HospitalInspections.org

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors in exit passageways and smoke/fire barriers were held open only by devices which would allow release of the door upon activation of the fire alarm, smoke detection or sprinkler systems. Additionally, this facility failed to ensure all like doors would close and latch properly with two sets of doors leaving a gap greater than one eighth inch between the door leafs when in the closed position. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the first and third floor smoke/fire barriers observation was made of doors failing to close and latch properly and doors which were propped open using unapproved devices. These doors were observed in the following locations:

First Floor:
* The smoke/fire barrier door in room 1155 was observed to be propped open with a chair.
* The smoke/fire barrier door in the specialty department room was observed to be propped open with a trash container.
* The smoke/fire barrier door located at the north section of the cath lab failed to close and latch properly.
* The smoke/fire barrier door located at the north section of the medical office building failed to close and latch properly.

Third Floor:
*The double smoke barrier doors near rooms 353 and 355 was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.

Fifth Floor:
*The smoke barrier door was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.


These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exits and exit passageways were marked with readily visible signs which could be viewed from all areas of the room or corridor which the exit exists. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the second floor observation was made of two exit access doors which had illuminated exit signs but they failed to be mounted in a position which were readily visible to all those utilizing these areas. They were located in the following locations:
*At the south wing medical surgery department, stairwell C.
*Within the recovery room of the surgery department near room 1202.

These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage location light switches and receptacles were mounted either outside of the room or mounted greater than five feet from the floor if located within the room. Additionally, this facility failed to ensure all medical gasses in storage were stored within the one hour fire rated room. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour
of the medical gas storage room observation was made within the room of one light switch and one receptacle mounted approximately four feet from the floor.
Additionally, tour of the surgical area reveals three H tanks of argon and 4 H tanks of helium along with two E tanks of nitrogen, two E tanks of oxygen, four E tanks of carbon dioxide, two E tanks of compressed air and two E tanks of nitrous oxide stored in an unprotected room which also housed medical equipment. This room was labeled as an equipment room and lacked any sign indicating medical gasses were stored within the room.

These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour observation was made of several smoke detectors which were located near air flow devices in the following areas:

Ground Floor:
*Within the housekeeping room near the receiving area.
*Within the MRI waiting area and the control room.
*At the entrance of the cafeteria.
*Within the IT department data center and director's office.

First Floor:
*Within the hyperbaric room.
*Within room # 1129 outside the cath lab.
*Within the radiology department corridor by the smoke barrier doors on the same side as the CAT scan room and by room #0164.
*By room # 1169
*Within room # 0150
*Within the emergency department room #'s 1101, 1103, 12, 1126, 1162, 1164, 0169, at the ambulance entrance and operations room of the registration area.

Second Floor:
*Beside the return vent near room # 0253 of the south wing medical surgery area.
*Within the ICU by bed # 8.
*Within the north wing medical surgery area room #'s 0218, 0220 and 0221.
*Within the surgery and recovery areas in room #'s 1202, 1206, 1208, 1209, 1222, 1214, 1215, 1216 and two smoke detectors within the waiting area.

Third Floor:
*Within the laser room # 0365.
*Just outside the delivery suites.
*Near the nurses station.
*Within the nursery room # 0343.
*Within the clean utility room # 0360.
*Within the physician's sleep room # 0345.
*Within lab room #'s 0382, 0383, 0384 and four smoke detectors within the open lab area.

Fourth Floor:
*Within the endoscopy waiting room.
*Within room #'s 0414, 0417, 0424, 0425 and 0450.

Fifth Floor:
*Within room #'s 0509, 0520, 0523 and 0534.

These findings were verified by staff J during tour and efforts were made to correct these deficiencies during the survey.

Based on interview with staff it was determined this facility failed to ensure all smoke detectors were sensitivity tested as required by the National Fire Protection Association (NFPA) 72 Chapter 7-3.2.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 156 at the beginning of the survey.

Findings include:

Documentation review for the fire alarm system took place on 11/16/11. Documentation verifies there was no sensitivity testing of the smoke detectors and staff J validated this during interview on 11/16/11 at approximately 10:55 AM.

Based on observation during tour and staff verification it was determined this facility failed to ensure all doors in exit passageways and smoke/fire barriers were held open only by devices which would allow release of the door upon activation of the fire alarm, smoke detection or sprinkler systems. Additionally, this facility failed to ensure all like doors would close and latch properly with two sets of doors leaving a gap greater than one eighth inch between the door leafs when in the closed position. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the first and third floor smoke/fire barriers observation was made of doors failing to close and latch properly and doors which were propped open using unapproved devices. These doors were observed in the following locations:

First Floor:
* The smoke/fire barrier door in room 1155 was observed to be propped open with a chair.
* The smoke/fire barrier door in the specialty department room was observed to be propped open with a trash container.
* The smoke/fire barrier door located at the north section of the cath lab failed to close and latch properly.
* The smoke/fire barrier door located at the north section of the medical office building failed to close and latch properly.

Third Floor:
*The double smoke barrier doors near rooms 353 and 355 was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.

Fifth Floor:
*The smoke barrier door was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.


These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure all exits and exit passageways were marked with readily visible signs which could be viewed from all areas of the room or corridor which the exit exists. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the second floor observation was made of two exit access doors which had illuminated exit signs but they failed to be mounted in a position which were readily visible to all those utilizing these areas. They were located in the following locations:
*At the south wing medical surgery department, stairwell C.
*Within the recovery room of the surgery department near room 1202.

These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage location light switches and receptacles were mounted either outside of the room or mounted greater than five feet from the floor if located within the room. Additionally, this facility failed to ensure all medical gasses in storage were stored within the one hour fire rated room. This had the potential to affect all those utilizing these areas of the facility. The patient census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour
of the medical gas storage room observation was made within the room of one light switch and one receptacle mounted approximately four feet from the floor.
Additionally, tour of the surgical area reveals three H tanks of argon and 4 H tanks of helium along with two E tanks of nitrogen, two E tanks of oxygen, four E tanks of carbon dioxide, two E tanks of compressed air and two E tanks of nitrous oxide stored in an unprotected room which also housed medical equipment. This room was labeled as an equipment room and lacked any sign indicating medical gasses were stored within the room.

These findings was verified by staff J during the tour on 11/14/11 through 11/17/11.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 156 at the beginning of the survey.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour observation was made of several smoke detectors which were located near air flow devices in the following areas:

Ground Floor:
*Within the housekeeping room near the receiving area.
*Within the MRI waiting area and the control room.
*At the entrance of the cafeteria.
*Within the IT department data center and director's office.

First Floor:
*Within the hyperbaric room.
*Within room # 1129 outside the cath lab.
*Within the radiology department corridor by the smoke barrier doors on the same side as the CAT scan room and by room #0164.
*By room # 1169
*Within room # 0150
*Within the emergency department room #'s 1101, 1103, 12, 1126, 1162, 1164, 0169, at the ambulance entrance and operations room of the registration area.

Second Floor:
*Beside the return vent near room # 0253 of the south wing medical surgery area.
*Within the ICU by bed # 8.
*Within the north wing medical surgery area room #'s 0218, 0220 and 0221.
*Within the surgery and recovery areas in room #'s 1202, 1206, 1208, 1209, 1222, 1214, 1215, 1216 and two smoke detectors within the waiting area.

Third Floor:
*Within the laser room # 0365.
*Just outside the delivery suites.
*Near the nurses station.
*Within the nursery room # 0343.
*Within the clean utility room # 0360.
*Within the physician's sleep room # 0345.
*Within lab room #'s 0382, 0383, 0384 and four smoke detectors within the open lab area.

Fourth Floor:
*Within the endoscopy waiting room.
*Within room #'s 0414, 0417, 0424, 0425 and 0450.

Fifth Floor:
*Within room #'s 0509, 0520, 0523 and 0534.

These findings were verified by staff J during tour and efforts were made to correct these deficiencies during the survey.

Based on interview with staff it was determined this facility failed to ensure all smoke detectors were sensitivity tested as required by the National Fire Protection Association (NFPA) 72 Chapter 7-3.2.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 156 at the beginning of the survey.

Findings include:

Documentation review for the fire alarm system took place on 11/16/11. Documentation verifies there was no sensitivity testing of the smoke detectors and staff J validated this during interview on 11/16/11 at approximately 10:55 AM.