HospitalInspections.org

Based on observation and interview, the facility failed to maintain the rating of the barriers surrounding hazardous areas. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/02/16 at 9:00 AM a tour was conducted of the facility ' s emergency department with Staff Q and M. On 02/01/16 at 9:30 AM observation above the drop down ceiling of the north/south one hour barrier between the clean utility room and soiled utility room revealed an open three inch conduit right next to two others that were sealed.

On 02/01/16 at 9:30 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure all means of egress was in compliance with chapter seven of National Fire Protection Association 101, specifically, 7.1.10.2.1 that no furnishings or other objects will obstruct exits. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/02/16 at 10:15 AM a tour was taken of the building with Staff Q and M. On 02/01/16 at 10:34 AM the path of egress in suite 104 as described on its evacuation was observed to travel down the hall, turns right, goes through an exam room and out an exit discharge door in the exam room. Tracing the path of egress revealed upon entering the exam room the lights were off and the room was pitch dark without windows/ Upon turning on the lights, an unlit exit sign was observed above the exit discharge door within, and two chairs were observed in front of the door.

On 02/01/16 at 10:34 AM in an interview, Staff Q and M confirmed the chairs were in place in front of the exit discharge door

Based on observation and interview, the facility failed to ensure each path of egress within the medical building was marked with signs with continuous illumination. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/02/16 at 10:15 AM a tour was taken of the building with Staff Q and M. On 02/01/16 at 10:34 AM the path of egress in suite 104 as described on its evacuation was observed to travel down the hall, turns right, goes through an exam room and out an exit discharge door in the exam room. Tracing the path of egress revealed upon entering the exam room the lights were off, the room was pitch dark, and an exit sign could not be seen. Upon turning on the lights, an unlit exit sign was observed above the exit discharge door and two chairs were observed in front it.

On 02/01/16 at 10:34 AM in an interview, Staff Q and M confirmed the chairs were in place in front of the exit discharge door and that the sign for it could not be seen in the dark.

Based on observation and interview, the facility failed to have installed a supervisory attachment installed to each of the control valves, specifically the outside screw and yoke at the sprinkler riser, of its sprinkler system. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/01/16 at 1:01 PM a tour was conducted of the facility with Staff Q and M.

On 02/01/16 at 1:20 PM observation of the outside screw and yoke at the sprinkler system ' s riser revealed it to be open with a loop of link chain hanging off the screw. Staff Q then proceeded to wrap the chain through the yoke and stem and lock it with a u-bolt lock.

On 02/01/16 at 1:20 PM he/she said he was told it was okay to use a chain to keep the valve open, and that the valve had to have been left unsecured since Friday, 01/29/16.

Based on observation and interview, the facility failed to maintain its sprinkler system in a reliable operating condition per National Fire Protection Association 25, 1998 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/02/16 at 9:00 AM a tour was conducted of the facility ' s emergency department with Staff Q and M. During the tour, the sprinkler heads observed in patient rooms five, six, 11, and 12 were observed to be covered in enough dust so that the fluid in bulb was difficult to discern.

On 02/01/16 at 9:50 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure all means of egress was in compliance with chapter seven of National Fire Protection Association 101, specifically, 7.1.10.2.1 that no furnishings or other objects will obstruct exits. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/02/16 at 10:15 AM a tour was taken of the building with Staff Q and M. On 02/01/16 at 10:34 AM the path of egress in suite 104 as described on its evacuation was observed to travel down the hall, turns right, goes through an exam room and out an exit discharge door in the exam room. Tracing the path of egress revealed upon entering the exam room the lights were off and the room was pitch dark without windows/ Upon turning on the lights, an unlit exit sign was observed above the exit discharge door within, and two chairs were observed in front of the door.

On 02/01/16 at 10:34 AM in an interview, Staff Q and M confirmed the chairs were in place in front of the exit discharge door

Based on observation and interview, the facility failed to have installed a supervisory attachment installed to each of the control valves, specifically the outside screw and yoke at the sprinkler riser, of its sprinkler system. This has the potential to affect all patients receiving services at the facility. The facility had a census of five patients at the time of survey.

Findings include:

On 02/01/16 at 1:01 PM a tour was conducted of the facility with Staff Q and M.

On 02/01/16 at 1:20 PM observation of the outside screw and yoke at the sprinkler system ' s riser revealed it to be open with a loop of link chain hanging off the screw. Staff Q then proceeded to wrap the chain through the yoke and stem and lock it with a u-bolt lock.

On 02/01/16 at 1:20 PM he/she said he was told it was okay to use a chain to keep the valve open, and that the valve had to have been left unsecured since Friday, 01/29/16.