HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that all doors in a required means of egress were operable. This deficient practice would not allow egress from a required exit and cause confusion and panic during an emergency. The facility had a census of 4 at the time of survey.

Findings are:
Observation and staff interview on 7-13-21 at 11:54 am revealed the panic bar on the right hand door of the south exit by the X-ray department required excessive force to release the door latch.

During an interview on 7-13-21 at 11:54 am, Maintenance Staff A and B confirmed the door failed to open without excessive force.

Based on observation and interview, the facility failed to ensure that the corridor doors held open by a release device would latch within the doorframe when released by the fire alarm. This deficient practice failed to prevent the spread of fire, smoke and gasses within the exit corridor. The facility had a census of 4 on the day of survey.

Findings are:
Observations on 7-13-21 at 11:15 am and 11:20 am revealed:
1. The door to the materials management room failed to latch within the door frame when released.
2. The door to the billing office failed to latch within the doorframe when released.

During interviews on 7-13-21 at 11:15 am and 11:20 am, Maintenance Staff A and B confirmed the doors failed to latch.

Based on observation and staff interview the facility failed to maintain exit signs. This deficient practice would cause confusion during an emergency. The facility had a census of 4 on the day of survey.

Findings are:
Observation on 7-13-21 at 11:43 am revealed only one light bulb was working in the exit sign above the exterior exit door by the physical therapy room.

During an interview on 7-13-21 at 11:43 am, Maintenance Staff A and B confirmed the findings.

Based on observation and interview the facility failed to maintain fire separation between hazardous areas and other spaces. This deficient practice could allow fire and toxic gases to spread to other areas in the facility. The facility had a census of 4 on the day of the survey.

Findings are:
Observations on 7-13-21 between 11:10 am and 12:35 pm revealed the following:
1. A 1 ½ inch hole in the ceiling of the shop.
2. Three missing ceiling tile in the ceiling of the dishwashing room of the kitchen.
3. The door to the laboratory failed to fully close and latch within the door frame.
4. A 1-½ inch hole in the ceiling of the mechanical room

During interviews on 7-13-21 between 11:10 am and 12:35 pm, Maintenance staff A and B confirmed the findings.