HospitalInspections.org

Based on observation, the facility failed to ensure that access to exits were marked by accurate and visible signs, and had emergency illumination.

Findings include:

-Emergency Department:

There was no exit sign with emergency illumination (internally or externally) at the Emergency Department Waiting Room exit.

The corridor leading to the Waiting Room had a door with an exit sign posted above it. (The door was blocked by plastic sheeting and there was construction in progress behind this door, thus blocking the exit (see Tag K038))

There were no directional markings to navigate the exit/construction pathway, with emergency illumination, visible from the corridor toward the Waiting Room exit. The only directional marking/arrow was a handmade, drawn arrow in blue ink on the plastic sheeting.

-Third Floor Patient Rooms:

3 East lacked an exit sign marking for 1 of its 2 exits from the Nurse's Station.

3 West: There was an exit sign adjacent to the Nurse's Station, however it was not illuminated.

3 West: There was no exit sign marking the exit leading from the NICU (Neonatal Intensive Care Unit) Nurse's Station to the lobby/atrium exit.

Based on observation, the facility failed to ensure that exit accesses were readily available for use.

Findings include:

-Second Floor Cath Lab (2 South)

There were 2 doors marked by exit signs in the Cath Lab. One of the 2 exits in the Cath Lab was completely blocked by furniture.

Based on interview, document review, and policy review, the facility failed to ensure fire drills were conducted quarterly on each shift in all areas throughout the facility.

Findings include:

-On 12/7/10, the Director of Plant Operations indicated there were 2 shifts: The day shift (7:00 AM - 7:00 PM) and the evening shift (7:00 PM - 7:00 AM). He further indicated it was the practice of the facility that the fire drills were only conducted within specific areas of the hospital and not hospital-wide quarterly on each shift for the year 2010.

The Director of Plant Operations verified there was a lack of fire drills conducted for the first quarter (only 1 fire drill conducted), second quarter (no fire drills conducted), and third quarter (only 2 fire drills conducted) of 2010.

-The only documented fire drills were listed as follows:

2/15/10: 2:58 PM (Housekeeping and Storage)
8/11/10: 9:32 AM - (At 4 West, OB/GYN; Away MCC 3 West)
9/14/10: 1530 (3:30 PM) - (At 4 East Med Surg; Away 3 East)
10/12/10: 5:30 AM - (At 3 East; Away IMC 2 East)
10/12/10: 5:30 PM - (Away 4 East Med Surg)
11/3/10: 5:53 AM - (At Surgery 2nd Floor; Away 1 West)
11/10/10: 10:47 - (At 1 West; Away 2nd Floor ICU)

-The facility's Fire Drill Policy and Procedure (undated) indicated as follows:

"...Fire drills will be performed in all areas of the hospital at least one per quarter per shift in accordance with CMS (Centers for Medicare / Medicaid Services) requirements. The Fire Safety Observation Checklist / Critique form will be used as follows: The observer will complete: 1) The Date of Drill, Start Time, and Location as well as circling either AT (for a scene of fire) and AWAY (for away from the scene of fire). 2) The observer will inform staff that he is conducted a fire drill and tell them the scenario..."

"Fire Drills: The Facilities Manager has accountability for assuring that fire drills are conducted on all shifts in all patient care buildings quarterly..."

Based on observation, interview, and policy review, the facility failed to ensure a smoking policy was developed, maintained, and complied within minimum provisions of smoking regulations.

Findings include:

On 12/7/10, 12/8/10, 12/9/10, and 12/10/10, the following observations were as follows:

-On 12/7/10, there were cigarette butts and ashes along the rim of the garbage can in front of the Emergency Room entrance and the front hospital entrance.

-On 12/7/10 in the late afternoon, 1 patient was observed smoking a cigarette while standing in the grassy area approximately 50 feet away from the front hospital entrance.

-On 12/7/10 throughout the day and on 12/8/10 in the mid-morning, there were three plastic buckets filled with white sand (5 gallon buckets) located on the facility premises approximately 150 feet from the Emergency Room entrance. There were people observed who were smoking cigarettes and using the plastic buckets as an ashtray.

-On 12/8/10, 12/9/10, and 12/10/10, there were people standing in front of the hospital entrance using the garbage can rim as an ashtray.

-On 12/9/10 and 12/10/10, there was 1 plastic bucket filled with white sand, which had cigarette butts located on the facility premises approximately 100 feet away from the hospital's front entrance.

-On 12/7/10, 12/8/10, 12/9/10, and 12/10/10, the Director of Plant Operations indicated the facility was a smoke free environment and that patients, visitors, and staff were not permitted to smoke on the premises. He further indicated that the plastic buckets were not allowed to be used as an ashtray, and that any smoking whatsoever violated the facility's policy.

The Smoking Policy and Procedure (originated 3/91, effective 7/10) stated as follows: "4.2: In an effort to protect the health of patients, physicians, staff, vendors, and visitors, smoking and use of tobacco in any form is prohibited on all SRDH (St. Rose Dominican Hospital) properties, including offsite locations, private vehicles on SRDH properties, and/or company vehicles. 4.3: Patients who adamantly insist on smoking or using tobacco products and cannot be safely discharged at this time, must sign the Temporary Absence From Hospital Property Release Form and follow the process for leaving the unit prior to leaving Hospital property to use tobacco products."

The Smoking Policy did not include a provision that patients who were classified as non-responsible were not allowed to smoke without supervision.

Based on observation and policy review, the facility failed to ensure decorations were not flammable and combustible.

Findings include:

The Policy and Procedure regarding Holiday Decorations (originated 12/02, revised 06/09) stated as follows: "2. Do not hang decorations / signs / banners, etc. from ceiling tiles or ceiling tile grids as this will infringe on the fire protection properties of the ceiling. 4. All decorations must be of the noncombustible type. Decorations need to have a U.L. (Underwriters Laboratory) or Facilities Maintenance (F.M.) approval tag. Decorations must be made of good quality materials and sound construction. Decorations: 1. No furnishings, decorations, posters or other objects are permitted in egress routes. 3. Loose paper, i.e., wrapping) or decorations on walls / doors shall not exceed 10% of the total wall surface. Only approved signage is allowed in corridors. Decorations such as tissue paper, crepe paper, cotton balls, or angel hair are not allowed. 4. Decorations are not permitted on corridor doors, as this may interfere with the proper operation of a smoke or fire door. 7. Metallic material may not be used for decoration, as it may confuse people when they exit during an emergency."

On 12/8/10, 12/9/10, and 12/10/10, the following areas had flammable/combustible decorations:

First Floor:
-The Cafeteria had crepe paper decorations hanging approximately 20 inches from the ceiling.
-On 1 West, there were wreaths (approximately 24 inches in diameter) with hanging bows (approximately 18 inches in length) on each patient door.

Fourth Floor:
-The stairwell door in the 4 West lobby had a covering of holiday paper approximately 3 x 3 feet.
-Each patient door in the Pediatric Unit was covered with holiday paper. The Nurse's Station lower exterior surrounding wall had holiday paper with garland.
-The doors to the Blood Gas Room, The Hospitalist Office, and the Soiled Utility Room were covered with holiday paper.

NFPA 99, Section 4-3.1.8.1: "Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1. Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over."

NFPA 99, Section 8-6.4.2: "Precautionary signs, readable from a distance of 5 ft (1.4 m) shall be conspicuously displayed at the site of administration and in aisles and walkways leading to the area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means."

Based on observation, the facility failed to ensure oxygen tanks were secured in accordance with NFPA 99.

Findings include:

-On 12/7/10 in the morning, there was an unsecured oxygen tank lying horizontally on the floor adjacent to Room 417.

-On 12/8/10, there was an unsecured oxygen tank in the corridor adjacent to the Psychiatric Observation Room.

-On 12/9/10, there was an unsecured oxygen tank in the 4 West corridor.

Based on interview and document review, the facility failed to ensure the generator was inspected on a weekly basis.

Findings include:

On 12/7/10, the maintenance records for the generator were reviewed. There was no documented evidence that the generator was inspected on a weekly basis by the facility.

On 12/7/10 and 12/8/10, the Director of Plant Operations verified the generator was only tested and inspected on a monthly basis, and were not inspected by the facility on a weekly basis for the year 2010.