HospitalInspections.org

Based on observation and interview the facility failed to ensure that the facility maintained all exits in a usable manner for the Jefferson Campus.
Findings included:
Observation on 6/13/12 at approximately 10:45 AM revealed that the stairwell labeled as "Stair 11" and between the first and ground floor had a trash can, two signs and a garden hose which ran from the first floor down the stairs to the ground floor and held open both the doors to the exterior of the building. There was debris from the crumbling wall and ceiling finishes on the stairs and throughout the area between the exit doors making it difficult to walk through the area.
During an interview on 6/13/12 at approximately 10:45 AM Staff PP stated that the equipment was from a previous water leak in the area and that it was currently no longer receiving any repair at the current time.
It was noted that the area was dry at time of observation with no active water leak in the area.

Based on observation the facility failed to ensure that all areas requiring sprinkler protection had this protection provided by necessary sprinkler heads. This affects the geriatric psychiatric unit in the Storage area at the Broadway campus. This had the potential to affect all patients admitted to this unit. The facility census was 124.

Findings included:
Observation on 06/12/12 at approximately 10:30 AM showed the geriatric psychiatric unit had a room labeled " pantry " used for storage of clothing and nine by five foot in size. The room had no sprinkler in the room but did have sprinkler protection in an adjoining room separated by a door.
The entire area except for this one room was protected by sprinklers.

According to NFPA 13 (1996 edition Published by the National Fire Protection Association) chapter 4-6.3.1 the maximum distance permitted between sprinklers shall comply with table 4-6.2. Table 4-6.2 showed that the maximum spacing for noncombustible construction is fifteen feet.

Based on record review and interview the facility failed to ensure that the generator was exercised weekly and run under a load (supplies power to facility) monthly for the campus at the Jefferson building.
Findings included:
Record review on 6/13/12 of showed an outside contractor performed a service inspection and load test to one of the generators on the Jefferson campus on 02/28/12.
During an interview on 6/13/12 at 12:55 PM Staff PP stated that the Jefferson campus building has two generators. There are no inspection forms that could be found for the smaller of the two generators on the campus and the inspection form from 02/28/12 was only for the larger of the two generators.
There were no other forms nor was there any testing of either of the generators weekly or a load test done monthly on the generators that he was aware of since February of 2012.

Based on observation and interview the facility failed to ensure that the facility maintained all exits in a usable manner for the Jefferson Campus.
Findings included:
Observation on 6/13/12 at approximately 10:45 AM revealed that the stairwell labeled as "Stair 11" and between the first and ground floor had a trash can, two signs and a garden hose which ran from the first floor down the stairs to the ground floor and held open both the doors to the exterior of the building. There was debris from the crumbling wall and ceiling finishes on the stairs and throughout the area between the exit doors making it difficult to walk through the area.
During an interview on 6/13/12 at approximately 10:45 AM Staff PP stated that the equipment was from a previous water leak in the area and that it was currently no longer receiving any repair at the current time.
It was noted that the area was dry at time of observation with no active water leak in the area.

Based on observation the facility failed to ensure that all areas requiring sprinkler protection had this protection provided by necessary sprinkler heads. This affects the geriatric psychiatric unit in the Storage area at the Broadway campus. This had the potential to affect all patients admitted to this unit. The facility census was 124.

Findings included:
Observation on 06/12/12 at approximately 10:30 AM showed the geriatric psychiatric unit had a room labeled " pantry " used for storage of clothing and nine by five foot in size. The room had no sprinkler in the room but did have sprinkler protection in an adjoining room separated by a door.
The entire area except for this one room was protected by sprinklers.

According to NFPA 13 (1996 edition Published by the National Fire Protection Association) chapter 4-6.3.1 the maximum distance permitted between sprinklers shall comply with table 4-6.2. Table 4-6.2 showed that the maximum spacing for noncombustible construction is fifteen feet.

Based on record review and interview the facility failed to ensure that the generator was exercised weekly and run under a load (supplies power to facility) monthly for the campus at the Jefferson building.
Findings included:
Record review on 6/13/12 of showed an outside contractor performed a service inspection and load test to one of the generators on the Jefferson campus on 02/28/12.
During an interview on 6/13/12 at 12:55 PM Staff PP stated that the Jefferson campus building has two generators. There are no inspection forms that could be found for the smaller of the two generators on the campus and the inspection form from 02/28/12 was only for the larger of the two generators.
There were no other forms nor was there any testing of either of the generators weekly or a load test done monthly on the generators that he was aware of since February of 2012.