HospitalInspections.org

31597

Based on observation, policy review and interview, the facility failed to protect medical records from potential water damage. This has the potential to affect all patients of the facility. The facility ' s active census was 197.

Findings include:

1. During a tour of medical records department on 7/7/14 at 9:40 AM, medical records were observed filed on open rolling shelves. Sprinkler heads were observed on the ceiling over the medical records. During the tour, Staff A confirmed the medical records were not scanned and could have water damage if the sprinklers were activated. On 7/8/14 at 11:09 AM, Staff A reported the facility's medical records were electronic and also paper files. Staff A indicated the medical records filed on the open shelves were for the years of 2008, 2009, 2010, 2011 and 2012.

2. Medical records were observed at the facility's off-site location on 07/08/14 at 9:12 AM with Staff D and Staff E. The off-site location had two large rooms with multiple large open shelves. Sprinkler heads were observed above the medical records. Staff D reported the medical records were from the years of 1970's to 2005. Staff D reported some of the files were medical records of pediatric patients and the files had not been scanned.

Review of the Retention Period for Hospital Records policy #111.150, effective August 2007, revealed Attachment III, which was titled Records Storage. The policy indicated the off-site storage facilities are to be secure locations that safeguard the records from ordinary hazards, such as water.

Based on review of facility schematics and documentation, facility observation and staff interview, the facility failed to ensure the building was constructed, arranged, and maintained to ensure the safety of the patients. The facility had a capacity of 441 beds with a census of 197 patients on the first day of the survey. Potentially all patients, visitors and staff could be affected.

Findings incude:

The facility failed to ensure that that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls were to properly extend above the ceilingl; failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors; and failed to ensure one hazardous area in the sleep clinic maintained a one hour fire resistance rating (A710).

Based on facility observation and staff confirmation, the facility failed to ensure the hospital met the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility had a capacity of 441 beds with a census of 197 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include:

On 07/07/14 between the hours of 10:30 A.M. and 3:50 PM, tour was conducted with Staff H, G, and I. On 07/08/14 between 9:15 AM and 12:30 PM, tour of the facility was conducted with Staff H, I, and J. The following observations of life safety measure revealed the following findings:

The facility's failure to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls were to properly extend above the ceiling. Refer to K17.

The facility's failure to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors, and also failed to ensure one hazardous area in the sleep clinic maintained a one hour fire resistance rating. Refer to K130.