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Based on observation and interview, it was determined one of one door to the oxygen storage room located in the Respiratory Therapy area was not self-closing. The failed practice had the potential to affect all patients, visitors, and staff in that area because it could not be assured the door would be closed and prevent the spread of smoke and fire during a smoke and fire event in the room. Findings follow:

A. On a tour of the facility on 12/14/2016 at 1010, it was observed the door to the oxygen storage room in the Respiratory Therapy area was not capable of self-closing.
B. During the tour, the Facilities Management Director verified the door to the oxygen storage room was not capable of self-closing.

Referenced code: NFPA 101, 2012 edition; Section 8.4.3.5

Based on observation and interview, it was observed in the electrical room located in the surgical corridor, three of four electrical panels did not have a minimum of 36 inches (three feet) of working space in front of the panels because of equipment stored in the electrical room. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency in addition to creating a potential fire hazard. Findings follow:

A. While touring the facility on 12/14/2016 at 1000, a rack, a cart, and an aspirator were observed stored in front of the electrical panels in the electrical room in the surgical corridor.
B. During the tour, it was verified by the Facilities Management Director the electrical panels were blocked.

Referenced Codes: NFPA 99, 2012 edition; Section: 6.3.2.1; NFPA 70, 2011 edition; Section: 110.26 See K911.

Based on review of the preventative maintenance logs and interview, no evidence was presented to show the facility maintained records for the required monthly testing of two of two Line Isolation Monitors (LIMs) for Operating Room (OR) #1 and #2. The failed practice had the potential to affect all patients and staff in the ORs because it could not be assured that medical equipment used in the ORs would not present an electrical shock hazard. Findings follow:

A. While reviewing the preventative maintenance logs on 12/12/2016 at 1245, no evidence was presented to show the facility performed the required monthly testing on the LIMs for OR #1 and #2.
B. While on tour of the facility on 12/14/2016 at 1000, the Facilities Management Director verified there was no record to show the facility had performed the monthly testing for the LIMs.

Referenced Code: NFPA 99, 2012 edition; Section: 6.3.2.6.3.6