HospitalInspections.org

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on April 14, 2015, between the hours of 11:00am and 2:00pm, I observed that the door from the exit corridor into the billing office is a hollow wood door and does not meet the fire rating requirements of a 20 minute fire door.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to maintain the exit discharge readily accessible at all times. This could cause an inability or delay in the evacuation of patients in the event of an emergency which would endanger patients, staff and/or visitors.
The findings include, but are not limited to:
Based upon observations and staff interviews on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed the following exit deficiency:
The north hall Administration Wing exit door was stuck. I could not open the door. The Environmental Services Manager had to use his body to get the door to open. The door is sticking when closed.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to maintain exit signs so that they are illuminated at all times. This could potentially delay evacuation of the building in an emergency and confuse patients, staff and/or visitors as to the location of the exits during an emergency.
The findings include, but are not limited to:
Based upon observations made during the survey tour on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed exit signs with bulbs burned out in the following locations:
1. North hall Administration wing exit sign has bulb out.
2. North exit Critical Care wing exit sign has bulb out.
3. Long hall center fire doors exit sign has bulb out.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger patients, staff and/or visitors.
The findings include, but are not limited to:
Based upon observations and staff interviews on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed that the two exterior entrance oxygen storage rooms did not have the required sprinkler protection.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to provide a required emergency stop button for the generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the the room housing the generators to shut off the generators. Failure to have an emergency shut off switch outside of the generator rooms could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour on April 14, 2015, between the hours of 11:00am and 2:00pm, and interviews with the Environmental Services Manager, revealed that staff was not aware that the generators required remote shut-off switches outside of the generator rooms. The following generator deficiencies were noted:

1. I observed that the generator located in a detached room outside of the hospital had the emergency stop button directly on the generator itself, and not outside of the generator room as required.

2. I observed that the generator inside the building did not have an emergency stop button on the outside of the generator room as required.

These findings were discussed and acknowledged by the Environmental Services Manager.

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on April 14, 2015, between the hours of 11:00am and 2:00pm, I observed that the door from the exit corridor into the billing office is a hollow wood door and does not meet the fire rating requirements of a 20 minute fire door.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to maintain the exit discharge readily accessible at all times. This could cause an inability or delay in the evacuation of patients in the event of an emergency which would endanger patients, staff and/or visitors.
The findings include, but are not limited to:
Based upon observations and staff interviews on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed the following exit deficiency:
The north hall Administration Wing exit door was stuck. I could not open the door. The Environmental Services Manager had to use his body to get the door to open. The door is sticking when closed.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to maintain exit signs so that they are illuminated at all times. This could potentially delay evacuation of the building in an emergency and confuse patients, staff and/or visitors as to the location of the exits during an emergency.
The findings include, but are not limited to:
Based upon observations made during the survey tour on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed exit signs with bulbs burned out in the following locations:
1. North hall Administration wing exit sign has bulb out.
2. North exit Critical Care wing exit sign has bulb out.
3. Long hall center fire doors exit sign has bulb out.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger patients, staff and/or visitors.
The findings include, but are not limited to:
Based upon observations and staff interviews on April 14, 2015 between the hours of 11:00am and 2:00pm, I observed that the two exterior entrance oxygen storage rooms did not have the required sprinkler protection.
The above was discussed and acknowledged by the Environmental Services Manager.

The facility has failed to provide a required emergency stop button for the generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the the room housing the generators to shut off the generators. Failure to have an emergency shut off switch outside of the generator rooms could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour on April 14, 2015, between the hours of 11:00am and 2:00pm, and interviews with the Environmental Services Manager, revealed that staff was not aware that the generators required remote shut-off switches outside of the generator rooms. The following generator deficiencies were noted:

1. I observed that the generator located in a detached room outside of the hospital had the emergency stop button directly on the generator itself, and not outside of the generator room as required.

2. I observed that the generator inside the building did not have an emergency stop button on the outside of the generator room as required.

These findings were discussed and acknowledged by the Environmental Services Manager.