HospitalInspections.org

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Based on observations and interviews the facility failed to ensure internally illuminated exit signs were fully illuminated and/or appropriately operational. This failed practice placed all occupants at risk for delay in egress during an emergency. Findings:

Observation on 6/2/16 at 9:16 am revealed an internally illuminated exit sign, above door D0037, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 10:05 am revealed an internally illuminated type exit sign, above door D0003, was not illuminated.

Observation on 6/2/16 at 10:27 am revealed an internally illuminated exit sign, above door D0062, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 10:55 am revealed an internally illuminated exit sign, above door D0098, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 2:30 pm revealed two internally illuminated exit signs in the operating room corridor that were insufficiently illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure doors protecting hazardous areas released and closed in a manner to prevent the passage of smoke or fire. These failed practices placed all occupants at risk for exposure to smoke and fire environment and loss of ancillary services. Findings:

Observation on 6/2/16 at 11:40 am revealed a fire-rated door (D0147) separating the boiler room from the HVAC room (heating, ventilation and air conditioning) did not shut and latch appropriately.

Observation on 6/2/16 at 1:15 pm revealed a door protecting the air-handling room did not shut and latch appropriately.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure a panic bar on an exit egress door was able to be easily compressed allowing the release of the door for egress. This failed practice placed all patients (based on an inpatient census of 5), visitors and staff at risk for a delay in egress during an emergency. Findings:

Observations from 6/1-2/16 revealed a set of double egress corridor doors leading from the inpatient unit to the sleep study area. Further observation revealed the left portion of the panic bar required a significant amount of force to be applied in efforts to release the door.

During an interview on 6/1/16 at 12:50 pm Charge Nurse #1 stated the door was difficult to open.

During an interview on 6/2/16 the Maintenance Director confirmed the door should not require an excessive amount of force to open.
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Based on observations and interviews the facility failed to ensure 1) four sprinkler heads contained appropriately placed escutcheon plates and 2) one sprinkler head was free from leaks. This failed practice placed all occupants at risk for being exposed to a smoke and/or fire environment as a result of an inadequately maintained sprinklers system.

Observation of the inpatient unit - room 4 on 6/2/16 at 9:17 am revealed a sprinkler head, located in the bathroom, did not contain an escutcheon plate.

Observation of the inpatient unit on 6/2/16 at 9:20 am revealed a sidewall sprinkler head, above door D0031, did not contain an escutcheon plate.

Observation on 6/2/16 at 11:11 am revealed a closet, located in physician ' s apartment, contained a sprinkler head without an escutcheon plate.

Observation mechanical space outside of the air plenum on 6/2/16 at 11:20 am revealed a suspended sprinkler head leaking a rust colored fluid. Additional observation revealed a green liquid leaking out of the pipe elbow adjacent to the sprinkler head.

Observation of emergency department room 282 on 6/2/16 at 2:15 pm revealed a sprinkler head did contain an escutcheon plate.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure privacy curtains were provided with the appropriate fire resistance rating in accordance with NFPA 701. This failed practice placed all occupants (including an inpatient census of 5) at risk for accelerated fire growth. Findings:

Observations of the in-patient department on 6/2/16 revealed rooms 2, 3, 4, 7 and 12 contained privacy curtains without appropriate documentation of fire resistant compliance.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interview the facility failed to ensure 2 rooms supplied with medical gas were labeled in conjunction with their respected medical gas shut-off zone valves. This failed practice placed all occupants at risk for an improper isolation of medical gases during an emergency event. Findings:

Observation on 6/2/16 at 9:50 am revealed a medical gas zone valve labeled " Nursery. " An additional observation revealed no identifying signage identifying which room was the nursery.

Observation on 6/2/16 at 2:39 pm revealed a medical gas zone valve labeled to service the endoscopy room. An additional observation revealed no identifying signage that indicated which room was the endoscopy room.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure: 1) one electrical panel was appropriately maintained and 2) one electrical panel free from obstructions and impediments. These failed practices placed all occupants of the building at risk for loss of electrical services or increased fire potential. Findings:

Observation of the central kitchen on 6/2/16 at 1:45 pm revealed an electrical panel box labeled as "Panel B" with black electrical tape placed over empty breakers slots 26 through 30.

Observation of the emergency department on 6/2/16 at 2:26 pm revealed emergency medical equipment and medication carts blocking access to an electrical panel.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure internally illuminated exit signs were fully illuminated and/or appropriately operational. This failed practice placed all occupants at risk for delay in egress during an emergency. Findings:

Observation on 6/2/16 at 9:16 am revealed an internally illuminated exit sign, above door D0037, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 10:05 am revealed an internally illuminated type exit sign, above door D0003, was not illuminated.

Observation on 6/2/16 at 10:27 am revealed an internally illuminated exit sign, above door D0062, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 10:55 am revealed an internally illuminated exit sign, above door D0098, was poorly illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

Observation on 6/2/16 at 2:30 pm revealed two internally illuminated exit signs in the operating room corridor that were insufficiently illuminated. Specifically, the sign ' s lettering appeared to have significant sections of darkness.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure doors protecting hazardous areas released and closed in a manner to prevent the passage of smoke or fire. These failed practices placed all occupants at risk for exposure to smoke and fire environment and loss of ancillary services. Findings:

Observation on 6/2/16 at 11:40 am revealed a fire-rated door (D0147) separating the boiler room from the HVAC room (heating, ventilation and air conditioning) did not shut and latch appropriately.

Observation on 6/2/16 at 1:15 pm revealed a door protecting the air-handling room did not shut and latch appropriately.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure a panic bar on an exit egress door was able to be easily compressed allowing the release of the door for egress. This failed practice placed all patients (based on an inpatient census of 5), visitors and staff at risk for a delay in egress during an emergency. Findings:

Observations from 6/1-2/16 revealed a set of double egress corridor doors leading from the inpatient unit to the sleep study area. Further observation revealed the left portion of the panic bar required a significant amount of force to be applied in efforts to release the door.

During an interview on 6/1/16 at 12:50 pm Charge Nurse #1 stated the door was difficult to open.

During an interview on 6/2/16 the Maintenance Director confirmed the door should not require an excessive amount of force to open.
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Based on observations and interviews the facility failed to ensure 1) four sprinkler heads contained appropriately placed escutcheon plates and 2) one sprinkler head was free from leaks. This failed practice placed all occupants at risk for being exposed to a smoke and/or fire environment as a result of an inadequately maintained sprinklers system.

Observation of the inpatient unit - room 4 on 6/2/16 at 9:17 am revealed a sprinkler head, located in the bathroom, did not contain an escutcheon plate.

Observation of the inpatient unit on 6/2/16 at 9:20 am revealed a sidewall sprinkler head, above door D0031, did not contain an escutcheon plate.

Observation on 6/2/16 at 11:11 am revealed a closet, located in physician ' s apartment, contained a sprinkler head without an escutcheon plate.

Observation mechanical space outside of the air plenum on 6/2/16 at 11:20 am revealed a suspended sprinkler head leaking a rust colored fluid. Additional observation revealed a green liquid leaking out of the pipe elbow adjacent to the sprinkler head.

Observation of emergency department room 282 on 6/2/16 at 2:15 pm revealed a sprinkler head did contain an escutcheon plate.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure privacy curtains were provided with the appropriate fire resistance rating in accordance with NFPA 701. This failed practice placed all occupants (including an inpatient census of 5) at risk for accelerated fire growth. Findings:

Observations of the in-patient department on 6/2/16 revealed rooms 2, 3, 4, 7 and 12 contained privacy curtains without appropriate documentation of fire resistant compliance.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interview the facility failed to ensure 2 rooms supplied with medical gas were labeled in conjunction with their respected medical gas shut-off zone valves. This failed practice placed all occupants at risk for an improper isolation of medical gases during an emergency event. Findings:

Observation on 6/2/16 at 9:50 am revealed a medical gas zone valve labeled " Nursery. " An additional observation revealed no identifying signage identifying which room was the nursery.

Observation on 6/2/16 at 2:39 pm revealed a medical gas zone valve labeled to service the endoscopy room. An additional observation revealed no identifying signage that indicated which room was the endoscopy room.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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Based on observations and interviews the facility failed to ensure: 1) one electrical panel was appropriately maintained and 2) one electrical panel free from obstructions and impediments. These failed practices placed all occupants of the building at risk for loss of electrical services or increased fire potential. Findings:

Observation of the central kitchen on 6/2/16 at 1:45 pm revealed an electrical panel box labeled as "Panel B" with black electrical tape placed over empty breakers slots 26 through 30.

Observation of the emergency department on 6/2/16 at 2:26 pm revealed emergency medical equipment and medication carts blocking access to an electrical panel.

These observations were acknowledged by the Maintenance Director at the time of their discovery.
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