HospitalInspections.org

Based upon observations and staff interviews on 7/24/18 during the physical tour of the facility between approximately 1030 and 1500 hours the facility has failed to ensure the means of egress are clearly identified with signage and that exit signs are maintained and constantly illuminated. This could result in a delay of evacuation in the event of a fire which would endanger patients, staff and/or visitors.

The findings include:

-The internally illuminated exit sign by the roof access door in the surgery suite did not illuminate in normal operation.

The above was discussed and acknowledged by the facility safety officer who said they had not previously observed the inoperative exit sign.

Based upon observations and staff interviews on 7/24/18 during the physical tour of the facility between approximately 1030 and 1500 hours, the facility has failed to maintain doors to hazardous areas as self or automatic closing and able to resist the passage of smoke and fire. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.

The findings include:


-The door to the corridor from storage room #0121 (Therapy) is over 50 square feet and was not equipped with a self-closing device.

-The door to the corridor from storage room #2058 is over 50 square feet and did not have enough self-closer force to fully close and latch.

-The door to the corridor from the OR equipment room #2 is over 50 square feet and did not have enough self-closer force to fully close and latch.

-The door to the corridor from the OB storage room OB52 is over 50 square feet and was not equipped with a self-closing device.

-The door to the corridor from the gym storage room over is 50 square feet and was not equipped with a self-closing device.

The above was discussed and acknowledged by facility safety officer who said they were unaware these storage rooms required self-closing devices and that they were unaware the ones equipped with closers were not closing.

Based upon observations and staff interviews on 7/24/18 during the physical tour of the campus between approximately 1030 and 1500 hours, the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to patients, staff and/or visitors within the facility.

The findings include:

-There was an ABHR-dispenser installed over an electrical outlet in OR #3.

The above was discussed and acknowledged by the facility safety officer who said the dispenser had not been previously observed to be above the outlet.

Based upon observations and staff interviews on 7/24/18 during the physical tour of the campus between approximately 1030 and 1500 hours, the facility has failed to maintain the ability of smoke barriers as being able to resist the passage of smoke. This could result in the products of combustion traveling from one compartment into another compartment, thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

-There was an unsealed through penetration in the cross-corridor smoke barrier above the drop ceiling near the rear entry into the Peri-op department.

-There was an unsealed through penetration in the cross-corridor smoke barrier above the drop ceiling near room #1065.

-There was an unsealed through penetration in the cross-corridor smoke barrier above the drop ceiling near room #1156.


The above was discussed and acknowledged by the facility safety officer who said they had not previously observed the unsealed/improperly sealed penetrations in the barriers.

Based upon observations and staff interviews on 7/24/18 during the review of facility documentation between approximately 0845 and 1030 hours, the facility has failed to properly maintain the Type 1 Medical Gas Piped System alarms in the facility. This could result in gas supply or delivery malfunction which could potentially endanger patients in the Critical Care/Ventilator Unit rooms within the facility.

The findings include:

-According to the facility's annual medical gas inspection report from September 2017, the master alarm panels in the Emergency Department and the maintenance office failed to operate when tested. The area alarm panels were operational.


The above was discussed and acknowledged by the maintenance director who said they were unaware if the issues were corrected and that they were unable to find work orders showing correction.

Based upon observations and staff interviews on 7/24/18 during the physical tour of the campus between approximately 1030 and 1500 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 99, NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the patients, staff and/or visitors within the facility.


The findings include:

-There was a powerstrip improperly mounted and hanging by the cord plugged into it in Physician Sleep Room #102.

-There was an extension cord used in place of permanent wiring with miscellaneous IT equipment in the IT closet of storage room #2043.


The above was discussed and acknowledged by the facility safety officer who said they were unaware why the extension cord was being used and that they had not previously observed the powerstrip to be suspended by the electrical cord.