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Tag No.: K0025
Tag No.: K0025
REMAINS CITED
Based on observations and staff interviews, the facility failed to repair all smoke barriers cited on the 06/08/12 survey as having penetrations. This affected one of four smoke barriers observed during this visit. The census during this visit was 142.
Findings include:
A tour was conducted in the facility on 07/23/12 at 1:47 PM, an observation was conducted of the smoke barrier in the 3B unit by room 31. This smoke barrier was observed with approximately an 8 inch high by 6 inch wide opening around conduit which penetrated the barrier. At the time of the observations, an interview with Staff F (Interim Safety Officer) verified this penetration. An interview with Staff B (Director Facility Operations), on the same date and time, verified this smoke barrier penetration was unchanged since the June 2012 survey, and had not been yet been repaired.
Tag No.: K0045
REMAINS CITED
Based on observations and staff interviews, the facility failed to follow their plan of correction to install the required lighting outside 1 of 2 exits cited on the 06/08/12 survey. The census during this visit was 142.
Findings include:
A tour was conducted in the facility on 07/23/12 at 3:39 PM with Staff B (Director Facility Operations) and Staff F (Interim Safety Officer) of the exit discharge from the Emergency Department West Exit door (near the ambulance entrance). This exit was observed with a single light outside the exit discharge. This was verified with Staff F at 3:17 PM. During this observation, Staff B stated there have been no changes to the lighting at this exit discharge since the June 2012 survey.
Tag No.: K0052
REMAINS CITED
Based on observations and staff interviews, the facility failed to follow their plan of correction to relocate twelve smoke detectors at least 36 inches from air return diffusers or air supply diffusers which were cited in regards to location on the 06/08/12.
The census during this visit was 142.
Findings include:
A tour was conducted on 07/23/12 with Staff B (Director Facility Operations), Staff C (Facility Operations Coordinator), and Staff F (Interim Safety Officer) between 1:40 PM and 3:55 PM. Based on observations, and interview with Staff B during this tour, the following smoke detectors were not relocated since the 06/08/12 survey, and were observed less than 36 inches from air return and air supply diffusers as follows:
a) Two detectors in the 1A inpatient Psych unit kitchen/dining room,
b) 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, the clean core area in back of OR 4,
c) In PACU outside the nurses' stations, and in the hall outside the holding room #2,
d) One detector in the ED waiting room,
e) In the PAT (pre admission testing area) in room #9 (which was relocated during the tour after identified as being within one foot of an air return diffuser),
f) and in patient room 3B-23. An interview with Staff B at 1:40 PM, on 07/23/12, revealed the smoke detector was located close to an exhaust to the "old system" which was verified not currently in use.
Staff B verified these aforementioned smoke detectors had not been relocated since the 06/08/12 survey.
Tag No.: K0062
REMAINS CITED
Based on observations and staff interviews, the facility failed to follow their plan of correction to ensure sprinkler heads were clean and free from foreign matter such as dirt and dust. This involved the 3A hallway and the staff locker room in the ICU unit. The census during this visit was 142.
Findings include:
A tour was conducted on 07/23/12 with Staff B (Director Facility Operations), Staff C (Facility Operations Coordinator), and Staff F (Interim Safety Officer) between 1:40 PM and 3:55 PM. Tour of the 3A inpatient unit revealed 3 dirty sprinkler heads in the hallway outside the 3A nursing station. These sprinkler heads were observed with clinging clumps of dust and dirt. One of these sprinkler heads was observed heavily coated with dust and dirt. Two additional sprinkler heads were observed in the hallway outside 3A room 15. These sprinkler heads were heavily coated with dust and dirt. The ICU locker room was also observed with a dirty, dust coated sprinkler head. These were verified with Staff B during tour.
On 07/24/12, a review of the monitoring tools revealed the following areas were monitored by Staff G( Environmental Services Manager):
a) On 07/02/12 five rooms in the Emergency Department, which identified these sprinkler heads needed cleaning,
b) On 07/12/12, room 3A-31, which identified the hallway sprinkler heads were dusty,
c) On 07/18/12, room 2A-11, and
d) On 07/24/12, room 3A-48, which identified sprinkler heads had a small amount of dust.
These monitoring tools revealed only one room of the facility was observed for dirty sprinkler heads during each of the aforementioned weeks. The facility lacked documentation of additional areas of monitoring since the survey of 06/08/12. These monitoring tools also lacked an action plan to clean the sprinkler heads when identified as being dusty and dirty. This was verified with Staff D on 07/24/12 at 12:04 PM. This employee stated the outside service company was called yesterday after the dirty sprinkler heads were identified on tour, and did come to the facility in the evening of 07/24/12 to clean these sprinkler heads. This employee stated the facility is currently discussing a future contract with this company to clean the sprinkler heads by units, as the feather dusters used by facility housekeeping staff are not working to appropriately clean the sprinkler heads.