HospitalInspections.org

Based on observation it was determined the facility failed to maintain the corridor doors.

The findings include:

Observation of the 2nd floor DON 's office in the nursery, the break room, dining room, and the Medical Office Building (MOB) adminstrators's office on 8/23/10 at 8:18 AM, revealed the doors were being held open with pegs. National Fire Protection Association (NFPA). 101, 7.2.1.8.1

These findings were acknowledged by the Administrator and veified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the hazardous areas.

The findings include:

Observation of mechanical room # 3 on 8/23/10 at 9:10 AM, revealed penetrations in the wall. National Fire Protection Association (NFPA). 101, 19.3.2.1

This finding was acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the exits.

The findings include:

Observation of the surgery corridor on 8/23/10 at 9:50 AM, revealed the exit was blocked with equipment. National Fire Protection Association (NFPA). 101, 7.5.1.1

This finding was acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the fire alarm system.

The findings include:

Observation of the corridor by room 270, the office next to room 280, next to mechanical room #9, and in the Medical Office Building (MOB) lobby on 8/23/10 at 8:30 AM, revealed the fire alarm pull stations were blocked with equipment. National Fire Protection Association (NFPA). 72, 2-8.2.1

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on records reveiw it was determined the facility failed to maintain the sprinkler system.

The findings included:

Record review on 8/23/10 at 10:00 AM, revealed no quarterly inspections were conducted of the sprinkler system. National Fire Protection Association (NFPA). 25

This finding was acknowledged by the Administrator and veified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the fire extinguishers.

The findings include:

Observation of the maintenance shop, the x-ray storage room, the Medical Office Building ( MOB) area, and the kitchen area on 8/23/10 at 8:45 AM, revealed the fire extinguishers were blocked with equipment. National Fire Protection Association (NFPA). 10, 1.6.3

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning System (HVAC).

The findings include:

(1) Observation of the 3rd floor area, the 2nd floor nursery bathroom, and the 1st floor Medical Office Building ( MOB) bathroom on 8/23/10 at 8:00 AM, revealed the exhaust fans were not working. National Fire Protection Association (NFPA) 101, 19.5.2.1

(2) Observation of room MA 262 on 8/23/10 at 8:25 AM, revealed the exhaust fan vent cover was hanging down. NFPA 101, 19.5.2.1

These findings were acknowledged by the Administrator and verified by the maintenance straff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the electrical system.

The findings include:

(1) Observation of the Patient Care Unit (PCU) nurses' station, room HK 234, the surgery corridor, and the surgery electrical room on 8/23/10 at 8:10 AM, revealed the electrical panels were blocked with equipment. National Fire Protection Association (NFPA) 70, 110-26(a)

(2) Observation of room MA 261 on 8/23/10 at 8:25 AM, revealed an electrical outlet cover was missing. NFPA 70, 110-12

(3) Observation of the coffee shop and the cath lab located on the 1st floor on 8/23/10 at 9:00 AM, revealed the electrical outlets next to the sinks were not ground fault circuit interrupters (GFCI). 70, 210-8(a)(5)

(4) Observation of room 134 on 8/23/10 at 9:20 AM, revealed an electrical Junction box cover was missing NFPA 70, 373-4

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the corridor doors.

The findings include:

Observation of the 2nd floor DON 's office in the nursery, the break room, dining room, and the Medical Office Building (MOB) adminstrators's office on 8/23/10 at 8:18 AM, revealed the doors were being held open with pegs. National Fire Protection Association (NFPA). 101, 7.2.1.8.1

These findings were acknowledged by the Administrator and veified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the hazardous areas.

The findings include:

Observation of mechanical room # 3 on 8/23/10 at 9:10 AM, revealed penetrations in the wall. National Fire Protection Association (NFPA). 101, 19.3.2.1

This finding was acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the exits.

The findings include:

Observation of the surgery corridor on 8/23/10 at 9:50 AM, revealed the exit was blocked with equipment. National Fire Protection Association (NFPA). 101, 7.5.1.1

This finding was acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the fire alarm system.

The findings include:

Observation of the corridor by room 270, the office next to room 280, next to mechanical room #9, and in the Medical Office Building (MOB) lobby on 8/23/10 at 8:30 AM, revealed the fire alarm pull stations were blocked with equipment. National Fire Protection Association (NFPA). 72, 2-8.2.1

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on records reveiw it was determined the facility failed to maintain the sprinkler system.

The findings included:

Record review on 8/23/10 at 10:00 AM, revealed no quarterly inspections were conducted of the sprinkler system. National Fire Protection Association (NFPA). 25

This finding was acknowledged by the Administrator and veified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the fire extinguishers.

The findings include:

Observation of the maintenance shop, the x-ray storage room, the Medical Office Building ( MOB) area, and the kitchen area on 8/23/10 at 8:45 AM, revealed the fire extinguishers were blocked with equipment. National Fire Protection Association (NFPA). 10, 1.6.3

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning System (HVAC).

The findings include:

(1) Observation of the 3rd floor area, the 2nd floor nursery bathroom, and the 1st floor Medical Office Building ( MOB) bathroom on 8/23/10 at 8:00 AM, revealed the exhaust fans were not working. National Fire Protection Association (NFPA) 101, 19.5.2.1

(2) Observation of room MA 262 on 8/23/10 at 8:25 AM, revealed the exhaust fan vent cover was hanging down. NFPA 101, 19.5.2.1

These findings were acknowledged by the Administrator and verified by the maintenance straff at the exit conference on 8/23/10.

Based on observation it was determined the facility failed to maintain the electrical system.

The findings include:

(1) Observation of the Patient Care Unit (PCU) nurses' station, room HK 234, the surgery corridor, and the surgery electrical room on 8/23/10 at 8:10 AM, revealed the electrical panels were blocked with equipment. National Fire Protection Association (NFPA) 70, 110-26(a)

(2) Observation of room MA 261 on 8/23/10 at 8:25 AM, revealed an electrical outlet cover was missing. NFPA 70, 110-12

(3) Observation of the coffee shop and the cath lab located on the 1st floor on 8/23/10 at 9:00 AM, revealed the electrical outlets next to the sinks were not ground fault circuit interrupters (GFCI). 70, 210-8(a)(5)

(4) Observation of room 134 on 8/23/10 at 9:20 AM, revealed an electrical Junction box cover was missing NFPA 70, 373-4

These findings were acknowledged by the Administrator and verified by the maintenance staff at the exit conference on 8/23/10.