HospitalInspections.org

Based on observations and interviews made during the walk through of the facility, the facility failed to ensure that door openings closed to resist the passage of smoke into an exit corridor. This potentially exposed residents to smoke. Findings:

Observation during the facility tour on 9/13/12 at 12:18 pm revealed the door to a janitors closet located next to the entrance to the operating room was being held open by the items stored in the closet. Preventing the door from closing.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





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Based on record review and interview the facility failed to ensure that the evacuation plan for residents included response to fire. The lack of a confirmed plan could potentially cause confusion and possibly prevent residents from being evacuated in an emergency and possibly prevent continuation of required medical care. Findings:

Record review of the emergency plan document done at approximately 2:40 pm on 9/13/12 revealed that the emergency plan did not include a section for response to a fire. Interview with the Director of Nursing revealed that the section for response to fire had been left out and they would add it back into the emergency plan.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





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Based on record review and interview the facility failed to ensure that the fire alarm system can continue to be maintained. This could potentially affect patients, staff, and visitors delaying notification to evacuate the facility in an emergency. Findings:

During the walk through at 1:05 pm on 9/13/12 revealed the Fire alarm panel was an Edwards 5721B. This fire alarm panel is a very old design. Interview with the Maintenance Director revealed that the service technician had informed them that parts for this panel were very difficult to locate. If it were to fail it may not be possible to repair it. This could potentially leave the facility without a working fire alarm system.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.






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Based on observation, record review and staff interview the facility failed to have the maintain the sprinkler system as required. This potentially exposed residents to a fire and/or smoke environment due to the delay in extinguishing a fire. Findings:

On 9/13/12 at 10:10 am record review of the report of inspection for the fire sprinkler system (dated 8/8/12) revealed that the service technician had noted several deficiencies. These included the need for additional hangers to support sprinkler piping in several locations.

Observations during the facilities walk through confirmed the need for additional hangers in the activities office, the down stairs conference room, and in the attic air handling room.

Review of the report also revealed the accelerator installed on riser #2 was not working properly.

Observation during the facility tour on 9/13/12 at 12:18 pm revealed the FE-25 special hazards fire suppression system installed in the CT Scanner trailer had been serviced and tagged by a person who did not hold the appropriate permit to work on the system.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





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Based on observation and interview the facility failed to enclose the room where the oxygen generator is located. This potentially exposed patients, staff and visitors to an unsafe environment. Findings:

Observation during the facility tour on 9/13/12 at 11:00 am revealed the space between the double doors to the room where the oxygen generator is located have a gap that is approximately 1/4 to 1/2 inch in width. This exceeds the allowable 1/8th inch wide space per NFPA 101 2000 edition Section 8.2.4.3.4 which references the 1999 edition of NFPA 80 the Standard for Fire Doors and Fire Windows.

NFPA 80, Section 2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch +/- 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.






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Based on observations and interviews the facility failed to ensure that proper humidity levels were maintained in the anesthetizing locations in the operating room as required by NFPA 99 (1999 edition) 5-4.1 and 5-4.1.1. This could affect the health and safety of patients and employees in the OR. Findings:

Observation during the facility walk through on 9/13/12 at 12:25 pm revealed the operating room humidity monitor was indicating the humidity in the room was at least 80% (the gauge did not go higher). The Maintenance Director said the controls for maintaining the humidity levels in the Operating Room were so old he was unable to alter the levels. The recommended level per NFPA 99, Section 5-4.1.1 is that it be greater than 35% and that it should be between 50 and 55%.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





.

Based on observations and interviews made during the walk through of the facility, the facility failed to ensure that door openings closed to resist the passage of smoke into an exit corridor. This potentially exposed residents to smoke. Findings:

Observation during the facility tour on 9/13/12 at 12:18 pm revealed the door to a janitors closet located next to the entrance to the operating room was being held open by the items stored in the closet. Preventing the door from closing.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





.

Based on record review and interview the facility failed to ensure that the evacuation plan for residents included response to fire. The lack of a confirmed plan could potentially cause confusion and possibly prevent residents from being evacuated in an emergency and possibly prevent continuation of required medical care. Findings:

Record review of the emergency plan document done at approximately 2:40 pm on 9/13/12 revealed that the emergency plan did not include a section for response to a fire. Interview with the Director of Nursing revealed that the section for response to fire had been left out and they would add it back into the emergency plan.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





.

Based on record review and interview the facility failed to ensure that the fire alarm system can continue to be maintained. This could potentially affect patients, staff, and visitors delaying notification to evacuate the facility in an emergency. Findings:

During the walk through at 1:05 pm on 9/13/12 revealed the Fire alarm panel was an Edwards 5721B. This fire alarm panel is a very old design. Interview with the Maintenance Director revealed that the service technician had informed them that parts for this panel were very difficult to locate. If it were to fail it may not be possible to repair it. This could potentially leave the facility without a working fire alarm system.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.






.

Based on observation, record review and staff interview the facility failed to have the maintain the sprinkler system as required. This potentially exposed residents to a fire and/or smoke environment due to the delay in extinguishing a fire. Findings:

On 9/13/12 at 10:10 am record review of the report of inspection for the fire sprinkler system (dated 8/8/12) revealed that the service technician had noted several deficiencies. These included the need for additional hangers to support sprinkler piping in several locations.

Observations during the facilities walk through confirmed the need for additional hangers in the activities office, the down stairs conference room, and in the attic air handling room.

Review of the report also revealed the accelerator installed on riser #2 was not working properly.

Observation during the facility tour on 9/13/12 at 12:18 pm revealed the FE-25 special hazards fire suppression system installed in the CT Scanner trailer had been serviced and tagged by a person who did not hold the appropriate permit to work on the system.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





.

Based on observation and interview the facility failed to enclose the room where the oxygen generator is located. This potentially exposed patients, staff and visitors to an unsafe environment. Findings:

Observation during the facility tour on 9/13/12 at 11:00 am revealed the space between the double doors to the room where the oxygen generator is located have a gap that is approximately 1/4 to 1/2 inch in width. This exceeds the allowable 1/8th inch wide space per NFPA 101 2000 edition Section 8.2.4.3.4 which references the 1999 edition of NFPA 80 the Standard for Fire Doors and Fire Windows.

NFPA 80, Section 2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch +/- 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.






.

Based on observations and interviews the facility failed to ensure that proper humidity levels were maintained in the anesthetizing locations in the operating room as required by NFPA 99 (1999 edition) 5-4.1 and 5-4.1.1. This could affect the health and safety of patients and employees in the OR. Findings:

Observation during the facility walk through on 9/13/12 at 12:25 pm revealed the operating room humidity monitor was indicating the humidity in the room was at least 80% (the gauge did not go higher). The Maintenance Director said the controls for maintaining the humidity levels in the Operating Room were so old he was unable to alter the levels. The recommended level per NFPA 99, Section 5-4.1.1 is that it be greater than 35% and that it should be between 50 and 55%.

The above findings were acknowledged at the time by the Facility Manager. The findings were also acknowledged by the acting CEO/Administrator and the interim CEO/Administrator during the exit conference on 9/13/12 at 4:15 pm.





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