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Based on observation and staff interview, the facility did not maintain doors in a required means of egress with doors not equipped with a latch or a lock that requires the use of a tool or key from the egress side in accordance with NFPA 101 (2012 edition), 19.2.2.2. This deficient practice could affect 8 of 8 patients and an undeterminable number of staff and visitors.

Findings include:

On 8/08/18 at 10:53 am, observation revealed the corridor exit door near room 129 required the use of a key to open the door. Staff on the wing did not have a key and could not find a key on the wing. The door did open upon operation of the fire alarm system.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff V, and Staff W. Staff W left a key that operated the door with the staff on the wing.

Based on observation and interview, the facility failed to protect a hazardous area in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2.1.3. This deficient practice could affect 3 of 11 inpatients and an undetermined number of outpatients and staff.

Findings include:

1. On 8/07/18 at 3:10 pm, observation revealed the operating room #3 door to the back sterile corridor didn't fully self-close and latch.

2. On 8/07/18 at 3:12 pm, observation revealed the sterile processing room door to the back sterile corridor did not fully self-close and latch.

3. On 8/07/18 at 3:15 pm, observation revealed the decontamination room door to the main sterile corridor did not fully self-close and latch.

4. On 8/07/18 at 4:04 pm, observation revealed the kitchen door to the café and corridor did not fully self-close and latch.

5. On 8/07/18 at 5:20 pm, observation revealed the decontamination room door to the main sterile corridor did not fully self-close and latch.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff T, and Staff V.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 4.7. This deficient practice could affect an undetermined number of staff.

Findings include:

1. On 8/08/18 at 10:35 am, observation revealed that a sprinkler in the hyperbaric chamber room was not kept free of lint and other foreign material.
2. On 8/08/18 at 10:38 am, observation revealed that a sprinkler in the nurse station area of the wound care center was not kept free of lint and other foreign material.
3. On 8/08/18 at 10:40 am, observation revealed that a sprinkler in the patient waiting area of the wound care center was not kept free of lint and other foreign material.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff V, and Staff W.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 4.7. This deficient practice could affect an undetermined number of staff.

Findings include:

On 8/07/18 at 4:25 pm, observation revealed in the lab EVS room that there was a missing 1.5'x2'ceiling tile. This hole did not duplicate the tight conditions that were used in the sprinkler UL certification test.

This condition was confirmed at the time of discovery by a concurrent interview with Staff S, Staff T, and Staff V.

Based on observation and interview the facility failed to provide corridor wall separations as required in NFPA 101 - 2012 edition, Sections 19.3.6 and 19.3.6.1. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:

On 8/07/18 at 3:55 pm, observation revealed the surgery waiting room was not equipped with latching hardware, making this area open to the corridor. The lounge did not meet one of the exceptions that allowed a space to be open to the corridor. There was no electrically supervised automatic smoke detection in the room and the space was not arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.

This condition was confirmed at the time of discovery by a concurrent interview with Staff S, Staff T, and Staff V.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect 3 of 11 inpatients as well as an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 8/07/18 at 3:16 pm, observation revealed that the operating room #3 door to the main sterile corridor did not fully self-close and latch
2. On 8/07/18 at 3:22 pm, observation revealed on the procedure room and operating rooms #1, #2 and #3 doors that the inactive leafs of the double doors were equipped with a manual flush bolt and would not automatically latch to provide separation to the main sterile corridor.
3. On 8/07/18 at 4:17 pm, observation revealed the lab reception door to the lab did not fully close and latch. The lab reception area was open to the corridor.
4. On 8/07/18 at 4:20 pm, observation revealed the lab drawing room #1 door to the lab did not fully close and latch. The lab drawing room #1 was open to the corridor.
5. On 8/07/18 at 4:22 pm, observation revealed the lab drawing room #2 door to the corridor did not fully close and latch.
6. On 8/07/18 at 4:32 pm, observation revealed the Emergency Department same day entrance did not latch because of missing hardware.
7. On 8/07/18 at 5:00 pm, observation revealed the clinic staff lounge door to the corridor did not fully close and latch.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff T, and Staff V.

8. On 8/08/18 at 11:37 am, observation revealed the high observation suite, double doors did not fully close and latch.
9. On 8/08/18 at 11:40 am, observation revealed that all four patient rooms in the high observation suite, were equipped with double doors and the inactive leafs of the double doors were equipped with a manual flush bolt and would not automatically latch to provide separation to the main sterile corridor.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff V, and Staff W.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect 3 of 11 inpatients as well as an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 8/08/18 at 10:50 am, observation revealed that room 124 did not latch.

2. On 8/08/18 at 11:40 am, observation revealed activity room 106 had double doors and the inactive leafs of the double doors were equipped with a manual flush bolt and would not automatically latch to provide separation to the main sterile corridor.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff V, and Staff W.

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments, in accordance with the requirements of NFPA 101 (2012 edition.), 19.3.7.8. This deficient practice could affect 11 of 11 inpatients and an undetermined number of staff and visitors.

Findings include:

1. On 8/08/18 at 11:34 am, observation revealed that the smoke barrier doors separating the inpatient room wings from the atrium did not fully close.

2. On 8/08/18 at 11:41 am, observation revealed that the 300 wing smoke barrier did not fully close.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff S, Staff V, and Staff W.