HospitalInspections.org

Based on observation and interview, the provider failed to maintain two hazardous areas (biohazardous storage room and old OR {operating room} now used for medical supply storage, both in building 1) as required. Findings include:

1. Observation on 5/31/23 at 11:00 a.m. revealed the biohazardous storage room on the ground level building 1 was greater than 100 square feet and contained combustible items. The corridor door was not equipped with a closer.

2. Observation on 5/31/23 at 2:00 p.m. revealed the old OR, building 1, now being used for medical storage was greater than 100 square feet and contained combustible items. The corridor door was equipped with a closer, but the closer was not functional.

Interview with the maintenance director at the time of each observation confirmed the findings.

The deficiency had the potential to affect 100% of the occupants of that smoke compartment.

Based on observation and interview, the provider failed to maintain conforming exit enclosures (enclosure at exit door 11, building 1). Items were stored in the exit enclosure. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. There shall be no open space within the enclosure used for any purpose that has the potential to interfere with egress. Findings include:

1. Observation on 5/31/23 at 11:30 a.m. revealed two E-cylinders, two garbage containers, and a fan in the exit enclosure discharging at door 11. The enclosure also contained insulation which appeared to be fiberglass being used to cover an out-of-service generator exhaust. If the insulation was fiberglass, the insulation may be fire resistant, however, fiberglass will melt, and may emit toxic fumes. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated he was unaware those items could not be kept in the stair enclosure.

The deficiency affected one of four exit enclosures.

Based on observation and interview, the facility failed to protect medical gas storage as required. Cylinders were found stored in the corridor adjacent to the exit enclosure to door 11, building 1. Findings include:

1. Observation on 5/31/23 at 11:30 a.m. revealed nineteen cylinders were stored in a rack in the corridor. A maximum of twelve cylinders may be stored in a smoke compartment without being placed in a room protected by an enclosure. The maintenance supervisor acknowledged the deficiency and said he was not aware of the requirement.

The deficiency affected one of six smoke compartments.