HospitalInspections.org

Based on observations and interview the facility failed to ensure that 4 patient room doors could resist the passage of smoke.

Findings include:

Observations during tour on 06/10/16 between 10:00 a.m. and 11:30 a.m. with Staff A (Director of Facility Services) revealed the following 4 doors that access egress corridors, have a gap between the door slab and the door frame that exceeds the maximum allowable gap of 1/2" to resist the passage of smoke.
These doors are as follows:
1. Patient room door MS # 20 has a gap of 5/8".
2. Patient room door MS # 10 has a gap of 5/8".
3. Patient room door MS # 8 has a gap of 5/8" and fails to latch in a closed position.
4. The "Sleep Lab" door has a gap of 7/8" and fails to latch in a closed position.

Interview with Staff A at the time of the observations confirmed the findings and the locations.

Based on observations and interview the facility failed to ensure that 1 storage room (combustible storage) has an automatic door closing device installed.

Findings include:

Observations during tour on 06/09/16 between 3:00 p.m. and 4:00 p.m. with Staff A (Director of Facility Services) revealed that the "Bio-Hazard" storage room, located next to the loading docks on the lower level, exceeds 50 sq.ft. and the door fails to be equipped with an automatic door closing device.

Interview with Staff A at the time of observation confirmed the finding and location.

Based on interview during record review the facility failed to ensure that "Fire Drills" are held at unexpected times for all shifts.

Findings include:

Record review during tour on 06/08/16 between 1:00 p.m. and 2:00 p.m. with Staff A (Director of Facility Services) revealed that the 1st shift, 2nd shift, and 3rd shift fire drills did not vary in the times they were conducted.
The Fire Drills were held as follows:
1st shift (7:00 a.m. - 3:00 p.m.)
04/28/16 10:26 a.m.
01/27/16 10:42 a.m.
10/21/15 10:21 a.m.
07/20/15 10:41 a.m.
04/29/15 09:44 a.m.

2nd shift (3:00 p.m. - 11:00 p.m.)
05/24/16 04:10 p.m.
03/25/16 03:00 p.m.
02/29/16 04:08 p.m.
12/09/15 03:06 p.m.
09/02/15 03:39 p.m.
05/21/15 03:11 p.m.
03/05/15 03:55 p.m.

3rd shift (11:00p.m.- 07:00 a.m.)
03/14/16 11:30 p.m.
12/22/15 11:20 p.m.
09/24/15 12:00 a.m.
06/25/15 11:10 p.m.
03/27/15 05:28 a.m.

Interview with Staff A confirmed the above fire drill times.

Based on observations and interview the facility failed to ensure that 4 patient room doors could resist the passage of smoke.

Findings include:

Observations during tour on 06/10/16 between 10:00 a.m. and 11:30 a.m. with Staff A (Director of Facility Services) revealed the following 4 doors that access egress corridors, have a gap between the door slab and the door frame that exceeds the maximum allowable gap of 1/2" to resist the passage of smoke.
These doors are as follows:
1. Patient room door MS # 20 has a gap of 5/8".
2. Patient room door MS # 10 has a gap of 5/8".
3. Patient room door MS # 8 has a gap of 5/8" and fails to latch in a closed position.
4. The "Sleep Lab" door has a gap of 7/8" and fails to latch in a closed position.

Interview with Staff A at the time of the observations confirmed the findings and the locations.

Based on observations and interview the facility failed to ensure that 1 storage room (combustible storage) has an automatic door closing device installed.

Findings include:

Observations during tour on 06/09/16 between 3:00 p.m. and 4:00 p.m. with Staff A (Director of Facility Services) revealed that the "Bio-Hazard" storage room, located next to the loading docks on the lower level, exceeds 50 sq.ft. and the door fails to be equipped with an automatic door closing device.

Interview with Staff A at the time of observation confirmed the finding and location.

Based on interview during record review the facility failed to ensure that "Fire Drills" are held at unexpected times for all shifts.

Findings include:

Record review during tour on 06/08/16 between 1:00 p.m. and 2:00 p.m. with Staff A (Director of Facility Services) revealed that the 1st shift, 2nd shift, and 3rd shift fire drills did not vary in the times they were conducted.
The Fire Drills were held as follows:
1st shift (7:00 a.m. - 3:00 p.m.)
04/28/16 10:26 a.m.
01/27/16 10:42 a.m.
10/21/15 10:21 a.m.
07/20/15 10:41 a.m.
04/29/15 09:44 a.m.

2nd shift (3:00 p.m. - 11:00 p.m.)
05/24/16 04:10 p.m.
03/25/16 03:00 p.m.
02/29/16 04:08 p.m.
12/09/15 03:06 p.m.
09/02/15 03:39 p.m.
05/21/15 03:11 p.m.
03/05/15 03:55 p.m.

3rd shift (11:00p.m.- 07:00 a.m.)
03/14/16 11:30 p.m.
12/22/15 11:20 p.m.
09/24/15 12:00 a.m.
06/25/15 11:10 p.m.
03/27/15 05:28 a.m.

Interview with Staff A confirmed the above fire drill times.