HospitalInspections.org

Based on observation, testing, and interview, the provider failed to maintain one of two sets of 90 minute rated self-closing cross-corridor doors (north) in the patient care wing. Findings include:

1. Observation at 3:00 p.m. on 3/7/11 revealed a set of 90 minute rated self-closing cross-corridor doors on the north side of the patient care area. Testing of those doors at that time revealed the south leaf would not latch and would swing free. Continued testing three more times revealed the south leaf would never latch into the striker plates on the top of the frame and in the floor.

Observation, testing, and interview at 3:00 p.m. on 3/8/11 with the executive director during the fire drill confirmed the above findings. She stated she was not aware that door was not latching. She stated there was no preventative maintenance for the doors in the building.

Based on document review and interview, the provider failed to include a policy for notification of proper authorities when the fire sprinkler system was out of service. Findings include:

1. Review of the provider's policy book revealed a policy could not be located for notification of proper authorities when the fire sprinkler system was out of service for more than four hours in a twenty four hour period.

Interview at 9:00 a.m. on 3/8/11 with a plant operations representative from the parent company revealed he thought there might be a blanket policy for the outlying facilities of the parent company. Interview at 3:00 p.m. on 3/11/11 with the executive director revealed she was not aware a separate policy must be placed in effect for the facility. The surveyor explained since the facility was separately licensed and was not completely owned by the parent company, the facility needed to retain its own policies.

Based on document review and interview, the provider failed to include a policy for notification of proper authorities when the fire alarm system was out of service. Findings include:

1. Review of the provider's policy book revealed a policy could not be located for notification of proper authorities when the fire alarm system was out of service for more than four hours in a twenty four hour period.

Interview at 9:00 a.m. on 3/8/11 with a plant operations representative from the parent company revealed he thought there might be a blanket policy for the outlying facilities of the parent company. Interview at 3:00 p.m. on 3/11/11 with the executive director revealed she was not aware a separate policy must be placed in effect for the facility. The surveyor explained since the facility was separately licensed and was not completely owned by the parent company, the facility needed to retain its own policies.