HospitalInspections.org

Based upon observation and staff interviews during a tour of
the facility from 1000 to 1300 on 09/14/12, the facility has
failed to maintain proper operation of exit doors. Doors are
not maintained to open easily. This could result in delay or
inability to exit in the event of a fire or other emergency.
These findings were acknowledged by the Non-Clinical
Operations Director.
The findings include, but are not limited to:
1. Exit door requires excessive force to open - exterior exit by Medical Records.

Based upon staff interviews and review of facility records
during a tour of the facility from 1000 to 1300 on 09/14/12, the
facility has failed to conduct fire drills at unexpected times
under varying conditions, at least quarterly on each shift. .
This could result in ineffective staff actions in the event of a
fire or other emergency. These findings were acknowledged
by the Non-Clinical Operations Director.
The findings include, but are not limited to:
1. No documented fire drills on night shift in 1st and 2nd
quarters of 2012.

Based upon staff interviews and review of facility records
during a tour of the facility from 1000 to 1300 on 09/14/12, the
facility has failed to maintain automatic sprinkler systems in a
continuously reliable operating condition. This could result in
failure of the fire sprinkler system to operate effectively in the
event of a fire. These findings were acknowledged by the
Non-Clinical Operations Director.
The findings include, but are not limited to:
1. System deficiencies noted on the annual test and
certification test documents (05/22/12) have not been
corrected.

Based upon observation and staff interviews during a tour of
the facility from 1000 to 1300 on 09/14/12, the facility has
failed to maintain medical gasses in accordance with NFPA
99, Standard for Health Care Facilities. These findings were
acknowledged by the Non-Clinical Operations Director.
The findings include, but are not limited to:
1. Oxygen cylinders are not properly secured against tipping
or falling - safety chain is of inadequate size and strength.

Based upon observation and staff interviews during a tour of
the facility from 1000 to 1300 on 09/14/12, the facility has
failed to maintain proper operation of exit doors. Doors are
not maintained to open easily. This could result in delay or
inability to exit in the event of a fire or other emergency.
These findings were acknowledged by the Non-Clinical
Operations Director.
The findings include, but are not limited to:
1. Exit door requires excessive force to open - exterior exit by Medical Records.

Based upon staff interviews and review of facility records
during a tour of the facility from 1000 to 1300 on 09/14/12, the
facility has failed to conduct fire drills at unexpected times
under varying conditions, at least quarterly on each shift. .
This could result in ineffective staff actions in the event of a
fire or other emergency. These findings were acknowledged
by the Non-Clinical Operations Director.
The findings include, but are not limited to:
1. No documented fire drills on night shift in 1st and 2nd
quarters of 2012.

Based upon staff interviews and review of facility records
during a tour of the facility from 1000 to 1300 on 09/14/12, the
facility has failed to maintain automatic sprinkler systems in a
continuously reliable operating condition. This could result in
failure of the fire sprinkler system to operate effectively in the
event of a fire. These findings were acknowledged by the
Non-Clinical Operations Director.
The findings include, but are not limited to:
1. System deficiencies noted on the annual test and
certification test documents (05/22/12) have not been
corrected.

Based upon observation and staff interviews during a tour of
the facility from 1000 to 1300 on 09/14/12, the facility has
failed to maintain medical gasses in accordance with NFPA
99, Standard for Health Care Facilities. These findings were
acknowledged by the Non-Clinical Operations Director.
The findings include, but are not limited to:
1. Oxygen cylinders are not properly secured against tipping
or falling - safety chain is of inadequate size and strength.