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PIGGOTT COMMUNITY HOSPITAL
No Description Available
Tag No.: K0029
Based on observation and interview, it was determined three (laundry, Room 115 and Emergency Department) of seven hazardous areas observed out of a total of seven hazardous areas in the facility were not protected as hazardous areas due to fire rated doors that were not self closing, missing and held open with a wood wedge. The failed practice had the potential to affect all patients admitted to the facility with an average daily census of 15 and all 15 patients in the facility on 11/22/10. The findings follow:
A. On a tour of the facility beginning at 1230 on 11/23/10 with the Director of Engineering the following observations were made:
1) A tour on 11/23/10 at 1230 revealed two entrance points to the laundry. The entrance to the folding room was open to the corridor and was without a door. The doorframe had a part of a closing device attached to it. The second entrance to the laundry was through a set of double doors. The left door did not have a closing device. The right door was held open by a wood wedge, preventing self-closing of the door. Neither of those doors were able to fully close or latch due to the doors rubbing against the doorframe.
2) Observation of the patient wings on 11/23/10 at 1300 revealed Room 115 was used as a housekeeping storage room. Combustible supplies were stored in the room in quantities to present a fire hazard. Combustible materials observed in the room included 5 boxes of toilet paper with 96 rolls each; 5 boxes of paper towels with six rolls each; a storage rack with individual toilet paper rolls filling one shelf; and 2 storage racks of clean linens. The room was not protected by fire rated construction or a sprinkler system. The door was not provided with a self-closing device and was not fire rated.
3) On a tour of the Emergency Department on 11/23/10 at 1400, the door to the Soiled Utility Room was observed with a plastic wedge, preventing self-closing of the door.
B. The Director of Engineering verified the above findings in interviews conducted at the time of the observations.