HospitalInspections.org

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the following deficiencies exist;

1) The fire rated door #1155 that leads into the Blood Lab does not close and latch properly as required.

2)The fire rated doors leading from the Chapel to the exit corridor were not closing and latching properly.

Based on observation of surveyor 16732 on 05/27/14

The fire rate corridor smoke barrier doors between 1236 and 1235 have a gap between doors greater than 1/8 inch

Based on observation of surveyor 16732 on 05/28/14
1) Solid utility room door in X-ray needs to be self closing-positive latching.
2) Clean storage room number 1216 needs to be self closing-positive latching.
3) Room open to corridor in x-ray has 3 garbage cans with old x-ray film to be recycled. The room has a accordion door which does not self close and positive latch
4) Document shredding room in Cancer Care door needs to be self closing-positive latching.


20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. The following deficiencies were observed;

1) It was observed that the fire door leading to the Materials Distribution Center did not close and latch properly as required.

2) It was observed that the Materials Distribution Center has an unprotected opening in the wall that is used to issue materials to customers. This opening is installed in a 1 hour rated wall and the opening is required to be protected or properly covered.

3) It was observed that the laundry room door in the P.A.R.C. area requires a closure device.

4) It was observed that room 090, the door in housekeeping requires a closure device.

5) It was observed that in the Health Information Med records room there is a hole in the wall that separates the area from the records storage room. The wall that the hole is in is a one hour fire rated wall that will require the proper doors to be installed or the hole covered making it a one hour rated wall.

5) It was observed that the storage room next to room #7 in the South Wing lower level requires a closure device.

6) It was observed that the fire door leading to room 1401 does not close and latch properly.

Based on observation of surveyor 16732 and 20980 on 05/27/14

1) 2nd floor exit south end has exit enclosure with 14 boxes of combustible stored in hall way

2) 2nd floor exit south end has storage room in exit enclosure that does not self close and positive latch and not a 1 hour fire rated door assembly.


The maintenance director was present during this observation

Based on observation of surveyor 16732 on 05/27/14


Treatment chair in mammography room blocking exit door leading to exit corridor (chair was removed)




20980

This tag not met as observed by surveyor 20980 and a facility maintenance person.

1) It was observed that a stretcher was placed in the exit discharge area of the ambulance entrance that could impede the path of egress.

2) It was observed that in the Emergency Room Entrance area chairs and wheel chairs were blocking the access to the exit from the area.

3) It was observed that in the South Wing slant area of the lower level a wheel chair, computer and medical supply cart were being stored in the corridor outside rooms 24 & 26.

4) The exit discharge area of the business occupancy located on the 2nd floor had a ground wire laying across the path of egress that was creating a tripping hazard.

5) The reentry door of the exit discharge area of the business occupancy located on the 2nd floor has a step down that is approximately 13 inches. This door will meet the requirements of NFPA 101 (2000 edition), chapter 7 pertaining to the exit door requirements, floor level requirements, and elevation of surfaces.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the exit sign in the emergency room corridor near the ambulance entrance was pointing in the wrong direction. It was pointing into a room versus down the corridor.

Based on records review of surveyor 16732 on 05/27/14

There is a fire drill missing third quarter 3-11 shift for year 2013


The maintenance director was present during this observation

Based on observation of surveyor 16732 on 05/28/14

There is a MRI trailer that is permanently left backed into the hospital building .There is no fire alarm device in the trailer where patients are taking and no policy of notifying the MRI staff if the fire alarm is activated in the hospital.

This tag not met as observed by surveyors 20980 and 16732 and the facility director.

1) It was observed that during review of the facility fire alarm inspection/ test records that the fire alarm audio/visual alarms were not being tested at the required intervals. The inspection report showed that the tests were not accomplished at the request of the facility.

2) It was observed that the fire alarm panel showed a trouble in the system for NODE #4 and a smoke detector located outside of the elevator located near the OB ward, main floor. The NODE device is a computer used for programing the system and printing reports for the system. The smoke detector is a detector that is a required part of the elevator recall system in the event of a fire emergency. A records review showed that the two items were logged out of service since 4-16-14. At the time of survey the facility had not yet established a workorder to have the system troubles corrected.

3) It was observed that room 1240, doctors quarters, requires single station smoke alarm.

Based on observation of surveyor 16732 and 20980 on 05/27/14

1) There is storage within 18 inches of sprinkler head in the CT computer room
2) There is an sprinkler escutcheon plate missing in CT computer room




20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. The following observations were made;

1) Required sprinkler protection was not provided in the corridor electrical rooms of the main level of the hospital.

2) Room 1457, Lab Storage room, draw room of the Blood Lab, and room 1215, were missing the escutcheon plates for the sprinkler heads.

3) The walkin freezer #3 in the kitchen is not proper sprinkler protected inside the unit.

4) Room 1240, doctors lounge, two sprinkler heads escutcheon plates missing.

This tag not met as observed by surveyors 20980, 16732 and the facility maintenance director. It was observed that the facility sprinkler system inspection/testing reports did not show that a five year internal inspection of the sprinkler piping has been accomplished as required.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that in the PACU area of the hospital an untreated combustible quilt was hanging at the nurses station.

Based on record review of surveyor 16732 on 05/28/14

1) There is no area alarm monitoring the medical gases for Exam Rooms 1-10 and Triage.

2) The area alarm located across from the Surgical Services entrance in hallway monitoring the Say Surgery is not in a location where it is under surveillance by Day Surgery Staff.

3) The area alarm located outside of the PACU entrance the hallway monitoring the PACU is not in a location where it is monitored by the PACU staff.

4) The medical air and vacuum pressure switches for the master alarm system are not located immediately after the source valves. They are located downstairs by the Surgical Services entrances.


The maintenance director was present during this observation


20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the emergency gas shut off for the medical gases located in room 1410C/D was not readly accessable to the area. It was discovered that the shutoffs were located in am offce to the rear of 1410 but personnel have to go through two lockable spaces prior to getting to the shutoffs

Based on record review of surveyor 16732 on 05/28/14


1) The evacuation and medical vacuum in all operating rooms are controlled by a single zone valve located left of the anesthesia work room.

The maintenance director was present during this review.

On 05-28-2014 Inspections made to the out building Existing Business Occupancies for this Health Care location.

Violations found at the below locations are under the 2000 Edition of Life Safety Code 101.

At Pen-Bay Pediatrics, 7 Madelyn Lane Rockport; Building Sprinkler System has not been serviced for the past 4 years last date of service was 2-9-2010. System failed to me Code NFPA 25 Inspection, Maintenance, Testing. Needs to be Inspected.

At Mid-Coast Speech / Hearing / Occupational Therapy, 7 Madelyn Lane Rockport. Basement area of building, wide open and unpertected / no separation from Oil Burner, Failed to meet Code, oil burner not protected as per Code Chapter 39 Section 39.3.2.1 will have to protected in accordance with Section 8.4. And storage of Flamable equipment ( lawn equipment and gasoline can) to be removed from building.

At the Robert Laurence, MD, 760 Commercial Street, Rockport. Basement area of building, Oil burner wide open and unpertected from the rest of the storage. Failed to meet Code oil burner need's to be protected as per Code Chapter 39 Section 39.3.2.1 and in accordance with Section 8.4.
General Storage in this same space Ceiling is not protected, Ceiling will have to protected in accordance to Section 8.4.

At Waldoboro Family Medicine, 27 Mill Street Waldoboro, Exit sign need's to be add to main Hall-way. Chapter 39 Section 39.2.10.

At the Robert Laurence MD Office. 760 Commercial Street, Rockport. Exit sign need's to be repaired. Chapter 39 Section 39.2.10.

At Charles F. Kava,D.O., 68 Ben Paul lane, Rockport. Emergency Lighting unit not working check all units in building, Chapter 39.2.9..

At Pen-Bay Specialty Clinic, 79 Schooner Street, Damariscotta. Emergency Lighting unit not working check all units in building, Chapter 39.2.9..



20980

The following additional deficiency were observed by this surveyor:


1) Ceiling tiles missing in the first floor Communications Center IT room. Tiles are to remain in place to maintain smoke tight enviroment.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that flammable liquids (gasoline) was being improperly stored in the facility boiler room and being stored in unapproved containers.

Based on observation of surveyor 16732 and 20980 on 05/27/14:

1) Electrical outlet cover missing in storage room in Stairway C

2) Exterior canopy at Emergency Room has junction cover missing in ceiling

The maintenance director was present during this observation


20980

This tag not met as observed by surveyor 20980 and the nurse supervisor for the operating rooms. It was observed that incorrect power strips (relocatable power taps) were being used in ORs 2, 3 & 4. The power strips being used were Tripp Lite PS-415- HG that are not designed for use in patient care areas as stated on the units and in the manufactures specifications.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the following deficiencies exist;

1) The fire rated door #1155 that leads into the Blood Lab does not close and latch properly as required.

2)The fire rated doors leading from the Chapel to the exit corridor were not closing and latching properly.

Based on observation of surveyor 16732 on 05/27/14

The fire rate corridor smoke barrier doors between 1236 and 1235 have a gap between doors greater than 1/8 inch

Based on observation of surveyor 16732 on 05/28/14
1) Solid utility room door in X-ray needs to be self closing-positive latching.
2) Clean storage room number 1216 needs to be self closing-positive latching.
3) Room open to corridor in x-ray has 3 garbage cans with old x-ray film to be recycled. The room has a accordion door which does not self close and positive latch
4) Document shredding room in Cancer Care door needs to be self closing-positive latching.


20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. The following deficiencies were observed;

1) It was observed that the fire door leading to the Materials Distribution Center did not close and latch properly as required.

2) It was observed that the Materials Distribution Center has an unprotected opening in the wall that is used to issue materials to customers. This opening is installed in a 1 hour rated wall and the opening is required to be protected or properly covered.

3) It was observed that the laundry room door in the P.A.R.C. area requires a closure device.

4) It was observed that room 090, the door in housekeeping requires a closure device.

5) It was observed that in the Health Information Med records room there is a hole in the wall that separates the area from the records storage room. The wall that the hole is in is a one hour fire rated wall that will require the proper doors to be installed or the hole covered making it a one hour rated wall.

5) It was observed that the storage room next to room #7 in the South Wing lower level requires a closure device.

6) It was observed that the fire door leading to room 1401 does not close and latch properly.

Based on observation of surveyor 16732 and 20980 on 05/27/14

1) 2nd floor exit south end has exit enclosure with 14 boxes of combustible stored in hall way

2) 2nd floor exit south end has storage room in exit enclosure that does not self close and positive latch and not a 1 hour fire rated door assembly.


The maintenance director was present during this observation

Based on observation of surveyor 16732 on 05/27/14


Treatment chair in mammography room blocking exit door leading to exit corridor (chair was removed)




20980

This tag not met as observed by surveyor 20980 and a facility maintenance person.

1) It was observed that a stretcher was placed in the exit discharge area of the ambulance entrance that could impede the path of egress.

2) It was observed that in the Emergency Room Entrance area chairs and wheel chairs were blocking the access to the exit from the area.

3) It was observed that in the South Wing slant area of the lower level a wheel chair, computer and medical supply cart were being stored in the corridor outside rooms 24 & 26.

4) The exit discharge area of the business occupancy located on the 2nd floor had a ground wire laying across the path of egress that was creating a tripping hazard.

5) The reentry door of the exit discharge area of the business occupancy located on the 2nd floor has a step down that is approximately 13 inches. This door will meet the requirements of NFPA 101 (2000 edition), chapter 7 pertaining to the exit door requirements, floor level requirements, and elevation of surfaces.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the exit sign in the emergency room corridor near the ambulance entrance was pointing in the wrong direction. It was pointing into a room versus down the corridor.

Based on records review of surveyor 16732 on 05/27/14

There is a fire drill missing third quarter 3-11 shift for year 2013


The maintenance director was present during this observation

Based on observation of surveyor 16732 on 05/28/14

There is a MRI trailer that is permanently left backed into the hospital building .There is no fire alarm device in the trailer where patients are taking and no policy of notifying the MRI staff if the fire alarm is activated in the hospital.

This tag not met as observed by surveyors 20980 and 16732 and the facility director.

1) It was observed that during review of the facility fire alarm inspection/ test records that the fire alarm audio/visual alarms were not being tested at the required intervals. The inspection report showed that the tests were not accomplished at the request of the facility.

2) It was observed that the fire alarm panel showed a trouble in the system for NODE #4 and a smoke detector located outside of the elevator located near the OB ward, main floor. The NODE device is a computer used for programing the system and printing reports for the system. The smoke detector is a detector that is a required part of the elevator recall system in the event of a fire emergency. A records review showed that the two items were logged out of service since 4-16-14. At the time of survey the facility had not yet established a workorder to have the system troubles corrected.

3) It was observed that room 1240, doctors quarters, requires single station smoke alarm.

Based on observation of surveyor 16732 and 20980 on 05/27/14

1) There is storage within 18 inches of sprinkler head in the CT computer room
2) There is an sprinkler escutcheon plate missing in CT computer room




20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. The following observations were made;

1) Required sprinkler protection was not provided in the corridor electrical rooms of the main level of the hospital.

2) Room 1457, Lab Storage room, draw room of the Blood Lab, and room 1215, were missing the escutcheon plates for the sprinkler heads.

3) The walkin freezer #3 in the kitchen is not proper sprinkler protected inside the unit.

4) Room 1240, doctors lounge, two sprinkler heads escutcheon plates missing.

This tag not met as observed by surveyors 20980, 16732 and the facility maintenance director. It was observed that the facility sprinkler system inspection/testing reports did not show that a five year internal inspection of the sprinkler piping has been accomplished as required.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that in the PACU area of the hospital an untreated combustible quilt was hanging at the nurses station.

Based on record review of surveyor 16732 on 05/28/14

1) There is no area alarm monitoring the medical gases for Exam Rooms 1-10 and Triage.

2) The area alarm located across from the Surgical Services entrance in hallway monitoring the Say Surgery is not in a location where it is under surveillance by Day Surgery Staff.

3) The area alarm located outside of the PACU entrance the hallway monitoring the PACU is not in a location where it is monitored by the PACU staff.

4) The medical air and vacuum pressure switches for the master alarm system are not located immediately after the source valves. They are located downstairs by the Surgical Services entrances.


The maintenance director was present during this observation


20980

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that the emergency gas shut off for the medical gases located in room 1410C/D was not readly accessable to the area. It was discovered that the shutoffs were located in am offce to the rear of 1410 but personnel have to go through two lockable spaces prior to getting to the shutoffs

Based on record review of surveyor 16732 on 05/28/14


1) The evacuation and medical vacuum in all operating rooms are controlled by a single zone valve located left of the anesthesia work room.

The maintenance director was present during this review.

On 05-28-2014 Inspections made to the out building Existing Business Occupancies for this Health Care location.

Violations found at the below locations are under the 2000 Edition of Life Safety Code 101.

At Pen-Bay Pediatrics, 7 Madelyn Lane Rockport; Building Sprinkler System has not been serviced for the past 4 years last date of service was 2-9-2010. System failed to me Code NFPA 25 Inspection, Maintenance, Testing. Needs to be Inspected.

At Mid-Coast Speech / Hearing / Occupational Therapy, 7 Madelyn Lane Rockport. Basement area of building, wide open and unpertected / no separation from Oil Burner, Failed to meet Code, oil burner not protected as per Code Chapter 39 Section 39.3.2.1 will have to protected in accordance with Section 8.4. And storage of Flamable equipment ( lawn equipment and gasoline can) to be removed from building.

At the Robert Laurence, MD, 760 Commercial Street, Rockport. Basement area of building, Oil burner wide open and unpertected from the rest of the storage. Failed to meet Code oil burner need's to be protected as per Code Chapter 39 Section 39.3.2.1 and in accordance with Section 8.4.
General Storage in this same space Ceiling is not protected, Ceiling will have to protected in accordance to Section 8.4.

At Waldoboro Family Medicine, 27 Mill Street Waldoboro, Exit sign need's to be add to main Hall-way. Chapter 39 Section 39.2.10.

At the Robert Laurence MD Office. 760 Commercial Street, Rockport. Exit sign need's to be repaired. Chapter 39 Section 39.2.10.

At Charles F. Kava,D.O., 68 Ben Paul lane, Rockport. Emergency Lighting unit not working check all units in building, Chapter 39.2.9..

At Pen-Bay Specialty Clinic, 79 Schooner Street, Damariscotta. Emergency Lighting unit not working check all units in building, Chapter 39.2.9..



20980

The following additional deficiency were observed by this surveyor:


1) Ceiling tiles missing in the first floor Communications Center IT room. Tiles are to remain in place to maintain smoke tight enviroment.

This tag not met as observed by surveyor 20980 and a facility maintenance person. It was observed that flammable liquids (gasoline) was being improperly stored in the facility boiler room and being stored in unapproved containers.

Based on observation of surveyor 16732 and 20980 on 05/27/14:

1) Electrical outlet cover missing in storage room in Stairway C

2) Exterior canopy at Emergency Room has junction cover missing in ceiling

The maintenance director was present during this observation


20980

This tag not met as observed by surveyor 20980 and the nurse supervisor for the operating rooms. It was observed that incorrect power strips (relocatable power taps) were being used in ORs 2, 3 & 4. The power strips being used were Tripp Lite PS-415- HG that are not designed for use in patient care areas as stated on the units and in the manufactures specifications.