HospitalInspections.org

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing performed during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the quarterly flow testing requirements.

Based on observation, testing, and interview, the provider failed to maintain the one hour self-closing door to the medical gas storage room. Two of two doors were held open with unapproved devices. Findings include:

1. Observation and testing at 2:50 p.m. on 4/11/11 revealed the north door to the medical gas storage room would open to approximately 60-70 degrees and then catch on the vinyl flooring. That vinyl flooring would hold that door open and not allow it to self-close. Interview with the maintenance supervisor at the time of the observation and testing confirmed that finding. He stated he was not aware that door would catch on the vinyl flooring.

2. Additional observation at that same time revealed a wooden wedge, with a chain hooked to the door frame, just inside of the south door to the same medical gas storage room. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he always used the wooden wedge to hold open the south door when he would remove and then replace the large oxygen Dewars. He stated he was aware wooden wedges could not be used to hold open doors.