HospitalInspections.org

Based on observation and interview, the facility failed to maintain emergency battery task lighting. This deficient practice affects all staff and visitors on the first floor corridor. This facility has a capacity of 49 and a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 11:38 a.m., revealed the facility failed to maintain the battery backup emergency light in the first floor corridor near Elevator A. This light failed to illuminate while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain a directional exit sign at the end of the corridor for one of three exits in the old ICU Unit. This deficient practice affects one staff. The facility has a capacity of 49 and a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 11:21 a.m., revealed the facility failed to maintain a directional exit sign in the Old ICU Unit corridor to Surgery. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72 by ensuring that an approved visible fire alarm strobe was provided to give visible warning of a fire emergency. This deficient practice could affect 12 patients, staff and visitors in the facility. The facility has a capacity of 49 with a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 11:15 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm did not have a functioning visual strobe for the Emergency Department Public Restroom near room #6. The Maintenance Director verified this observation at the time of the survey process.

Based on interview and record review, the facility did not maintain complete documentation of the testing of the fire alarm system as required by NFPA 72. This deficient practice of not providing complete and verifiable documentation of the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants in the facility. The facility has a capacity of 49 with a census of 12.

Findings include:

Based on interview and record review on 3/8/2022 at 11:00 a.m., revealed the facility was unable to produce documentation that contained the smoke detector sensitivity testing results including the manufacturer's specifications along with the sensitivity testing results. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2010 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 49 and a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 1:58 p.m., revealed the facility failed to maintain the sprinkler system in Ambulatory Surgical Center Lab Room #1307. This room contained 1/4 inch mess at the top eighteen inches of the privacy curtain. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 12 patients, visitors and staff. The facility has a capacity of 49 with a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 1:15 p.m., revealed the smoke barrier near Patient Room #222 contained a one half inch flex conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. This deficient practice could affect 12 patients, staff and visitors. The facility has a capacity of 49 and a census of 12.

Findings include:

Observation and interview on 3/8/2022 at 12:07 p.m., revealed the facility failed to maintain the barrier doors to the Old Cath Lab. The north double door failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, affecting one staff in this room. The facility had a capacity of 49 and a census of 12.

Findings Include:

Observation and interview on 3/8/2022 at 2:10 p.m., revealed the facility failed to maintain the electrical system in the Ambulatory Surgical Center Prep Room #1404. This room contained a standard outlet near the sink not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.