HospitalInspections.org

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition. This deficient practice could affect all patients, staff, and visitors in the event of a fire.

The findings include:

During the comparative survey in the Burton Building on July 10, 2018 with the Director of Facilities Compliance and the Director of Facilities Engineering, it was observed between 9:00 am and 2:40 pm that the compressor for the dry-pipe sprinkler system in the loading dock and environmental services office/storage room was running during the survey - staff reported that it activates 3-4 times per shift - this could indicate an air leak in the piping of the sprinkler system.

This deficiency was confirmed by all participants during the Life Safety Code exit conference.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings provided with a means suitable for keeping the doors closed or in proper operating condition without impediments. This deficient practice could prevent the doors from being quickly and easily closed and latched in the event of an emergency, could allow the passage of smoke, and could affect the patients of these rooms and all patients, visitors, and staff in the identified corridors.

The findings include:

During the comparative survey in the main hospital building on July 9, 2018 with the Director of Facilities Compliance and the Director of Facilities Engineering, it was observed between 9:30 am and 3:00 pm that:

1.) the corridor door to patient room #563 was impeded by a trash can - when the can was removed the door drifted;
2.) all corridor doors to resident rooms on 5th floor Med A unit were impeded by trash cans placed in the doorways on the thresholds;
3.) the corridor door to a janitor's closet (P6 3 25) on the 6th floor surgical unit had a pen wedged into the strike plate opening to prevent latching - this was removed during the survey and housekeeping staff education was implemented.

This deficiency was confirmed by all participants during the LSC exit conference and was corrected while the survey team was on-site.