HospitalInspections.org

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Based on observation and interview the facility failed to ensure a corridor door was properly labeled and functioned appropriately. This failed practice had the potential to expose staff to a smoke and fire environment. Findings:

Observation on 8/17/15 at 1:22 revealed an unlabeled door from the west entrance to the billing department did not close and latch.

Review of the code plan accessed from the building plans on 8/17/15 revealed the unlabeled door should have been of fire rated assembly.

The Director of Maintenance acknowledged the finding at the time of discovery on 8/17/15.
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Based on document review, observation and interview the facility failed to ensure an exit sign were properly displayed in an exit corridor. This deficient practice had the potential to delay egress of patients, staff and visitors during an emergency situation. Findings:

Review of the facility's blueprint A2.1 on 8/17/15 revealed a corridor entitled "Corridor 100 06" contained two double bed inpatient rooms, an exit egress and an exit discharge to public way.

Review of the facility's Evacuation Plan on 8/17/15 revealed corridor 100 06 was identified as a means of egress during an emergency.

Observation on 8/17/15 at 12:26 pm revealed no exit sign displayed at the beginning of the corridor indicating an exit was located behind a set of double doors.

During an interview on 8/17/15 at 12:26 pm the Maintenance Director confirmed the absence of an exit sign.
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Based on observations and interview the facility failed to ensure doors in a smoke barrier were labeled accordingly and/or functioned as designed to prevent the passage of smoke. These deficiencies had the potential to expose patients, staff and visitors to a smoke and fire environment.

Observation on 8/17/15 at 12:25 revealed double doors leading into corridor 100.06 did not contain any identifying information that displayed a fire rating.

Observation on 8/17/15 at 12:35 revealed double doors leading into corridor 100.10 (Emergency Department) did not shut completely preventing the passage of smoke.

Observation on 8/17/15 at 1:00 revealed a smoke/fire door leading from the corridor 100.10 (Emergency Department) to corridor 100.11 (service hallway) did not close due to impediment from a laundry cart stored next to the doorframe.

The Director of Maintenance acknowledged the findings at the time of discovery.
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Based on observation and interview the facility failed to ensure the hazardous areas were properly protected. Specifically, the facility failed to ensure doors protecting the laboratory, receiving storage and oxygen supply room closed and latched in a manner to provide complete protection. These failed practices prevented a complete protection of hazardous areas and had the potential to expose patients, staff, and visitors to a smoke/fire environment and/or loss of services. Findings:

Observation of the laboratory on 8/17/15 at 11:55 am revealed a one hour fire rated door connecting room 151 and room 152 failed to close and latch.

During an interview on 8/17/15 at 11:55 am the Maintenance Director acknowledged the door's inability to properly close and latch.

Observation of the receiving storage room on 8/17/15 at 1:18 pm revealed a one and half hour fire rated door that failed to close and latch. In addition, the door was a direct access from the storage room to an exit corridor.

During an interview on 8/17/15 at 1:18 pm the Maintenance Director acknowledged the door's inability to properly close and latch

Observation of the oxygen storage on 8/17/15 at 1:37 pm revealed a fire door entering the medical gas storage room failed to close and latch.

During an interview on 8/17/15 at 1:37 pm the Maintenance Director acknowledged the door's inability to properly close and latch. In addition, the Maintenance Director stated the door was installed incorrectly.
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Based on observation and interview the facility failed to ensure: 1) patients placed in a seclusion room are able to exit the facility under emergency conditions and 2) failed to ensure the unlocking methods on the seclusion room was easily accessible and staff can readily unlock the door at all times. This deficient practice had the potential to affect the residents of the facility and their visitors. Findings:

Observation during the facility tour on 8/17/15 at 12:52 pm revealed a seclusion room intended for use of psychiatric patients. Additional observation revealed the door had two locking mechanisms. One mechanism was located on the door knob; the other was located on the outside of the door frame. The locking mechanism on the door knob had a key placed into the knob itself that was easily removable.

Emergency Conditions:

During an interview on 8/17/15 at 12:52 pm the Director of Patient Care Services (DPCS) stated the door does not unlock during activation of the fire alarm.

During an interview on 8/17/15 at 12:53 pm the Director of Maintenance stated the door requires staff to manually unlock a patient from the seclusion room during the activation of the fire alarm system.

During an interview on 8/17/15 at 3:28 pm Staff #1 and Staff #2 were asked if the seclusion room door automatically unlocked during the activation of the fire alarm system. Both Staff #1 and #2 stated they were not sure if the door would unlock during a fire alarm system activation.

Accessibility of Keys:

During an interview on 8/17/15 at 3:30 pm Staff #1 and #2 were asked to demonstrate and explain the process of how the room was used. Both staff members stated a set of nursing keys are kept in a drawer at the nurse's station. This set of keys needed to be obtained and taken to the medication room which required a special code only accessible to nurses. Once in the medication room a box was unlocked to access key ring (containing 3 keys) that managed the seclusion room door. The nurse would have to walk down the hall and access the lock outside the door frame. Staff #1 had difficulty figuring out which of the three keys on the ring was the correct key. Next, Staff #1 stated a key would have to placed in the wall mounted lock and use the door knob key to lock and unlock the door. When asked if that was the only key, Staff #1 stated it was the only key he or she was aware of at this time. Staff #2 stated the door knob key stays in the locking mechanism at all times. In addition, Staff #2 stated the room has been used frequently for psychiatric patients.
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Based on observation and interview the facility failed to ensure emergency lighting in the generator room was being appropriately tested and maintenance records were maintained, easily accessable, and readily available. This failed practice potentially prevented the facility from identifying emergency lights that may need repair or battery replacement. An inadequate review and analysis of emergency backup lighting performance had the potential to cause insufficient illumination of the generator set resulting in delay or loss of services to patients, staff and visitors. Findings:

Observation on 8/17/15 at 1:38 pm revealed a battery operated emergency lighting unit located in the generator housing.

During an interview on 8/17/15 at 3:08 pm the Maintenance Director stated the facility has not been conducting monthly or annual testing to the emergency lighting unit located in the generator room.
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Based on observation and interview the facility failed to: 1) appropriately display signage indicating no smoking due to oxygen use; 2) provide an ashtray of noncombustible materials; and 3) provide a self-closing noncombustible container (for the disposal of ashtray contents). This deficiency placed all patients, staff and visitors at risk for injury related to exposure to a smoke and fire environment. Findings:

Random observations on 8/17/15 from 11:00 am to 2:00 pm revealed oxygen being used by a patient in the facility. In addition, no signage was displayed at all major entrances or on the patient's room indicating oxygen was in use and no smoking should be conducted in the facility.

Observation on 8/17/15 at 12:33 pm revealed an area outside of an inpatient corridor that was identified as a smoking area. Additional observation revealed no ashtray or self-closing noncombustible container for disposal of ashtray contents were provided. A white plastic bucket located in the area was observed and contained combustible trash and cigarette butts.

During an interview on 8/17/15 at 12:34 pm, the Maintenance Director confirmed staff brought patients out to the identified area above to smoke. In addition, the Maintenance Director confirmed no smoking - oxygen in use signage was not appropriately displayed on all major entrances or patient's rooms.

During an interview on 8/17/15 at 12:34 pm, Medical Staff #1 confirmed the facility does not place any signage up identifying a patient was actively using oxygen and no smoking should be conducted.
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Based on observation and interview, the facility failed to ensure that appropriate clearances to combustible materials were maintained from heating, ventilation, air conditioning (HVAC) system. This deficiency had the potential to expose patients, staff and visitors to a hazardous environment and/or smoke or fire environment. Findings:

Observations of the room containing the HVAC system on 8/17/15 from 1:10 pm to 1:13 pm revealed multiple cans of paint, chemicals and other potentially hazardous materials located directly under the plenum duct work that supplied air to the HVAC system. Additional observation revealed combustible boxes and drawers stored on top of the plenum.

During an interview on 8/17/15 from 1:10 pm to 1:13 pm the Maintenance Director stated that the cans observed should be sorted through and removed. In addition, the Maintenance Director stated the combustibles items should not be placed on top of the plenum.
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Based on observations and interview the facility failed to ensure privacy curtains used in patient sleeping rooms and common use areas were flame resistant in accordance with NFPA 701. Failure to ensure flame resistance standards had potential to allow curtains to ignite and spread fire more rapidly which could affect all patients, staff, and visitors throughout the facility. Findings:

Random observations during facility tour on 8/17/15 from 11:00 pm to 3:00 pm revealed multiple privacy curtains which hung in patient rooms, treatment rooms, diagnostic rooms and exam rooms had no labels or tags that indicated flame resistance in accordance with NFPA 701.

During interviews on the facility tour on 8/17/15 the Maintenance Director acknowledged the findings and stated some of the curtains are old and some were recently purchased.
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Based on observation and interview the facility failed to maintain the air compressor unit that supplied medical air to the facility. This failed practice had the potential to provide insufficient medical air supply or loss of services to patients requiring the use of medical grade air. Findings:

Observation on 8/17/15 at 1:05 pm revealed an air compressor with a maintenance service sticker that stated last maintenance provided on 10/5/2010, next service due on 10/2011.

During an interview on 8/17/15 at 1:05 pm the Maintenance Director confirmed the air compressor was used for the movement of medical grade air supply to the facility. Additionally, the Maintenance Director confirmed the air compressor has not been serviced since 2010.
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Based on observation and interview the facility failed to ensure a remote manual shut off was located outside the generator room accordance with NFPA 110. Failure to have a remote means to shut down the generator in the event of a fire or emergency potentially placed all residents, staff, and visitors at risk for loss of services. Findings:

Observation on 8/17/15 at 1:38 pm revealed no remote manual shut off for the generator was located outside the generator set housing.

The Maintenance Director confirmed the absence of a remote manual shut off during an interview on 8/17/15 at 1:38 pm.
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Based on observations and interviews the facility failed to ensure: 1) an electrical outlet was protected with ground-fault interrupter (GFI) near a water source; 2) power strips were safely and appropriately used and, 2) electrical wires were free from exposure and properly covered. These deficiencies had the potential to expose occupants to a smoke or fire environment, electrocution, and/or loss of services. Findings:

Observation on 8/17/15 at 12:06 pm revealed an electrical outlet next to the sink in room 120 (supply room) was not GFI protected.

Observation on 8/17/15 at 12:22 pm revealed a refrigerator in room 141 (medication storage room) was plugged directly into a power strip.

Observation on 8/17/15 at 1:16 pm revealed a microwave and small refrigerator in room 173 was plugged directly into a power strip. In addition, the power strip was resting on top of a pitcher filled with water.

Observation on 8/17/15 at 1:38 pm revealed multiple wires protruding out of a hole on the wall of the generator housing.

The above findings were acknowledged at the time by the Maintenance Director.
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Based on observations and interview the facility failed to ensure all alcohol-based hand dispensers were not installed adjacent to an ignition source. This deficient practice had the potential to expose patients, residents, staff and visitors to a possible smoke or fire environment through heightened ignition potential. Findings:

Observations on 8/17/15 at 11:52 am revealed an alcohol-based hand rub dispenser installed adjacent to an electrical ignition source in room 150 (phlebotomy).

Observations on 8/17/15 at 12:42 am revealed an alcohol-based hand rub dispenser installed adjacent to an electrical ignition source in room 133 (inpatient room 1).

During random interviews on 8/17/15 the Maintenance Director acknowledged and confirmed the findings.
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Based on observation and interview the facility failed to ensure a corridor door was properly labeled and functioned appropriately. This failed practice had the potential to expose staff to a smoke and fire environment. Findings:

Observation on 8/17/15 at 1:22 revealed an unlabeled door from the west entrance to the billing department did not close and latch.

Review of the code plan accessed from the building plans on 8/17/15 revealed the unlabeled door should have been of fire rated assembly.

The Director of Maintenance acknowledged the finding at the time of discovery on 8/17/15.
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Based on document review, observation and interview the facility failed to ensure an exit sign were properly displayed in an exit corridor. This deficient practice had the potential to delay egress of patients, staff and visitors during an emergency situation. Findings:

Review of the facility's blueprint A2.1 on 8/17/15 revealed a corridor entitled "Corridor 100 06" contained two double bed inpatient rooms, an exit egress and an exit discharge to public way.

Review of the facility's Evacuation Plan on 8/17/15 revealed corridor 100 06 was identified as a means of egress during an emergency.

Observation on 8/17/15 at 12:26 pm revealed no exit sign displayed at the beginning of the corridor indicating an exit was located behind a set of double doors.

During an interview on 8/17/15 at 12:26 pm the Maintenance Director confirmed the absence of an exit sign.
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Based on observations and interview the facility failed to ensure doors in a smoke barrier were labeled accordingly and/or functioned as designed to prevent the passage of smoke. These deficiencies had the potential to expose patients, staff and visitors to a smoke and fire environment.

Observation on 8/17/15 at 12:25 revealed double doors leading into corridor 100.06 did not contain any identifying information that displayed a fire rating.

Observation on 8/17/15 at 12:35 revealed double doors leading into corridor 100.10 (Emergency Department) did not shut completely preventing the passage of smoke.

Observation on 8/17/15 at 1:00 revealed a smoke/fire door leading from the corridor 100.10 (Emergency Department) to corridor 100.11 (service hallway) did not close due to impediment from a laundry cart stored next to the doorframe.

The Director of Maintenance acknowledged the findings at the time of discovery.
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Based on observation and interview the facility failed to ensure the hazardous areas were properly protected. Specifically, the facility failed to ensure doors protecting the laboratory, receiving storage and oxygen supply room closed and latched in a manner to provide complete protection. These failed practices prevented a complete protection of hazardous areas and had the potential to expose patients, staff, and visitors to a smoke/fire environment and/or loss of services. Findings:

Observation of the laboratory on 8/17/15 at 11:55 am revealed a one hour fire rated door connecting room 151 and room 152 failed to close and latch.

During an interview on 8/17/15 at 11:55 am the Maintenance Director acknowledged the door's inability to properly close and latch.

Observation of the receiving storage room on 8/17/15 at 1:18 pm revealed a one and half hour fire rated door that failed to close and latch. In addition, the door was a direct access from the storage room to an exit corridor.

During an interview on 8/17/15 at 1:18 pm the Maintenance Director acknowledged the door's inability to properly close and latch

Observation of the oxygen storage on 8/17/15 at 1:37 pm revealed a fire door entering the medical gas storage room failed to close and latch.

During an interview on 8/17/15 at 1:37 pm the Maintenance Director acknowledged the door's inability to properly close and latch. In addition, the Maintenance Director stated the door was installed incorrectly.
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Based on observation and interview the facility failed to ensure: 1) patients placed in a seclusion room are able to exit the facility under emergency conditions and 2) failed to ensure the unlocking methods on the seclusion room was easily accessible and staff can readily unlock the door at all times. This deficient practice had the potential to affect the residents of the facility and their visitors. Findings:

Observation during the facility tour on 8/17/15 at 12:52 pm revealed a seclusion room intended for use of psychiatric patients. Additional observation revealed the door had two locking mechanisms. One mechanism was located on the door knob; the other was located on the outside of the door frame. The locking mechanism on the door knob had a key placed into the knob itself that was easily removable.

Emergency Conditions:

During an interview on 8/17/15 at 12:52 pm the Director of Patient Care Services (DPCS) stated the door does not unlock during activation of the fire alarm.

During an interview on 8/17/15 at 12:53 pm the Director of Maintenance stated the door requires staff to manually unlock a patient from the seclusion room during the activation of the fire alarm system.

During an interview on 8/17/15 at 3:28 pm Staff #1 and Staff #2 were asked if the seclusion room door automatically unlocked during the activation of the fire alarm system. Both Staff #1 and #2 stated they were not sure if the door would unlock during a fire alarm system activation.

Accessibility of Keys:

During an interview on 8/17/15 at 3:30 pm Staff #1 and #2 were asked to demonstrate and explain the process of how the room was used. Both staff members stated a set of nursing keys are kept in a drawer at the nurse's station. This set of keys needed to be obtained and taken to the medication room which required a special code only accessible to nurses. Once in the medication room a box was unlocked to access key ring (containing 3 keys) that managed the seclusion room door. The nurse would have to walk down the hall and access the lock outside the door frame. Staff #1 had difficulty figuring out which of the three keys on the ring was the correct key. Next, Staff #1 stated a key would have to placed in the wall mounted lock and use the door knob key to lock and unlock the door. When asked if that was the only key, Staff #1 stated it was the only key he or she was aware of at this time. Staff #2 stated the door knob key stays in the locking mechanism at all times. In addition, Staff #2 stated the room has been used frequently for psychiatric patients.
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Based on observation and interview the facility failed to ensure emergency lighting in the generator room was being appropriately tested and maintenance records were maintained, easily accessable, and readily available. This failed practice potentially prevented the facility from identifying emergency lights that may need repair or battery replacement. An inadequate review and analysis of emergency backup lighting performance had the potential to cause insufficient illumination of the generator set resulting in delay or loss of services to patients, staff and visitors. Findings:

Observation on 8/17/15 at 1:38 pm revealed a battery operated emergency lighting unit located in the generator housing.

During an interview on 8/17/15 at 3:08 pm the Maintenance Director stated the facility has not been conducting monthly or annual testing to the emergency lighting unit located in the generator room.
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Based on observation and interview the facility failed to: 1) appropriately display signage indicating no smoking due to oxygen use; 2) provide an ashtray of noncombustible materials; and 3) provide a self-closing noncombustible container (for the disposal of ashtray contents). This deficiency placed all patients, staff and visitors at risk for injury related to exposure to a smoke and fire environment. Findings:

Random observations on 8/17/15 from 11:00 am to 2:00 pm revealed oxygen being used by a patient in the facility. In addition, no signage was displayed at all major entrances or on the patient's room indicating oxygen was in use and no smoking should be conducted in the facility.

Observation on 8/17/15 at 12:33 pm revealed an area outside of an inpatient corridor that was identified as a smoking area. Additional observation revealed no ashtray or self-closing noncombustible container for disposal of ashtray contents were provided. A white plastic bucket located in the area was observed and contained combustible trash and cigarette butts.

During an interview on 8/17/15 at 12:34 pm, the Maintenance Director confirmed staff brought patients out to the identified area above to smoke. In addition, the Maintenance Director confirmed no smoking - oxygen in use signage was not appropriately displayed on all major entrances or patient's rooms.

During an interview on 8/17/15 at 12:34 pm, Medical Staff #1 confirmed the facility does not place any signage up identifying a patient was actively using oxygen and no smoking should be conducted.
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Based on observation and interview, the facility failed to ensure that appropriate clearances to combustible materials were maintained from heating, ventilation, air conditioning (HVAC) system. This deficiency had the potential to expose patients, staff and visitors to a hazardous environment and/or smoke or fire environment. Findings:

Observations of the room containing the HVAC system on 8/17/15 from 1:10 pm to 1:13 pm revealed multiple cans of paint, chemicals and other potentially hazardous materials located directly under the plenum duct work that supplied air to the HVAC system. Additional observation revealed combustible boxes and drawers stored on top of the plenum.

During an interview on 8/17/15 from 1:10 pm to 1:13 pm the Maintenance Director stated that the cans observed should be sorted through and removed. In addition, the Maintenance Director stated the combustibles items should not be placed on top of the plenum.
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Based on observations and interview the facility failed to ensure privacy curtains used in patient sleeping rooms and common use areas were flame resistant in accordance with NFPA 701. Failure to ensure flame resistance standards had potential to allow curtains to ignite and spread fire more rapidly which could affect all patients, staff, and visitors throughout the facility. Findings:

Random observations during facility tour on 8/17/15 from 11:00 pm to 3:00 pm revealed multiple privacy curtains which hung in patient rooms, treatment rooms, diagnostic rooms and exam rooms had no labels or tags that indicated flame resistance in accordance with NFPA 701.

During interviews on the facility tour on 8/17/15 the Maintenance Director acknowledged the findings and stated some of the curtains are old and some were recently purchased.
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Based on observation and interview the facility failed to maintain the air compressor unit that supplied medical air to the facility. This failed practice had the potential to provide insufficient medical air supply or loss of services to patients requiring the use of medical grade air. Findings:

Observation on 8/17/15 at 1:05 pm revealed an air compressor with a maintenance service sticker that stated last maintenance provided on 10/5/2010, next service due on 10/2011.

During an interview on 8/17/15 at 1:05 pm the Maintenance Director confirmed the air compressor was used for the movement of medical grade air supply to the facility. Additionally, the Maintenance Director confirmed the air compressor has not been serviced since 2010.
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Based on observation and interview the facility failed to ensure a remote manual shut off was located outside the generator room accordance with NFPA 110. Failure to have a remote means to shut down the generator in the event of a fire or emergency potentially placed all residents, staff, and visitors at risk for loss of services. Findings:

Observation on 8/17/15 at 1:38 pm revealed no remote manual shut off for the generator was located outside the generator set housing.

The Maintenance Director confirmed the absence of a remote manual shut off during an interview on 8/17/15 at 1:38 pm.
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Based on observations and interviews the facility failed to ensure: 1) an electrical outlet was protected with ground-fault interrupter (GFI) near a water source; 2) power strips were safely and appropriately used and, 2) electrical wires were free from exposure and properly covered. These deficiencies had the potential to expose occupants to a smoke or fire environment, electrocution, and/or loss of services. Findings:

Observation on 8/17/15 at 12:06 pm revealed an electrical outlet next to the sink in room 120 (supply room) was not GFI protected.

Observation on 8/17/15 at 12:22 pm revealed a refrigerator in room 141 (medication storage room) was plugged directly into a power strip.

Observation on 8/17/15 at 1:16 pm revealed a microwave and small refrigerator in room 173 was plugged directly into a power strip. In addition, the power strip was resting on top of a pitcher filled with water.

Observation on 8/17/15 at 1:38 pm revealed multiple wires protruding out of a hole on the wall of the generator housing.

The above findings were acknowledged at the time by the Maintenance Director.
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