HospitalInspections.org

Based on observation of surveyor 16732 on October 5, 2011 following smoke barrier does not resist the passage of smoke with evidence of as follows:

1) Smoke petition doors at entrance of labor and delivery have a gap between that does not resist passage of smoke.

The safety officer was present during this observation.

Based on observation of surveyor 16732 on October 5 th, 2011 the following egress was not readily accessible with evidence as follows:

The rear exit of cardiac rehab area has egress obstructed with chairs.

The safety office was present during this observation.

Based on observation of surveyor 16732 on October 5 th, 2011 the following directional exit signs were not working properly with evidence as follows:

1) Exit sign at kitchen has bulb not working

2) Exit sign at entrance to labor and delivery has bulb not working

3) Exit sign rear exit of labor and delivery has bulb not working.

4) Sleep lab doors have 8X10 sign on door advising not to enter causing a dead end corridor.



The safety officer was present during this observation.

Based on records review of surveyor 16732 on October 5 th, 2011 the emergency plan has deficiencies with evidence as follows:

1) Emergency book on acute care has call list that are not updated and several plans have not been updated since 2001.

The safety officer was present during this review.

Based on observation of surveyor 16732 on October 5 th 2011:

Storage within 18 inches of sprinkler head in Pediatric Supply closed on acute care wing.



The safety officer was present during this observation.

Based on observation of surveyor 16732 on October 5, 2011 following smoke barrier does not resist the passage of smoke with evidence of as follows:

1) Smoke petition doors at entrance of labor and delivery have a gap between that does not resist passage of smoke.

The safety officer was present during this observation.

Based on observation of surveyor 16732 on October 5 th, 2011 the following egress was not readily accessible with evidence as follows:

The rear exit of cardiac rehab area has egress obstructed with chairs.

The safety office was present during this observation.

Based on observation of surveyor 16732 on October 5 th, 2011 the following directional exit signs were not working properly with evidence as follows:

1) Exit sign at kitchen has bulb not working

2) Exit sign at entrance to labor and delivery has bulb not working

3) Exit sign rear exit of labor and delivery has bulb not working.

4) Sleep lab doors have 8X10 sign on door advising not to enter causing a dead end corridor.



The safety officer was present during this observation.

Based on records review of surveyor 16732 on October 5 th, 2011 the emergency plan has deficiencies with evidence as follows:

1) Emergency book on acute care has call list that are not updated and several plans have not been updated since 2001.

The safety officer was present during this review.

Based on observation of surveyor 16732 on October 5 th 2011:

Storage within 18 inches of sprinkler head in Pediatric Supply closed on acute care wing.



The safety officer was present during this observation.