HospitalInspections.org

Bringing transparency to federal inspections

272 HOSPITAL ROAD

CHILLICOTHE, OH 45601

No Description Available

Tag No.: K0018

Based on observations, and staff interviews, the facility failed to ensure corridor doors had gaps less than 1/8 inch. This affected a total of 18 patient room doors. The code at 18.3.6.3.1 requires corridor doors to resist the passage of smoke. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:50 PM and 2:27 PM, on 06/05/12 between 9:20 AM and 10:33 AM, and on 06/06/12 between 1:22 PM and 2:20 PM, with Staff H, I, J, and K.

The following second and third floor in patient units were observed with double leaf patient room corridor doors that contained greater than a 1/8 inch gap between the door leafs:

On 3 NE rooms 34, 33, 29, 28, 26, 25, 23, 21, 20, 18, 17, and 16
On 2 NE rooms 25,
On 2 N rooms 15, 14, 13, and 9, and
On 1 NE room 33.

These door gaps were verified with Staff H during the time of the tour.

No Description Available

Tag No.: K0021

Based on observations and staff interviews, the facility failed to ensure fire doors on held open devices automatically closed and latched into the frame when released from the hold open device in accordance with the code at 18.2.2.2.6. This affected 1 set of fire doors. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/05/12 at 9:55 AM with Staff H, I, J, and K. During this tour, the fire doors located on 2 North, doors 2N-04, failed to close and latch when released from the automatic hold open device.

On 06/06/12 at 8:50 AM, an interview with Staff H (Director Facility Operations) and with Staff I (Safety Officer), on 06/08/12 at 10:15 AM, revealed the facility does not currently have a proactive maintenance plan in place to test the fire doors to ensure they close and latch properly.

No Description Available

Tag No.: K0021

Based on observations and staff interviews, the facility failed to ensure fire doors on hold open devices automatically closed and latched into the frame when released from the hold open device in accordance with the code at 18.2.2.2.6. This affected 2 sets of fire doors. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 through 06/06/12 with Staff H, I, J, and K. During this tour, the following fire doors located in a one hour fire barrier failed to latch into the frame when released from the automatic hold open device:
a) on the second floor between the NE Addition and unit 2A on 06/04/12 at 9:10 AM. These doors were located in a one hour fire barrier.
b) and on the second floor in the inpatient Endoscopy suite near the stairs in the West Wing Atrium on 06/06/12 at 11:32 AM

On 06/06/12 at 8:50 AM, an interview with Staff H (Director Facility Operations) and with Staff I (Safety Officer), on 06/08/12 at 10:15 AM, revealed the facility does not currently have a proactive maintenance plan in place to test the fire doors to ensure they close and latch properly.

No Description Available

Tag No.: K0025

Based on observations and staff interviews, the facility failed to ensure smoke barriers maintained at least a one hour fire resistance rating in accordance with the code at 8.3. This involved 3 smoke barriers. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:50 PM and 2:27 PM, on 06/05/12 between 9:20 AM and 10:33 AM, and on 06/06/12 between 1:22 PM and 2:20 PM, with Staff H, I, J, K, and M.

The following smoke barriers were observed with penetrations in the barrier, and around or inside conduit:

On the 3rd floor:
a) On the 3rd floor in the 3B unit by room 31, an approximately 8 inch high by 6 inch wide opening around conduit,and
b) Between the 3A/#NE barrier by the visitor elevators and bathroom a 3/4 inch opening inside rigid conduit which contained wires.

These penetrations were verified with Staff J (Security Officer) and Staff H at the time of the tour.

No Description Available

Tag No.: K0025

Based on observations and staff interviews, the facility failed to ensure smoke barriers were maintained to provide at least a one hour fire resistance rating in accordance with the code at 8.3. This involved 4 smoke barriers. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:50 PM and 2:27 PM, on 06/05/12 between 9:20 AM and 10:33 AM, and on 06/06/12 between 1:22 PM and 2:20 PM, with Staff H, I, J, K, and M. The following smoke barriers were observed with penetrations in the barrier, and around or inside conduit:

On the 3rd floor
a) The smoke barrier between units 3A and 3NE, by the visitor elevator, was observed with a 3/4 inch diameter rigid conduit containing wires. The inside of the conduit was observed open and not sealed.

On the 2nd floor
b) The smoke barrier located near the Atrium, inside the nutrition area, was observed with an opening inside the 3/4 inch diameter curved conduit which contained a white wire.

c) The smoke barrier over the fire doors by the visitors' bathroom, near the Atrium, was observed with a 3/4 inch diameter conduit which contained wires. The inside of the conduit was observed open at the time of the tour.

On the 1st floor:
d) The smoke barrier over doors 1 N-04, in the 1 N hallway by the Triage Labor and Delivery room, was observed with a 3 inch unsealed conduit, and approximately a 1/2 inch wide by 2 feet long penetration around a heating and air duct. This barrier was observed with approximately an 8 inch wide by 5 inch long hole on both sides of the barrier around a rigid conduit. Staff H verified this smoke barrier should maintain a one hour fire resistance rating.

These openings were verified with Staff J and M on tour. Staff H was made aware of these penetrations during tour of the facility on 06/04/12 through 06/06/12.

No Description Available

Tag No.: K0029

Based on observations and staff interview, the facility failed ensure one hazardous area had a self-closing door in accordance with the code at 19.3.2.1. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/08/12 with Staff I (Safety Officer), between 9:20 AM and 10:25 AM. Observations, and interview with Staff I, revealed a soiled utility room that contained soiled linen. Although the door was equipped with a positive latching mechanism, the door lacked an automatic closing device. When in the open position, the door remained open. The room was observed as a holding area for soiled linen, and contained bags of soiled linen at the time of the tour. This room was located near exam rooms, and the pulmonary testing area. Staff I verified the lack of an automatic closing device on the door.

No Description Available

Tag No.: K0038

Based on observations, and staff interview, the facility failed to ensure one of three exits was readily accessible at all times in accordance with the code at 7.1. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/08/12 with Staff I (Safety Officer), between 9:20 AM and 10:25 AM. Observations revealed a designated exit at the bottom of the stairwell on the East side of the building next to the vending machines. The exit discharge was observed with two metal doors, which were very difficult to open when tested. Staff I made several attempts to open the doors, and only succeeded by applying full body weight and pressure to the doors. Staff I verified the exit doors were difficult to open. An interview with three maintenance staff, at 10:25 AM, who were working on the doors, stated there was no preventative maintenance to test the exit doors.

No Description Available

Tag No.: K0045

Based on observations and staff interviews, the facility failed to ensure 3 exits were arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness, in accordance with the code at 18.2.8 and 7.8. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted with Staff H (Director Facility Operations) on 06/06/12 between 1:22 PM and 3:25 PM. During this tour, observations revealed two exit discharges on the first floor; one on the 1A Psych unit (by rooms 44 and 46), and one outside the Emergency Department West Exit door, without the required lighting at the discharges.

These exits were observed without a source of lighting, and were observed with sidewalks leading to the public way. There was no lighting observed along these pathways to the public way.

This was verified with Staff H during tour.

No Description Available

Tag No.: K0045

Based on observations and staff interviews, the facility failed to ensure 4 exits were arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness, in accordance with the code at 18.2.8 and 7.8. The facility has a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted with Staff H on 06/06/12 between 1:22 PM and 3:25 PM. During this tour, observations revealed two exit discharges without the required lighting at the discharge. These exits were located outside the 1 North Unit, between the 1 North and the Women/Children's unit, and between 1 NE wing and 1A Psych units. These exits were observed without a source of lighting, and were observed with sidewalks leading to the public way. There was no lighting observed along these pathways to the public way.

This was verified with Staff H during the tour.

No Description Available

Tag No.: K0052

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers in accordance with the code at 9.6.1.3 and NFPA 72, A-2.3.5.1. This affected 1 smoke detector in the facility. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/08/12 with Staff I (Safety Officer), between 9:20 AM and 10:25 AM. During this tour, on the ground floor, by the elevator, one smoke detector was observed less than 36 inches from an air supply diffuser. This smoke detector was verified by Staff I as being inner connected into the fire alarm system, and verified the location of the detector was less than 36 inches from the air supply vent.

No Description Available

Tag No.: K0052

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers in accordance with the code at 9.6.1.3 and NFPA 72, A-2.3.5.1. This affected 1 smoke detector on one of three floors of the facility. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:50 PM and 2:27 PM, on 06/05/12 between 9:20 AM and 10:33 AM, and on 06/06/12 between 1:22 PM and 2:20 PM, with Staff I, J, and K. Staff H was present on the tours on 06/04/12 through 06/06/12.
During this tour, smoke detectors were observed less than 36 inches from air supply diffusers and air returns. Staff H verified these smoke detectors were inner connected into the fire alarm system, and verified the location of the detectors, as well as whether they were located close to an air supply diffuser or an air return grill. On 06/06/12 at 11:12 AM, Staff H stated the fire alarm service company verified the smoke detectors should be located at least 36 inches from these air vents.

Observations of the smoke detectors revealed the following location:
On the 2nd floor, at the 2NE nurses' station.

No Description Available

Tag No.: K0052

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers in accordance with the code at 9.6.1.3 and NFPA 72, A-2.3.5.1. This affected 31 smoke detectors on three floors of the facility. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:50 PM and 2:27 PM, on 06/05/12 between 9:20 AM and 10:33 AM, and on 06/06/12 between 1:22 PM and 2:20 PM, with Staff I, J, and K. Staff H (Director of Facility Operations) was present on the tours on 06/04/12 through 06/06/12. During these tours, smoke detectors were observed less than 36 inches from air supply diffusers and air returns. Staff H verified these smoke detectors were inner connected into the fire alarm system, and verified the location of the detectors, as well as whether they were located close to an air supply diffuser or an air return grill. On 06/06/12 at 11:12 AM, Staff H stated the fire alarm service company verified the smoke detectors should be located at least 36 inches from these air vents.

Observations of these smoke detectors revealed the following locations:

On the 3rd floor in room 3B-23.

On the 2nd floor:
a) In the Emergency Room South Department in rooms 22, 23, 25, 28, 29, 30, 31, 32, 33, 24, and 26,
b) In the main Emergency Department (ED) in the corridor by room 6, in the ED waiting room,
c) In the Endoscopy Suite, in rooms E3 and E2 and by room T2,
d) One in the PAT (preadmission testing) area, and in storage room 9,
e) In PACU outside the nurses' station, and in the hall to holding room #2,
f) In the OR suite on the back side of the nurses' station in the OR hall, outside OR 3 core area, in the hall outside OR 5, the backside of OR 5, and the clean core area in back of OR 4,
g) In the 1A inpatient Psych unit in rooms 24, 53, 44/45, in the hall by the exit door near rooms 44/45, and two in the kitchen/dining room.

No Description Available

Tag No.: K0062

Based on observations and staff interviews, the facility failed to ensure sprinkler heads were free from foreign matter such as dirt and dust. This affected sprinkler heads on two floors of the facility. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/04/12 between 1:30 PM and 2:30 PM, on 06/05/12 between 8:10 AM and 4:30 PM, and on 06/06/12 at 11:05 AM with Staff H, I, J, and K. Sprinkler heads were observed with a heavy coating of dust and dirt in the following areas:

On the 3rd floor:
a) 6 heads in the 3A nurses' station,

On the 2nd floor:
b) In the locker room in the ICU unit, and
c) In the Radiology unit in Office A.

These dirty sprinkler heads were verified with Staff H (Director of Facility Operations) during the tour. This employee stated the housekeeping department was responsible for cleaning the sprinkler heads.

No Description Available

Tag No.: K0076

Based on observations and staff interview, the facility failed to store medical gas in accordance with NFPA 99, 8-3.1.11.2, when the amount exceeded 300 cubic feet in one smoke compartment. This involved two different rooms of the facility and could affect all patients, staff, and visitors. The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/08/12 with Staff I (Safety Officer), between 9:20 AM and 10:25 AM. During the tour, observations in one smoke compartment revealed cylinders of oxygen in two different areas of the facility where patients were examined. In the respiratory testing room, one H-sized cylinder of oxygen (250 cubic feet each), and 2 E-tanks (24 cubic feet each) of oxygen were observed in the room. In the EKG room, three H-sized cylinders of oxygen were observed. Both rooms were observed with open doors on tour, and lacked a one hour fire resistance rating. The total amount of oxygen in both rooms was 1048 cubic feet. Staff I verified the presence of these oxygen tanks on tour, and verified they were not stored as required by the code.

No Description Available

Tag No.: K0144

Based on generator testing logs and staff interview, the facility failed to document weekly generator inspections in accordance NFPA 99, 3-4.1.1.4, and NFPA 110, 6-4.1 The facility has a census of 105 patients at the time of the survey.

Findings include:

A tour conducted on 06/07/12 at 1:10 PM, with Staff I and Staff M, revealed the facility has 4 generators powered with diesel fuel in order to provide emergency power to the facility. A review of the generator testing logs was conducted on 06/08/12, at which time it was revealed there were no weekly inspection logs of these four generators. An interview with Staff K (Facility Operations Coordinator), on 06/08/12 at 3:00 PM, verified the lack of weekly inspection logs for these generators.

No Description Available

Tag No.: K0144

Based on review of generator testing logs and staff interview, the facility failed to document weekly generator inspections in accordance with NFPA 99, 3-4.1.1.4, and NFPA 110, 6-4.1 The facility had a census of 105 patients at the time of the survey.

Findings include:

A tour was conducted on 06/07/12 at 1:10 PM, with Staff I and Staff M, revealed the facility has 4 generators powered with diesel fuel in order to provide emergency power to the facility. A review of the generator testing logs was conducted on 06/08/12, at which time it was revealed there were no weekly inspection logs of these four generators. An interview with Staff K (Facility Operations Coordinator), on 06/08/12 at 3:00 PM, verified the lack of weekly inspection logs for these generators.