HospitalInspections.org

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 22 patient beds in the smoke compartment. The facility census was five.

Findings included:

1. Observation on 08/07/11 at 9:45 AM showed the corridor door to the entrance of patient room 218 could not be closed into the frame and latched.

During an interview on 08/07/11, the Director of Plant Operations, Staff K stated that no work order or repair request had been called in on the door. He stated that either the door or the latch, or both, might have to be adjusted to prevent the door from binding at the edge of the frame.

Based on observation and interview, the facility failed to ensure privacy curtains in patient rooms do not affect the water discharge and dispersion of automatic sprinklers in two of six single patient rooms of the OB/GYN wing in accordance with NFPA 13, 8.6.5.2.2. The patient census was five.

Findings included:

1. Observation on 08/07/11 at 9:00 AM showed privacy curtains in Post Partum Rooms 205 and 206 with less than one quarter inch weave mesh at the top which could potentially interfere and restrict the water dispersion pattern of sprinkler heads in the room.

During an interview on 08/07/11 at 9:00 AM, Director of Plant Operations, Staff K stated the privacy curtains would be removed and management staff will make a determination on whether to replace them with currently acceptable larger mesh curtains as is currently installed in the other three single-bed rooms, or to just close the entrance door to the room when privacy is necessary.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and patients. The facility census was five.

Findings included:

1. Observation on 08/07/11 at 3:00 PM showed three "E" size cylinders of compressed gases standing upright on the floor in front of a blanket warming cabinet in the sterile corridor. None of the three cylinders were secured and supported safely by a wheeled stand, rack or other a manner to protect one from falling into the wall or another cylinder. Breakage or damage to the neck/valve connection could result in a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo. Two of the cylinders were labeled oxygen and the third was labeled compressed air.

During an interview on 08/07/11, the Director of Plant Operations, Staff K, and the Project Coordinator, Staff L telephoned surgical personnel and stated the cylinders were empty and due to be returned and exchanged for full ones. They stated they could not determine why the three were left standing unprotected and not in a rack or on wheeled carts.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 22 patient beds in the smoke compartment. The facility census was five.

Findings included:

1. Observation on 08/07/11 at 9:45 AM showed the corridor door to the entrance of patient room 218 could not be closed into the frame and latched.

During an interview on 08/07/11, the Director of Plant Operations, Staff K stated that no work order or repair request had been called in on the door. He stated that either the door or the latch, or both, might have to be adjusted to prevent the door from binding at the edge of the frame.

Based on observation and interview, the facility failed to ensure privacy curtains in patient rooms do not affect the water discharge and dispersion of automatic sprinklers in two of six single patient rooms of the OB/GYN wing in accordance with NFPA 13, 8.6.5.2.2. The patient census was five.

Findings included:

1. Observation on 08/07/11 at 9:00 AM showed privacy curtains in Post Partum Rooms 205 and 206 with less than one quarter inch weave mesh at the top which could potentially interfere and restrict the water dispersion pattern of sprinkler heads in the room.

During an interview on 08/07/11 at 9:00 AM, Director of Plant Operations, Staff K stated the privacy curtains would be removed and management staff will make a determination on whether to replace them with currently acceptable larger mesh curtains as is currently installed in the other three single-bed rooms, or to just close the entrance door to the room when privacy is necessary.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and patients. The facility census was five.

Findings included:

1. Observation on 08/07/11 at 3:00 PM showed three "E" size cylinders of compressed gases standing upright on the floor in front of a blanket warming cabinet in the sterile corridor. None of the three cylinders were secured and supported safely by a wheeled stand, rack or other a manner to protect one from falling into the wall or another cylinder. Breakage or damage to the neck/valve connection could result in a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo. Two of the cylinders were labeled oxygen and the third was labeled compressed air.

During an interview on 08/07/11, the Director of Plant Operations, Staff K, and the Project Coordinator, Staff L telephoned surgical personnel and stated the cylinders were empty and due to be returned and exchanged for full ones. They stated they could not determine why the three were left standing unprotected and not in a rack or on wheeled carts.