HospitalInspections.org

Based on observation and interview the facility does not maintain all fire doors in a closed position or on an automatic release device.

Findings Include:

Observation on 3/3/16 at approximately 10:20am revealed the door to the maintenance suite was open. There were holes in the door in the area where a self-closer device would be secured to the door.

Interview with Staff #66 on 3/3/16 at 10:20am revealed that the door is a fire door and that it should be kept closed.

This finding was verified with Staff #66 on 3/3/16 at approximately 12:45pm.

Based on observation and interview the facility did not provide adequate training for staff in areas of the hospital protected by a Halon extinguishing system, nor was an alarm in place to notify staff in the event of an imminent Halon discharge.
Findings Include:
Observation on 3/2/16 at approximately 10:00am revealed that a Halon system sign was posted above the entrance door to the transcription area and an extinguishing head that appeared to be part of the Halon system was present in the transcription area, adjacent to the IT room.
On interview with Staff #28 on 3/2/16 at approximately 10:00am it was stated that Halon was not in the room.
Interview with Staff #66 on 3/2/16 revealed that the head was a Halon extinguishing head.
Interview with Staff #27 on 3/2/16 at approximately 2:00pm revealed that transcription staff did not train for a Halon discharge and that there was no alarm system to alert staff in that room of an imminent discharge.
These finding were verified with Staff #66 on 3/2/16 at approximately 2:00pm

Based on observation and interview the facility does not maintain all fire doors in a closed position or on an automatic release device.

Findings Include:

Observation on 3/3/16 at approximately 10:20am revealed the door to the maintenance suite was open. There were holes in the door in the area where a self-closer device would be secured to the door.

Interview with Staff #66 on 3/3/16 at 10:20am revealed that the door is a fire door and that it should be kept closed.

This finding was verified with Staff #66 on 3/3/16 at approximately 12:45pm.

Based on observation and interview the facility did not provide adequate training for staff in areas of the hospital protected by a Halon extinguishing system, nor was an alarm in place to notify staff in the event of an imminent Halon discharge.
Findings Include:
Observation on 3/2/16 at approximately 10:00am revealed that a Halon system sign was posted above the entrance door to the transcription area and an extinguishing head that appeared to be part of the Halon system was present in the transcription area, adjacent to the IT room.
On interview with Staff #28 on 3/2/16 at approximately 10:00am it was stated that Halon was not in the room.
Interview with Staff #66 on 3/2/16 revealed that the head was a Halon extinguishing head.
Interview with Staff #27 on 3/2/16 at approximately 2:00pm revealed that transcription staff did not train for a Halon discharge and that there was no alarm system to alert staff in that room of an imminent discharge.
These finding were verified with Staff #66 on 3/2/16 at approximately 2:00pm