HospitalInspections.org

Based on documentation review and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours 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:

The dry heads on the exterior canopies that are older than 5 years must be tested or replaced.
NFPA 101 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 5.3.1.1.2

Kitchen cooler - sprinkler head discharge obstructed by food. Corrected during inspection.
NFPA 101 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 5.2.1.2

Linen pass through between laundry and physical therapy - shelving makes sprinkler head inaccessible for inspection and maintenance.
NFPA 101 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 4.1.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours the facility has failed to maintain corridors construction as capable of resisting smoke. This could result in toxic products of combustion getting into the room or into the exit corridor in the event of a fire which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

Dietary office - penetration in wall to corridor due to computer wires added.

Central Supply - penetration in wall to corridor with low voltage wires.

NFPA 101 (2012) 19.3.6.2.2

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours the facility has failed to maintain all doors as smoke resistent. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

Long Hall Soiled Linen Room - penetrations were observed in the door frame.

North Hall Tub Room - penetrations were observed in the door.

NFPA 101 (2012) 19.3.7.3

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

Social Services/Infection Control Office - a powerstrip was plugged into another powerstrip at the infection control desk.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A) 400.8

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide a policy for testing, repairs and modifications of patient care related medical equipment.

NFPA 99 (2012) 10.5.2.1

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on April 19, 2022 between approximately 0830 and 1630 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include:

The facility was unable to provide guidelines and training documentation of staff on usage and risks of medical gas equipment.

NFPA 99 (2012) 11.5.2.1

The above was discussed and acknowledged by the facility staff.