HospitalInspections.org

Based on facility tour and staff verification it was determined this facility failed to ensure all vertical openings were protected with at least a one hour fire rated construction and a two hour fire barrier had a door with at least a 90 minute fire resistance rating. This had the potential to affect all those who utilized these areas of the facility. The patient census at the beginning of the survey was 356.

Findings include:

Facility tour of the main building took place on 12/13/12 through 12/14/12 with staff members A1, B2 and C3.

First Floor:
*During tour of stair D1 located in corridor 1028Z, observation was made of no fire rating tag located on the door.

Second Floor:
*The metal back door at the special care nursery located between rooms 2842E and 2842D was observed lacking a fire rating tag.

Interview with staff A1 on 12/14/12 at 1:10 PM revealed the door company who had been hired to assess and re-label the doors that were identified in the original survey completed on 11/02/12 had missed these two doors. The facility immediately made a purchase for these doors and will hang them when they receive them. A copy of the purchase order is included.

THIS IS A RE-CITE

Based on facility observation and staff interview and verification of purchase orders, the facility failed to ensure that patient room doors were arranged so that the patients could open the door from inside without using a key. Potentially all patients on the unit could be affected. The facility had census of 356 patients at the time of the survey.

Findings included:

On 12/13/12 tour of the sixth floor was initiated with staff members A1, B2 and C3. The sixth floor was identified as a psychiatric care floor with two units. The 6100 unit was for crisis intervention and more acutely ill patients and had a capacity for 25 patients. The 6400 unit was for patients less acutely ill and had a capacity for 15 patients.

Observation of the patient bed rooms revealed the presence of dead bolt type locks on all patient room doors. When locked from the corridor side of the door, no one could get out of the room without a key.

As stated in the facility's plan of correction the special locking mechanisms are not available until January 31, 2013 and will be installed at the time they receive them. Interview with staff B2 in the morning hours of 12/14/12 revealed this facility has to replace not only the locking mechanisms but the entire door for each room due to the special needs for this unit. The facility provided a copy of the purchase orders for the doors, hinges and latches.