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Based on observation and staff interview, the facility does not ensure that a self-closing device is present on the janitor's closet in the dietary department or on the door entering the oxygen cylinder storage area. Failure to provide a self-closing device on this door may result in staff harm in the event of an actual emergency.

Findings include:

During the facility tour on 10/18/19 at 3:00 PM, it was observed that a self-closing device was not present on the door entering the janitor's closet in the dietary department. A self-closing device must be provided on this door to ensure that this doors is closed at all times and to impede the travel of smoke and fire gases that would be created from the cleaning chemicals present in this room.

During the facility tour on 10/19/19 at 11:50 AM, it was observed that a self closing device was not present on the room containing 16 full E sized oxygen cylinders. A self closing device must be provided when the door opens into a marked egress pathway.

Interview with Staff (B), Maintenance and Staff (S), Dietary on 10/18/19 at 3:10 PM and 10/19/18 at 11:55 AM verified this finding.

Based on observation and staff interview, the facility does not ensure that 1 of 2 fire exit doors latch when closed. Failure to ensure that fire exit doors latch when closed may result in staff, patient and visitor harm.

Findings include:

During the facility tour on 10/19/18 at 1:10 PM, it was observed that the fire exit door to the Medical Care Unit (MCU) parking area did not latch. It was noted that the left side of the fire door assembly did not latch when closed.

Interview with Staff (B), Maintenance on 10/19/18 at 1:10 PM indicated that the staff and visitors to the MCU utilize this entrance for entering and exiting the facility and that the outside handle is in need of maintenance to close and latch properly.

Based on observation and staff interview, the facility does not ensure that 1 of 2 egress pathways is maintained in the Medical Care Unit (MCU). Failure to maintain the egress corridor may result in delayed removal of patients in the event of an emergency.

Findings include:

During the facility tour on 10/19/18 at 1:00 PM, it was observed that the patient scale, located adjacent to Room #215, was in the egress corridor.

Interview with Staff (B), Maintenance on 10/19/18 at 1:00 PM revealed that the clear width of the corridor with the patient scale in place to be approximately 36 inches when measured. This egress corridor must have a minimum clear width of 48 inches.

Based on observation and staff interview, the facility does not ensure that the exit light in the boiler room is maintained or that an exit light is provided in the kitchen area to indicate the egress pathway. Failure to maintain and provide exit lights may result in delay of staff in the event of an actual emergency.

Findings include:

During the facility tour on 10/18/18 at 1:00 PM, it was observed that the exit light in the boiler room was not illuminated and was obstructed by a silver pipe approximately 2 inches in diameter. Exit signs must be visually inspected monthly to ensure proper operation in the event of an emergency.

Interview with Staff (B) on 10/18/18 at 1:25 PM verified this finding.

During the facility tour on 10/18/18 at 2:00 PM, it was observed that an exit sign, with chevrons indicating the egress pathway, was not provided in the kitchen area. Exit signage must be provided when the pathway of egress is not evident.

Interview with Staff (B), Maintenance and Staff (S), Dietary on 10/18/18 at 2:45 PM verified this finding.

Based on document review and staff interview, the facility does not ensure that all devices that comprise the fire alarm system are tested annually or that sensitivity testing is conducted per NFPA 72 - 2010 Ed. Failure to test all devices annually and to perform sensitivity testing may result in staff, patient and visitor harm in the event of an actual fire.

Findings include:

Review of the Fire Alarm System Inspection and Testing form on 10/18/18 at 10:00 AM from 12/2017 through 09/2018 did not provide evidence that all components were tested.Review of the reports revealed the following:
-Review of the 12/27/17 report indicates 34 photo smoke detectors were present but only 33 were tested and 12 visual devices were present but only 11 were tested;
-Review of the 03/28/18 report indicated 22 heat detectors were present but only 9 were tested.
-Review of the 09/21/18 report indicated 30 photo smoke detectors were present but only 29 were tested.

Interview with Staff (B), Maintenance on 10/18/18 at 11:30 AM verified the above finding.

Review of the Fire Alarm System Inspection and Testing Forms from 12/2017 through 09/2018 on 10/18/18 at 10:00 AM revealed no documentation to indicate that sensitivity testing had been performed on the photo smoke detectors.

Interview with Staff (B), Maintenance on 10/18/18 at 11:00 AM stated that he could not locate the sensitivity testing report but thought that "it had been done". Sensitivity testing must be performed per NFPA 72.

Based on observation, document review and staff interview, the facility does not ensure that adequate separation is maintained from the sprinkler heads, spare sprinkler heads are available for the sprinkler system or that internal inspection is performed on the sprinkler system. Failure to perform this activity may result in malfunctioning of the sprinkler system in the event of an emergency.

Findings include:

During the facility tour on 10/18/18 at 2:00 PM, it was observed that supplies were stored less than 18 inches from the sprinkler heads in the dry storage room and in the janitor's closet in the kitchen area. It was noted that platter lids, carafes, christmas ornaments, paper doilies, and chafing dishes were located less than 18 inches from the sprinkler heads. A minimum of 18 inches must be maintained between supplies and the sprinkler heads to ensure a proper spray pattern.

Interview with Staff (B), Maintenance and Staff (S), Dietary on 10/18/18 at 2:10 PM verified this finding.

During the facility tour on 10/18/18 at 1:30 PM, it was observed that the spare sprinkler heads in the cabinet in the boiler room were not adequate for the type of sprinkler system that is present in the facility. Although the facility's sprinkler system consists of pendant, concealed and upright heads, the six heads present included, two wall heads and four dry heads.

Interview with Staff (B), Maintenance on 10/18/18 at 1:40 PM confirmed that the facility sprinkler system consists of pendant, concealed and upright heads, which were not available in the cabinet and that the facility does not have a dry sprinkler system or any wall sprinkler heads.

Review of the sprinkler inspection reports from 12/2017 through 09/2018 on 10/18/18 at 10:00 AM did not provide evidence that the five-year internal inspection of the sprinkler system had occurred.

Interview with Staff (B), Maintenance on 10/18/18 at 10:50 AM verified that he was not aware that a five-year internal inspection had been conducted and that there was no documentation to indicate otherwise.

Based on document review, observation and staff interview, the facility does not ensure that annual inspections are performed on the fire doors. Failure to perform these inspections may result in the door malfunctioning in the event of an actual emergency.

Findings include:

During the facility tour on 10/18/18 at 1:30 PM it was observed that the fire door entering the dishroom of the kitchen did not close, was not a rated assembly and a liquid substance was leaking out of the closure device. It was also observed that the fire door at the receiving entrance was not labeled and panic hardware was not present and the fire exit door from the medical care unit into the visitor parking lot did not close and latch.

Review of the provided documentation on 10/18/18 at 10:30 AM did not reveal any documentation to verify that the rated fire doors had been inspected.

Interview with Staff (B), Maintenance on 10/18/18 at 1:30 PM verified the above findings.

Based on observation and staff interview, the facility does not ensure that the medical gas shut-off valves are labeled with the area that they serve. Failure to provide labeling on these valves may result in the incorrect valves being shut-off in the event of an actual emergency.

Findings include:

During the facility tour on 10/19/18 at 1:15 PM, it was observed that the medical gas shutoff valves in the corridor adjacent to the kitchen area on the Medical Care Unit were not labeled with the area/rooms that are served from these valves.

Interview with Staff (B), Maintenance on 10/19/18 at 1:45 PM verified this finding.

Based on observation and staff interview, the facility does not ensure that ensure the piped oxygen system is maintained.

Findings include:

During the facility tour on 10/19/18 at 12:00 PM, it was observed that the piping for the central oxygen system was not labeled above the ceiling tiles in the PT/OT corridor. This piping must have a green/white background with contrasting green/white labeling.

Interview with Staff (B), Maintenance on 10/19/18 at 11:45 AM verified this finding.

Based on document review and staff interview, the facility does not ensure that documentation is maintained to indicate the milliamperes (mA) at which the Ground Fault Circuit Interrupters (GFCI) were inactivated. Failure to ensure that the GFCI are fully operational may result in patient, staff and visitor harm.

Findings include:

Review of the GFCI testing report for 2017 and 2018 on 10/18/18 at 11:45 AM, did not provide evidence of the mA in which these outlets were inactivated. This reading must be documented to ensure that these electrical outlets do not exceed 10 mA when utilized.

Interview with Staff (B), Maintenance on 10/18/18 at 11:55 AM verified this finding.

Based on document review and staff interview, the facility does not ensure that the generator is tested every three years for four continous hours or that electrical panel and the circuits are marked. Failure to operate the generator for an extended period and to adequately identify the panel and circuits may result in failure of the generator in an emergency situation

Findings include:

Review of the Emergency Full Load Generator Test log on 10/17/18 at 2:00 PM did not provide evidence that the emergency generator is tested every three years for four continous hours. Review of this log was for the monthly inspection and testing of the generator. The emergency generator must be tested every three years for a minimum of four hours to ensure that the generator is capable of operating under the required load rating.

Interview with Staff (B), Maintenance on 10/17/18 at 2:15 PM confirmed there was no documentation to indicate that a full load generator test had been performed in the last three years.

Based on observation and staff interview the facility does not ensure adequate separation of the full and empty oxygen tanks. Failure to provide adequate separation may result in the staff obtaining the incorrect tank.

Findings include:

During the facility tour on 10/19/18 at 11:00 AM it was observed that full and empty oxygen tanks were stored in the same rack in the medical gas room. It was observed that 41 empty E tanks and 16 full E tanks were stored together.

Interview with Staff (B), Maintenance on 10/19/18 at 11:35 AM verified this finding.