HospitalInspections.org

Based on observations and staff interview, the facility failed to maintain proper door latching / closure as evidenced by the lack of latching /closing of several door throughout the facility. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the tour of the facility between 2:50 pm and 4:35 pm on March 5, 2012 with the Maintenance Director, it was revealed that several doors did not latch / close properly : (1) second floor Northeast Clean Utility Room and (2) second floor Telecommunications Room. This deficiency was noticed again at 11:10 am on March 6, 2012 in the Dark Room in the Operating Rooms Area.

During the Staff Interview between 2:55 pm and 4:40 pm on March 5, 2012, and at 11:15 am on March 6, 2012 the Maintenance Director stated that repairs would be done to provide proper door latching / closure.

Based on observations and staff interview, the facility failed to maintain proper sprinkler coverage for all portions of the facility as evidenced by the rusted sprinkler head in Cooler #2. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the Life Safety Survey tour of the facility at 11:45 am on March 6, 2012 with the Maintenance Director, it was revealed that a fire sprinkler head was rusted in Cooler #2.

During the Staff Interview at 11:50 am on March 6, 2012 the Maintenance Director acknowledged the sprinkler head in Cooler #2 was rusted..

Based on observation and staff interview, it was determined that the facility failed to properly maintain the cooking hood fire suppression system as required. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the Life Safety Survey tour of the facility at 11:40 am on March 6, 2012 with the Maintenance Director, it was noticed that the cooking hood nozzles were not properly aligned as designed / installed.

During the Staff Interview at 11:45 am on March 6, 2012, the Maintenance Director acknowledged that the cooking hood nozzles were not properly aligned as designed / installed.

Based on observation and staff interview, the facility failed to properly maintain secured oxygen cylinder as evidenced by several unsecured oxygen cylinders on the floor throughout the facility. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the Life Safety Survey tour of the facility between 10:50 am and 12:30 pm on March 6, 2012 with the Maintenance Director, it was revealed that several unsecured oxygen cylinders were on the floor in Recovery and Radiology.

During the Staff Interview between 10:55 am and 12:35 pm on March 6, 2012, the Maintenance Director stated that the oxygen cylinders will be immediately secured.

Based on record review, observation, and staff interview, the facility failed to comply with all electrical safety requirements as evidenced by the lack of documentation for the main and feeder breaker exercise test performance. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the records review process of the facility between 3:05 pm and 3:10 pm on March 5, 2012 with the Maintenance Director, it was revealed that there was no documentation for the main and feeder breaker exercise test performance nor the Line Isolation Monitor test performance.

During the Staff Interview between 3:10 pm and 3:15 pm on March 5, 2012 the Maintenance Director confirmed the lack of documentation for the main and feeder breaker exercise performance and the Line Isolation Monitor test performance.

During the life safety tour of the facility at 4:25 pm on March 5, 2012 with the Maintenance Director, it was observed that the second floor water fountain was connected to an improper outlet without a ground fault circuit interrupter (GFCI outlet) as required.
During the staff interview at 4:30 pm on March 5, 2012 the Maintenance Director acknowledged the second floor water fountain was connected to an improper outlet without a ground fault circuit interrupter (GFCI outlet) as required.