HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain exit stair towers.

Findings include:

1. Observation on July 2, 2019, at 9:30 a.m., revealed the west stair tower door near the ICU had a gap in excess of 3/16 of an inch across the top.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the door gap was in excess of allowable tolerance for fire rated metal doors.

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas.

Findings include:

1. Observation on July 2, 2019 at 10:30 a.m., revealed the double doors from the kitchen, near the elevator, failed to latch in the frame.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the doors lacked positive latching.

2. Observation on July 2, 2019 at 10:45 a.m., revealed a 3/4 inch gap across the top of the single, boiler room door.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the door was not smoke tight.

Based on documentation review and interview, it was determined the facility failed to maintain the sprinkler system.

Findings include:

1. Review of documentation on July 2, 2019, between 8:00 a.m. and 9:00 a.m., revealed the facility could not provide documentation that a required inspection of the sprinkler system for the 3rd calendar quarter of 2018 was conducted.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the sprinkler documentation was not available for review.

2. Observation on July 2, 2019, at 11:00 a.m., revealed an open grate style ceiling tile in the ER office that could cause a delay in the activation of the sprinkler system.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the ceiling was not smoke tight.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers.

Findings include:

1. Observation on July 2, 2019 at 9:40 a.m., revealed the red indicator light for the fire extinguisher near room 214 on the 3rd floor was not illuminated.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the indicator light was burned out.

Based on observation and interview, it was determined the facility failed to maintain corridor doors.

Findings include:

1. Observation on July 2, 2019, at 11:05 a.m., revealed the corridor into the morgue area failed to latch in the frame.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the door lacked positive latching.

Based on observation and interview, the facility failed to maintain the piped medical gas system.

Findings include:

1. Observation on July 2, 2019, at 10:00 a.m., revealed steel hangers in contact with a copper oxygen line above the ceiling outside the O.R. entrance on the 3rd floor.

Interview at the time of the exit conference with the administrator and the maintenance supervisor on July 2, 2019, at 11:30 a.m., confirmed the dissimilar metals were in contact.