HospitalInspections.org

Based upon observations and staff interviews on 12/06/2017 between approximately 1000 and 1300 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

Findings were the following doors did not close and latch correctly:

ER room 1 & 2
Main entrance corridor doors
Door number 161 by cafeteria
Door number 161-A by cafeteria (Fixed at time of inspection)
Door 110-A

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 12/06/2017 between approximately 1100 and 1200 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
Findings were two over hangs in front of facility that need fire sprinklers added; one by the Medical records exit on south side with a 6 foot wood overhang and the other is the Lab entrance that is an 8 foot over hang with soffit vents open to attic.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 12/06/2017 between approximately 1300 and 1330 hours the facility has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:
Found space heater with no tip over device and open elements in Lab Managers office plugged into power-strip. (Fixed at time of inspection)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 12/06/2017 between 1000 and 1030 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include, but are not limited to:

Finds were an extension cord in use for the fax machine back in the medical records office.



The above was discussed and acknowledged by the facility staff.