HospitalInspections.org

29087

K20
Based on observation, interviews, and operational testing, the facility failed to protect vertical openings as required. Failure to protect vertical openings as required increases the risk of death on injury due to smoke and fire and affected 2 of 2 stories.

Findings include;

During observational tour of the facility conducted on 1/8/16 from 8:30 AM to 1:00 PM doors protecting atrium openings did not latch as required. Atrium doors are required to meet opening requirements for corridor walls.

The door leading from medical Records to the atrium (1E6-08) did not fully close and failed to latch when tested by the facility Maintenance Manager (MM). MM confirmed the door would not close fully and therefore would not latch.

The Labor and Delivery door (2C3-18) which opened to the atrium failed to latch when tested. MM confirmed the door would not latch.

29087

Based on observation, interviews, and operational testing, the facility failed to protect hazardous areas as required. Failure to protect hazardous areas increased the risk of injury or death related to smoke and fire. The failure affected two treatment areas.

Findings include;

During observational tour of the facility conducted on 1/8/16 from 8:30 AM to 1:00 PM the PACU and two dental storage areas exceeded 50 square feet in size and contained combustible materials. PACU storage door 2C1-19 had no self-closer and dental storage doors 1D2-27 and 1D2-05 failed to latch when tested.

The Facility Maintenance Manager was present at the time of observation and confirmed the findings.

29087

Based on observation, interview, and operational testing the facility failed to maintain the means of egress as required.

Findings include;

During observational tour of the facility conducted on 1/8/16 from 8:30 AM to 1:00 PM doors on the Adolescent Care Unit (ACU) were found equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.

ACU exam room door 1A3-08
ACU #2 teaching room door 1A3-04
ACU #2 teaching room a second door
ACU girls day room
ACU laundry room
ACU housekeeping closet
ACU Janitor closet
ACU patient belonging storage room.
ACU Reflection room
ACU treasure Chest door 1A1-10
ACU Group Therapy door 1A1-14

The facility Maintenance Manager confirmed the presence of the keyed locks on the doors.

In an interview at 11:40 AM on 1/8/16 the ACU Manager said she did not carry keys for the door locks. The RN charge nurse said she did not carry keys but was able to locate a key after a brief search. The ACU Manager said the locks were not locked and said the deadbolt locks were not necessary. The ACU Manager said she understood the risk of patients not being able to exit a room in an emergency.