HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the means of egress corridor free of obstructions or impediments for full instant use in the case of fire or other emergencies per requirements of:

2012 NFPA 101, 19.2.1, 7.1.10.1, and 7.1.10.2.1

This deficiency could affect 8 residents.

Findings include:

On 02/13/2019, during a tour of the facility from 8:00 am to 11:45 am, the surveyor observed a professional business copier permanently stationed in the Clinic's means of egress corridor. The copier was removed from the means of egress corridor after the surveyor brought this to the facility's attention.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the smoke barrier doors per the requirements of:

2012 NFPA 101, 19.3.7.8, and 8.5.4.1

This deficiency could affect 4 of 16 smoke compartments.

Findings include:

On 02/13/2019, during a tour of the facility from 8:00 am to 11:45 am, the surveyor observed the following smoke barrier doors failed to fully close during activation of the fire alarm system:

1. Between the Outpatient Laboratory and Admissions there was an approximately 8 inch opening between the two doors
2. At the Kitchen there was an approximately 1/2 inch opening between the two doors

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the receptacles at patient bed locations and where deep sedation or general anesthesia is administered per the requirements of:

2012 NFPA 99, 6.3.4.1.1, and 6.3.4.1.3

This deficiency could affect all residents.

Findings include:

On 02/13/2019, during a tour of the facility from 8:00 am to 11:45 am, the facility failed to provide documentation for testing the following receptacles:

1. Hospital-grade at patient bed locations and where deep sedation or general anesthesia is administered - after initial installation, replacement or servicing (from this date forward)
2. Those not listed as hospital-grade at the patient bed locations within the past 12 months

A member of maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency could affect 4 residents.

Findings include:

On 02/13/2019, during a tour of the facility from 8:00 am to 11:45 am, the surveyor observed two unsecured oxygen cylinders on the floor in the Exam Treatment Room in the Geriatric Psychiatric Unit. The oxygen cylinders were removed and secured after surveyor brought them to the facility's attention.

A member of the maintenance staff was present when this deficiency was identified.