HospitalInspections.org

Based on observations and interview on 9-25-14 at 3:30PM, the facility failed to keep adequate separation from hazardous areas for 1) The wall between maintenance and laboratory and 2) The janitor's closet near E.R. Not separating hazardous areas from other areas can help the spread of fire or smoke. This practice affected all patients of the E.R. Facility census was 8 patients on 9-25-14.

Findings are:

Observations on 9-25-14 at 3:30PM revealed:

1) The fire rated wall between the maintenance shop and laboratory had holes around pipes, conduits and wires above the ceiling.

2) The janitor's closet near E.R. did not have a self-closing device despite being a fire rated door separating a sprinklered area from a non-sprinklered area.

During an interview on 9-25-14 at 3:30PM, Maintenance A confirmed the findings.

Based on record review and interview on 9-25-14 at 4:00PM, the facility failed to have the fire alarm tested and inspected every 6 months as per NFPA 72, National Fire Alarm Code. Failing to test the fire alarm within this time frame may allow problems with the fire alarm system to go undetected. This practice affected all patients of the hospital.

Findings are:

Record Review on 9-25-14 at 4:00PM revealed the fire alarm was last inspected and tested by a licensed company on 2-5-2014.

During an interview on 9-25-14 at 4:00PM, Maintenance A confirmed the finding.

Based on observation and interview on 9-25-14 at 3:15PM, the facility failed to maintain a 36 inch clearance between electrical breaker boxes and combustible materials in the surgery clean-up room. Combustibles too close to electric panels are a hazard during a potential power surge. This practice had the potential to affect all surgery patients. Facility census was 8 patients on 9-25-14.

Findings are:

Observations on 9-25-14 at 3:15PM revealed housekeeping items as well as a compressed nitrogen cylinder were up against an electrical breaker box in the surgery clean-up room.

During an interview on on 9-25-14 at 3:15PM, Maintenance A confirmed the findings.

Based on observations and interview on 9-25-14 at 3:30PM, the facility failed to keep adequate separation from hazardous areas for 1) The wall between maintenance and laboratory and 2) The janitor's closet near E.R. Not separating hazardous areas from other areas can help the spread of fire or smoke. This practice affected all patients of the E.R. Facility census was 8 patients on 9-25-14.

Findings are:

Observations on 9-25-14 at 3:30PM revealed:

1) The fire rated wall between the maintenance shop and laboratory had holes around pipes, conduits and wires above the ceiling.

2) The janitor's closet near E.R. did not have a self-closing device despite being a fire rated door separating a sprinklered area from a non-sprinklered area.

During an interview on 9-25-14 at 3:30PM, Maintenance A confirmed the findings.

Based on record review and interview on 9-25-14 at 4:00PM, the facility failed to have the fire alarm tested and inspected every 6 months as per NFPA 72, National Fire Alarm Code. Failing to test the fire alarm within this time frame may allow problems with the fire alarm system to go undetected. This practice affected all patients of the hospital.

Findings are:

Record Review on 9-25-14 at 4:00PM revealed the fire alarm was last inspected and tested by a licensed company on 2-5-2014.

During an interview on 9-25-14 at 4:00PM, Maintenance A confirmed the finding.

Based on observation and interview on 9-25-14 at 3:15PM, the facility failed to maintain a 36 inch clearance between electrical breaker boxes and combustible materials in the surgery clean-up room. Combustibles too close to electric panels are a hazard during a potential power surge. This practice had the potential to affect all surgery patients. Facility census was 8 patients on 9-25-14.

Findings are:

Observations on 9-25-14 at 3:15PM revealed housekeeping items as well as a compressed nitrogen cylinder were up against an electrical breaker box in the surgery clean-up room.

During an interview on on 9-25-14 at 3:15PM, Maintenance A confirmed the findings.