the third shift fire drill consistently occurred between 11:17 P.M. and 11:35 P.M., with both, the 04/20/12, and the 07/10/12 drills, occurring at 11:30 P.M.

The review revealed the second shift fire drills occurred around 4:15 P.M.: on 05/10/12 at 4:15 P.M., on 08/21/12 at 4:20 P.M., and 11/29/12 at 4:15 P.M.

The review revealed the first shift fire drills occurred between 2:00 P.M. and 3:00 P.M.: 03/12/12 at 2:13 P.M., 06/15/12 at 2:45 P.M., 09/19/12 at 2:31 P.M., and 12/18/12 at 2:10 P.M.

On 01/09/13 at 9:15 A.M. during an interview, Staff B2 stated fire drills were held at change of shifts because that's when there were two security guards.

Based on review of the facility's documentation of operating room humidity level measurements, and interview, the facility failed to ensure the relative humidity in each operating room was maintained equal to or greater than 35 percent. This affected all three operating rooms, and has the potential to affect all patients, staff, and visitors of the facility. The facility census was 21 patients.

Findings:
The review of the facility's operating room humidity level measurements documentation for November 2012, was completed on 01/09/13. The review revealed, operating room three had humidity level measurements documented everyday, that were less than 35 percent, the lowest level measurements were 17 percent on 11/28/12 and 11/29/12.
During November, 2012, with exception of 11/12/12 and 11/23/12, operating room one had a humidity level measurements documented everyday, at less than 35 percent. The lowest measurement was 17 percent on 11/28/12.

The review of the humidity level measurement documentation for December 2012, was completed on 01/09/13. The review revealed, with the exception of 12/03/12 and 12/04/12, operating room one had humidity level measurements documented everyday at less than 35 percent. The lowest humidity level measurement was 19 percent on 12/13/12, and 12/31/12.

The review of the humidity level measurements documentation for operating room three revealed, with the exception of 12/03/12, 12/04/12, and 12/10/12, operating room three had humidity level measurements documented everyday at less than 35 percent. The lowest humidity level measurement was 19 percent on 12/12/12, 12/13/12, 12/28/12, and 12/31/12.

Review of the January, 2013, humidity level measurements documentation for all three operating rooms, from January 1, 2013, until January 8, 2013, was completed on 01/09/13. The review revealed all three operating rooms had humidity level measurements documented at less than 35 percent. The lowest level measurement was 15 percent in all three rooms on 12/03/12.

On 01/08/13 at 4:45 P.M. during an interview, Staff A1 confirmed the humidity level measurements were less than 35 percent because nobody had notified him/her of the low humidity level measurements.

Based on facility tour, and staff verification it was determined this facility failed to ensure all exit accesses and discharges were arranged in a manner to provide a safe access for patients, visitors and staff to a paved public way. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 21.

Findings include:

A facility tour of the main building took place on 01/07/13 through 01/08/13 with staff members A1 and B2. During tour of the exits discharge from the first floor finance area, observation was made of two exits discharges located approximately twenty feet apart which were identical to each other. Each exit discharge had a cement stoop measuring approximately eight foot by seven foot just outside of each door. From the cement stoop to the nearest paved common way was approximately 150 feet of grass.

During tour of the basement level exit discharge located at the south end of the pharmacy corridor, observation was made of and exit discharge which had a cement walk way which lead to approximately 15 feet of patio stones. From the end of the patio stones to the nearest paved public way was approximately 15 feet of grass.

These findings were verified by the staff members present during tour.

Based on interview and record review, the facility failed to hold fire drills under varying conditions at random, unexpected times. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 21 patients.

Findings include:

Review of the facility's 2012 fire drill reports revealed the fire drills were conducted quarterly on each shift. The review revealed the third shift fire drill consistently occurred between 11:17 P.M. and 11:35 P.M., with both, the 04/20/12, and the 07/10/12 drills, occurring at 11:30 P.M.

The review revealed the second shift fire drills occurred around 4:15 P.M.: on 05/10/12 at 4:15 P.M., on 08/21/12 at 4:20 P.M., and 11/29/12 at 4:15 P.M.

The review revealed the first shift fire drills occurred between 2:00 P.M. and 3:00 P.M.: 03/12/12 at 2:13 P.M., 06/15/12 at 2:45 P.M., 09/19/12 at 2:31 P.M., and 12/18/12 at 2:10 P.M.

On 01/09/13 at 9:15 A.M. during an interview, Staff B2 stated fire drills were held at change of shifts because that's when there were two security guards.

Based on review of the facility's documentation of operating room humidity level measurements, and interview, the facility failed to ensure the relative humidity in each operating room was maintained equal to or greater than 35 percent. This affected all three operating rooms, and has the potential to affect all patients, staff, and visitors of the facility. The facility census was 21 patients.

Findings:
The review of the facility's operating room humidity level measurements documentation for November 2012, was completed on 01/09/13. The review revealed, operating room three had humidity level measurements documented everyday, that were less than 35 percent, the lowest level measurements were 17 percent on 11/28/12 and 11/29/12.
During November, 2012, with exception of 11/12/12 and 11/23/12, operating room one had a humidity level measurements documented everyday, at less than 35 percent. The lowest measurement was 17 percent on 11/28/12.

The review of the humidity level measurement documentation for December 2012, was completed on 01/09/13. The review revealed, with the exception of 12/03/12 and 12/04/12, operating room one had humidity level measurements documented everyday at less than 35 percent. The lowest humidity level measurement was 19 percent on 12/13/12, and 12/31/12.

The review of the humidity level measurements documentation for operating room three revealed, with the exception of 12/03/12, 12/04/12, and 12/10/12, operating room three had humidity level measurements documented everyday at less than 35 percent. The lowest humidity level measurement was 19 percent on 12/12/12, 12/13/12, 12/28/12, and 12/31/12.

Review of the January, 2013, humidity level measurements documentation for all three operating rooms, from January 1, 2013, until January 8, 2013, was completed on 01/09/13. The review revealed all three operating rooms had humidity level measurements documented at less than 35 percent. The lowest level measurement was 15 percent in all three rooms on 12/03/12.

On 01/08/13 at 4:45 P.M. during an interview, Staff A1 confirmed the humidity level measurements were less than 35 percent because nobody had notified him/her of the low humidity level measurements.