HospitalInspections.org

Based on observation and interview, the facility failed to provide a self-closing device on a hazardous area room door and failed to provide a smoke resistant enclosure for hazardous areas. The deficient practices would allow fire and smoke to travel beyond the hazardous area into the main level corridor. Facility census was 4.
Findings are:

1. Observation on 10-03-17 at 10:00 AM revealed unsealed openings in the ceilings of Storage Rooms 246 and 233.
2. Observation on 10-03-17 at 10:00 AM revealed a transfer grill had been installed in the door to Storage Room 246.
3. Observation on 10-03-17 at 10:50 AM. revealed the door to Storage Room 243 was not equipped with a self-closing device.

The findings were verified during the exit interview on 10-03-17 at 2:00 pm with Maintenance Personnel 1.

Based on interview, and record review the facility failed to provide automatic power disconnect to all cooking appliances located under the kitchen exhaust hood and failed to provide continuous exhaust fan operation in the event the hood extinguishing system activated. The deficient practices would allow the fryer and convection oven to continue to operate after the fire extinguishing system had been activated which could contribute to the spread of the fire, and would not exhaust the smoke and combustion products from the kitchen smoke compartment. Facility census was 4.

Findings are:
1. Review of the hood inspection records on 10-03-17 at 11:30 AM. revealed that the small electrical fryer, and the electrical convection oven were not interconnected to the hood fire extinguishing system, and would automatically shut off upon activation of the heed extinguishing system.
2. Review of the hood inspection records on 10-03-17 revealed the exhaust fan for the kitchen hood failed to keeping operating upon activation of the hood extinguishing system.


During the exit interview with Maintenance Personnel 1 at 2:00 PM the findings were verified.

Based on observation and interview the facility failed to provide smoke detection in areas open to the corridors. The deficient practice would delay detection and occupant notification of a fire in these areas which could result in delayed evacuation of occupants. Facilty census was 4.

Findings are:
1. Observation on 10-03-17 at 9:50 AM revealed the main Entrance Lobby, which was open to the corridor was not provided with smoke detection connected to the building fire alarm system.
2. Observation on 10-03-17 at 11:00 AM. revealed the Basement Classroom adjacent to the Finance Office and Laundry Room, which was open to the corridor, was not provided with smoke detection connected to the building fire alarm system.


During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on record review and interview, the facility failed to conduct required inspection and testing of the sprinkler system. The deficient practice did not ensure the sprinkler system would operate as designed in the event of a fire due to potential obstructions in the sprinkler piping caused by rust and other debris. Facility census was 4.

Findings are:

Record review of the facility sprinkler inspection records on 10-03-17 at 1:30 PM revealed the last five year full flow test was conducted in 2011.

During the exit interview with Maintenance Peronnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on observation and interview the facility failed to provide smoke detection in areas open to the corridors. The deficient practice would delay detection and occupant notification of a fire in these areas which could result in delayed evacuation of occupants. Facilty census was 4.

Findings are:
1. Observation on 10-03-17 at 9:50 AM revealed the main Entrance Lobby, which was open to the corridor was not provided with smoke detection connected to the building fire alarm system.
2. Observation on 10-03-17 at 11:00 AM. revealed the Basement Classroom adjacent to the Finance Office and Laundry Room, which was open to the corridor, was not provided with smoke detection connected to the building fire alarm system.


During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on observation and interview the facility allowed a corridor door to be held open with an unapproved hold-open device (a kick down door stop). The deficient practice wold delay closing the door in am emergency and would allow smoke to either enter the room from the corridor or enter the corridor from the room. Facility census was 4.


Findings are:
Observation on 10-03-17 at 10:10 AM revealed a kick down door stop was installed at the bottom of the door to Patient Room 261.

During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on observation and interview the facility to ensure fire separation doors would close and latch within the door frames. The deficient practice would allow smoke and fire to extend beyond the fire barrier into an adjacent compartment. Facility census was 4.

Findings are:

1. Observation on 10-03-17 at 11:45 AM. revealed the fire doors adjacent to Central Storage failed to close and latch within the door frame when tested.
2. Observation on 10-03-17 at 12:00 PM revealed one of the fire doors leading to the 2002 Addition was equipped with a kick down hold open device located at the bottom of the door.
During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on observation and interview the facility failed to use electrical equipment in a manner that would prevent damage to the equipment. The deficient pactice could result in an electrical fire due to damaged equipment. Facilty census was 4.

Findings are:
Observation on 10-03-17 at 10:30 AM. revealed a power strip located on the floor of the X-ray Break Area. The power strip was not secured or protected from damage. .

During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 PM the findings were verified.

Based on record review and interview the facility failed to establish procedures for a fire emergency occurring in the operating room. The deficient practice did not provide training to Operating Room (OR) staff in operating room fire prevention and emergency procedures in the event of a fire. Facility census was 4.

Findings are:
Record review on 10-03-17 at 1:45 PM revealed the facility did not have procedures developed to address a fire occurring in the operating room. No documentation could be provided concerning alarm activation, evacuation, equipement shutdown, and control operations. No documentation could be provided that an evaluation had been conducted of hazards that could be encountered in the operating room when using flammabel germicides, electrosurgery, cautery or lasers. No documentation could be provide that OR staff had been trained in emegency procedures with respect to chemical spills and extinguishment of drapery, clothing and equipment fires.

During the exit interview with Maintenance Personnel 1 on 10-03-17 at 2:00 M the findings were verified