HospitalInspections.org

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Fire alarm control panel room holes in fire resistive construction.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Cross corridor doors near room 139 fail to close and latch properly.

The above was discussed and acknowledged by the Maintence Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:
Third quarter and fourth quarter fire drills not conducted once per shift.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a water supply problem to the fire sprinkler system and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility has failed to provide documentation of sensitivity testing for zone fire alarm system.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.
1. The annual report of the backflow prevention valve on the fire sprinkler indicated the valve failed to function properly.
2. The facility failed to maintain 18 inches of clearance around the fire sprinkler heads in Operating Room storage room 1.
3. Fire sprinkler heads in central sterilizing room have excessive dust build up on frangible bulbs.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Commercial cooking hood system filter improperly positioned/loose.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to properly provide documentation of humidity in opertating rooms. This could result in the humidity level exceeding regulated limits and put a patient at risk of electrical shock.

The findings include, but are not limited to:
All operating rooms failed to maintain humidity logs.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Operating room #1 emergency lighting fails to activate upon testing.
Operating room #3 emergency lighting fails to activate upon testing.
The above was discussed and acknowledged by the Maintenance director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Microscope in soil utility room has wires spliced.
2. Extension cord in dialysis used as permanent wiring.
3. Family birthing center nurse station open electrical missing outlet cover under desk.
4. Internist doctor office extension cord used as permanent wiring.
5. Internist doctors office power strip plugged into power strip.
6. Operating room #2 power strip on floor in patient care area.
7. Front entrance administrating area brick wall open electrical. Missing electrical cover.
8. Conference room microwave plugged into powerstrip.
9. Stock room power strip plugged into power strip under clerks desk.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
ABHR placed below and within 6 inches of electrical outlet in Nuclear Medicine scanning room.
ABHR placed over power strip located on the floor of operating room #2.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Fire alarm control panel room holes in fire resistive construction.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Cross corridor doors near room 139 fail to close and latch properly.

The above was discussed and acknowledged by the Maintence Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:
Third quarter and fourth quarter fire drills not conducted once per shift.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a water supply problem to the fire sprinkler system and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility has failed to provide documentation of sensitivity testing for zone fire alarm system.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.
1. The annual report of the backflow prevention valve on the fire sprinkler indicated the valve failed to function properly.
2. The facility failed to maintain 18 inches of clearance around the fire sprinkler heads in Operating Room storage room 1.
3. Fire sprinkler heads in central sterilizing room have excessive dust build up on frangible bulbs.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Commercial cooking hood system filter improperly positioned/loose.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to properly provide documentation of humidity in opertating rooms. This could result in the humidity level exceeding regulated limits and put a patient at risk of electrical shock.

The findings include, but are not limited to:
All operating rooms failed to maintain humidity logs.
The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Operating room #1 emergency lighting fails to activate upon testing.
Operating room #3 emergency lighting fails to activate upon testing.
The above was discussed and acknowledged by the Maintenance director.

Based upon observations and staff interviews on 03/30/2015 between approximately 13:00 and 18:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. Microscope in soil utility room has wires spliced.
2. Extension cord in dialysis used as permanent wiring.
3. Family birthing center nurse station open electrical missing outlet cover under desk.
4. Internist doctor office extension cord used as permanent wiring.
5. Internist doctors office power strip plugged into power strip.
6. Operating room #2 power strip on floor in patient care area.
7. Front entrance administrating area brick wall open electrical. Missing electrical cover.
8. Conference room microwave plugged into powerstrip.
9. Stock room power strip plugged into power strip under clerks desk.

The above was discussed and acknowledged by the Maintenance Director.