HospitalInspections.org

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls on one of three floors.

Findings include:

Observation on August 13, 2013, at 10:15 am revealed the second floor smoke barrier had an unsealed penetration above the door by patient room 205.

Interview with Maintenance Specialist (MS) on August 13, 2013, at 10:15 am confirmed the unsealed penetration in the smoke barrier.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on two of three floors.

Findings include:

Observation on August 13, 2013, between 9:10 am and 10:45 am revealed smoke barrier doors lacked positive latching with latching hardware at the following locations:
1. Third floor smoke barrier door by patient room 324.
2. First floor smoke barrier door by Restrooms.

Interview with MS on August 13, 2013, at 10:45 am confirmed the above listed smoke barrier doors lacked positive latching.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of three floors.

Findings include:

1. Observation on August 13, 2013, between 9:15 am and 1:00 pm revealed Soiled Utility doors at the following locations lacked positive latching:
A. Third floor Soiled Utility room across from patient room 326.
B. First floor Ambulatory Surgery Soiled Utility room across from Outpatient Treatment.

Interview with MS on August 13, 2013, at 1:00 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #B during the time of the survey.

2. Observation on August 13, 2013, at 10:35 am revealed the Kitchen Dry Storage room door lacked positive latching with the closure.

Interview with MS on August 13, 2013, at 10:35 am confirmed the Kitchen Dry Storage room door lacked positive latching.

3. Observation on August 13, 2013, at 11:00 am revealed the two doors to the Dialysis Supply room lacked positive latching. One door from the Treatment Area and one door from the Office Area.

Interview with MS on August 13, 2013, at 11:00 am confirmed the Supply room doors lacked positive latching.

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations on one of two floors.

Findings include:

1. Observation on August 13, 2013, at 10:37 am revealed the Kitchen Hood Suppression pull station was blocked from access by a juice machine.

Interview with MS on August 13, 2013, at 10:37 am confirmed the pull station was blocked by a juice machine.

2. Observation on August 13, 2013, at 10:39 am revealed Kitchen staff did not know where the emergency hood suppression system pull station was located.

Interview with MS on August 13, 2013, at 10:39 am confirmed the staff did not know where the pull station was located.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of three floors.

Findings include:

1. Observation on August 13, 2013, at 12:40 pm revealed the first floor Cardiac Rehab office had a portable space heater plugged into a surge protector.

Interview with MS on August 13, 2013, at 12:40 pm confirmed the portable space heater was plugged into a surge protector and the subsequent correction during the time of the survey.

2. Observation on August 13, 2013, at 12:45 pm revealed the first floor ER break room had a microwave oven plugged into an extension cord.

Interview with MS on August 13, 2013, at 12:45 pm confirmed the microwave oven was plugged into an extension cord.

Based upon observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls on one of three floors.

Findings include:

Observation on August 13, 2013, at 10:15 am revealed the second floor smoke barrier had an unsealed penetration above the door by patient room 205.

Interview with Maintenance Specialist (MS) on August 13, 2013, at 10:15 am confirmed the unsealed penetration in the smoke barrier.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on two of three floors.

Findings include:

Observation on August 13, 2013, between 9:10 am and 10:45 am revealed smoke barrier doors lacked positive latching with latching hardware at the following locations:
1. Third floor smoke barrier door by patient room 324.
2. First floor smoke barrier door by Restrooms.

Interview with MS on August 13, 2013, at 10:45 am confirmed the above listed smoke barrier doors lacked positive latching.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of three floors.

Findings include:

1. Observation on August 13, 2013, between 9:15 am and 1:00 pm revealed Soiled Utility doors at the following locations lacked positive latching:
A. Third floor Soiled Utility room across from patient room 326.
B. First floor Ambulatory Surgery Soiled Utility room across from Outpatient Treatment.

Interview with MS on August 13, 2013, at 1:00 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #B during the time of the survey.

2. Observation on August 13, 2013, at 10:35 am revealed the Kitchen Dry Storage room door lacked positive latching with the closure.

Interview with MS on August 13, 2013, at 10:35 am confirmed the Kitchen Dry Storage room door lacked positive latching.

3. Observation on August 13, 2013, at 11:00 am revealed the two doors to the Dialysis Supply room lacked positive latching. One door from the Treatment Area and one door from the Office Area.

Interview with MS on August 13, 2013, at 11:00 am confirmed the Supply room doors lacked positive latching.

Based on observation and interview, it was determined the cooking equipment/facilities do not comply with regulations on one of two floors.

Findings include:

1. Observation on August 13, 2013, at 10:37 am revealed the Kitchen Hood Suppression pull station was blocked from access by a juice machine.

Interview with MS on August 13, 2013, at 10:37 am confirmed the pull station was blocked by a juice machine.

2. Observation on August 13, 2013, at 10:39 am revealed Kitchen staff did not know where the emergency hood suppression system pull station was located.

Interview with MS on August 13, 2013, at 10:39 am confirmed the staff did not know where the pull station was located.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of three floors.

Findings include:

1. Observation on August 13, 2013, at 12:40 pm revealed the first floor Cardiac Rehab office had a portable space heater plugged into a surge protector.

Interview with MS on August 13, 2013, at 12:40 pm confirmed the portable space heater was plugged into a surge protector and the subsequent correction during the time of the survey.

2. Observation on August 13, 2013, at 12:45 pm revealed the first floor ER break room had a microwave oven plugged into an extension cord.

Interview with MS on August 13, 2013, at 12:45 pm confirmed the microwave oven was plugged into an extension cord.