HospitalInspections.org

Based on observations, the facility failed to maintain clear access to exits.

The findings included:

Observation on 7/6/17 from 10:20 AM until 12:20 PM, revealed the fire exit door was obstructed by 4 wheel-chairs and a shred it box in the surgery hallway
National Fire Protection Association (NFPA) 101, 19.2.3.5

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency on 7/6/17.

Based on records and interview, the facility failed to annually test emergency lights.

The findings included:

During the records review on 7/6/17 at 7:40 AM, the facility failed to provide records documenting the annual 90 minute battery test for the emergency lighting. The maintenance mechanic revealed they changed the batteries in the emergency lights annually but did not have the documentation.
National Fire Protection Association (NFPA) 101, 19.2.9.1 (2012 Ed.)
NFPA 101, 7.8.1.2 (2012 Ed.)

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.

Based on records review, the facility failed to provide fire alarm testing records.

The findings included:

During the records review on 4/10/17 at 7:45 AM, revealed the sensitivity test numerical results of each smoke detector was not recorded on the annual fire alarm test on 6/3/16.
National Fire Protection Association (NFPA) 101, 19.3.4.1 (2012 Ed)
NFPA 101, 9.6 (2012 Ed)
NFPA 72, 4.5.3.2 (2010 Ed.)

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.

Based on observations, the facility failed to maintain the sprinkler system.


The findings included:


1. Observation on 7/6/17 at 11:25 AM, revealed 3 of 3 corroded sprinklers in the ambulance entrance hall of the emergency department.
National Fire Protection Association (NFPA) 101, 9.7.1.1 (2012 Ed.)
NFPA 25, 5.2.1.1.2 (6) (2011 Ed.)

2. Observation on 7/6/17 at 11:25 AM, revealed 9 of 9 loaded sprinklers in the emergency department hall.
NFPA 101, 9.7.1.1 (2012 Ed.)
NFPA 25, 5.2.1.1.2 (5) (2011 Ed.)

3. Observation on 7/6/17 at 9:02 AM, revealed a sprinkler assembly obstructed by storage items in the file storage room of the medical records department.
NFPA 101, 19.3.5.3 (2012 Ed.)
NFPA 101, 9.7 (2012 Ed.)
NFPA 13, 8.5.6.1 (2010 Ed.)


The maintenance mechanic was present when the deficiencies were identified and the administrator acknowledged the deficiencies during the exit conference on 7/6/17.

Based on observation, the facility failed to maintain corridor doors.
The findings include:
Observation on 7/6/17 at 11:25 AM, revealed the bio-hazard room door would not latch inside the emergency department.
National Fire Protection Association (NFPA) 101, 19.3.6.3.5 (2012 Ed.)

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.

Based on records review, the facility failed to conduct all required fire drills.

The findings included:

During the records review on 7/6/17 at 7:40 AM, the facility failed to conduct 3rd shift fire drills for staff for 2016 and 2017.
National Fire Protection Association (NFPA) 101, 19.7.1.6 (2012 Ed.)


The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.

Based on records review, the facility failed to maintain the generator.

The findings included:

During the records review on 7/6/17 at 7:40 AM, the facility failed to provide documentation of an annual load bank test conducted.
National Fire Protection Association (NFPA) 101, 19.5.1 (2010 Ed.)
NFPA 101, 9.1 (2010 Ed.)
NFPA 101, 9.1.3.1 (2010 Ed.)
(NFPA) 110, 8.4.2.3 (2010 Ed.)

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.

Based on observations, the facility failed to maintain electrical equipment.

The findings included:

Observation on 7/6/17 at 10:15 AM, revealed unapproved power strips connected to the following patient-care-related electrical equipment (CREE):
1. the vital signs monitor in the blood infusion room.

2. the otoscope in exam room #2 in the emergency department.
Centers for Medicare and Medicaid Services Ref: S & C 14-46-LSC

The maintenance mechanic was present when the deficiencies were identified and the administrator acknowledged the deficiencies during the exit conference on 7/6/17.

Based on observations, the facility failed to maintain oxygen cylinders.

The findings included:

Observation on 7/6/17 at 10:08 AM, revealed an unsecured oxygen cylinder was stored behind a cubicle curtain across from the nurses station. A staff nurse re-located the cylinder to the oxygen storage room.
National Fire Protection Association 99, 11.3.2.1 (2012 Ed.)

The maintenance mechanic was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference on 7/6/17.