HospitalInspections.org

Based on observation and staff interview, the facility failed to provide adequate emergency egress lighting in the Administration wing. The deficient practice could delay or prevent egress from the area under low-light conditions.

Findings are:

Observation on 4-20-2022 at 11:13 AM revealed the following:

1) The emergency light in the Administration wing near the conference room did not illuminate when the test button was depressed.

During an interview on 4-20-2022 at 11:13 AM, Maintenance Staff confirmed the finding.

Based on observation and interview, the facility failed to maintain the Fire Sprinkler System by allowing fire sprinklers to not be installed per NFPA 13. The deficient practice did not ensure the system would activate or operate as designed.

Findings are:

Observations on 4-20-2022 at 11:16 AM revealed the following:

A fire sprinkler in the Oxygen Storage room was hanging approximately 2-inches below the finished ceiling.

During an interview on 4-20-2022 at 11:16 AM, Maintenance Staff confirmed the findings.

Based on observations and staff interview, the facility failed to ensure electrical receptacle boxes were equipped with cover plates, and that there was at least 36 inches of clear space at electrical panel and breaker boxes. This deficient practice could cause a fire or shock upon accidental contact, or prevent access to an electrical panel in the event of an emergency.

Findings are:

Observations on 4-20-2022 between 11:01 AM and 11:26 AM revealed the following:

1) Electrical breaker panels in the surgery storage room were obstructed by a floor scrubber.
2) An electrical junction box was missing a cover in the maintenance room above the sprinkler riser.
3) The electrical panels in the kitchen were obstructed by a shelving unit.

During interviews on 4-20-2022 between 11:01 AM and 11:26 AM, Maintenance Staff confirmed the findings.

Based on observation and staff interview, the facility allowed the use of electric extension cords in lieu of permanent wiring. The deficient practice increases the potential for an electrical injury or fire.

Findings are:

Observation on 4-20-2022 at 11:05 AM revealed the following:

1) Facility allowed the use of an electric extension cord to power decorative lighting in the ambulance bay.

During an interview on 4-20-2022 at 11:05 AM, Maintenance Staff confirmed the findings.

Based on observation and staff interview, the facility failed to label oxygen cylinders as empty or full, and failed to segregate full and empty cylinders. The deficient practice increased the potential for an empty cylinder to be taken when a full one was needed.

Findings are:

Observations on 4-20-2022 at 11:16 AM revealed the following:

1. The Oxygen Storage room did not have signs identifying full and empty oxygen cylinders in the storage rack.
2. The Oxygen Storage room had full and empty cylinders intermixed within the same rack with no means of separation.

During an interview on 4-20-2022 at 11:16 AM, Maintenance Staff confirmed the finding.