HospitalInspections.org

Based on observation and interview, the facility failed to maintain the doors protecting corridor openings. 2 of 2 operating room doors failed to latch within door frame. This deficient practice would allow fire and smoke to migrate within the exiting. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 10:38 am, 2 of 2 Operating Room doors equipped with self-closing devices failed to close and latch within the door frame.

During an interview on 12-11-14 at 10:38 am, Maintenance Director confirmed the doors failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain doors in hazardous rooms. This deficient practice would allow fire and smoke to migrate out of the hazard areas. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 12:48 pm revealed, the Trash Room door equipped with a self-closing device failed to close and latch within the door frame.

During an interview on 12-1-14 at 12:48 pm, Maintenance Director confirmed the door failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain magnetically locked doors so that they could release within 15 seconds. This deficient practice would delay egress during an emergency. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 11:10 am and 11:18 am revealed two of two delayed egress doors in the patient area failed to be programed so that the mechanism could be tested.

During an interview on 12-11-14 at 11:10 am and 11:18 am, Maintenance Director confirmed the findings.

Based on observation and interview the facility failed to assure the sound level of the fire alarm system could be heard in all areas of the mechanical room. This deficient practice could potentially delay response to a fire. The facility census was 10 patients.

Findings are:
Observations during a fire alarm test on 12-11-14 at 11:25 am revealed that the audible signal for the fire alarm could not be heard in the Mechanical Room.

During an interview on 12-11-14 at 11:25 am, Maintenance Director confirmed the findings.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice would delay egress during an emergency. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 between 10:25 am and 11:12 am revealed:
1. 18 cardboard boxes, containing medical records stored in the corridor outside of the Medical Records Office.
2. Nine cardboard boxes, containing IT equipment stored in the corridor near Medical Records Office.
3. 2 exam tables, 2 file cabinets, 2 office chairs stored in the exit corridor near Clean Linen.

During an interview on 12-11-14 between 10:25 am and 11:12 am, Maintenance Director confirmed all the findings.

Based on observation and interview, the facility failed to assure that electrical adaptors were not used as permanent wiring. This deficient practice would increase the potential for an electrical fire which would allow fire and smoke to spread. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 12:37 pm revealed, a three way electrical adaptor used as permanent wiring for microwave, refrigerator and two coffee makers in the Maintenance Shop break area.

During an interview on 12-11-14 at 12:37 pm, Maintenance Director confirmed the findings.

Based on observation and interview, the facility failed to maintain the doors protecting corridor openings. 2 of 2 operating room doors failed to latch within door frame. This deficient practice would allow fire and smoke to migrate within the exiting. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 10:38 am, 2 of 2 Operating Room doors equipped with self-closing devices failed to close and latch within the door frame.

During an interview on 12-11-14 at 10:38 am, Maintenance Director confirmed the doors failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain doors in hazardous rooms. This deficient practice would allow fire and smoke to migrate out of the hazard areas. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 12:48 pm revealed, the Trash Room door equipped with a self-closing device failed to close and latch within the door frame.

During an interview on 12-1-14 at 12:48 pm, Maintenance Director confirmed the door failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain magnetically locked doors so that they could release within 15 seconds. This deficient practice would delay egress during an emergency. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 11:10 am and 11:18 am revealed two of two delayed egress doors in the patient area failed to be programed so that the mechanism could be tested.

During an interview on 12-11-14 at 11:10 am and 11:18 am, Maintenance Director confirmed the findings.

Based on observation and interview the facility failed to assure the sound level of the fire alarm system could be heard in all areas of the mechanical room. This deficient practice could potentially delay response to a fire. The facility census was 10 patients.

Findings are:
Observations during a fire alarm test on 12-11-14 at 11:25 am revealed that the audible signal for the fire alarm could not be heard in the Mechanical Room.

During an interview on 12-11-14 at 11:25 am, Maintenance Director confirmed the findings.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice would delay egress during an emergency. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 between 10:25 am and 11:12 am revealed:
1. 18 cardboard boxes, containing medical records stored in the corridor outside of the Medical Records Office.
2. Nine cardboard boxes, containing IT equipment stored in the corridor near Medical Records Office.
3. 2 exam tables, 2 file cabinets, 2 office chairs stored in the exit corridor near Clean Linen.

During an interview on 12-11-14 between 10:25 am and 11:12 am, Maintenance Director confirmed all the findings.

Based on observation and interview, the facility failed to assure that electrical adaptors were not used as permanent wiring. This deficient practice would increase the potential for an electrical fire which would allow fire and smoke to spread. The facility census was 10 patients.

Findings are:
Observations on 12-11-14 at 12:37 pm revealed, a three way electrical adaptor used as permanent wiring for microwave, refrigerator and two coffee makers in the Maintenance Shop break area.

During an interview on 12-11-14 at 12:37 pm, Maintenance Director confirmed the findings.