HospitalInspections.org

Based on observation and interview on 3-10-15 at 3:15PM, the facility failed to install an astragal (or smoke stopper) for the set of double smoke doors leading into the trauma unit. Gaps between smoke doors can allow the passage of smoke. This practice had the potential to affect 4 patients in the emergency room area. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 3:15PM revealed the pair of smoke doors near the trauma unit had come out of adjustment which caused a 3/8" gap between the doors.

During an interview on 3-10-15 at 3:15PM, Maintenance A confirmed the finding.

Based on observation and interview on 3-10-15 at 4:00PM, the facility failed to maintain fire separation walls in the computer server room. Failing to maintain fire walls could allow the passage of fire and smoke to other areas. This practice affected no patients due the location of the room but had the potential to affect other service areas and staff. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 4:00PM revealed several holes in the walls of the computer servers room. Many holes and conduits were sealed up with fire caulk but several others were not.

During an interview on 3-10-15 at 4:00PM, Maintenance A confirmed the deficiency.

Based on record review and interviews, the facility failed to activate the fire alarm for 1 of 12 required fire drills. Failing to activate the fire alarm during drills could lead to panicked or poor staff performance during a real fire emergency. This practice affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Record review on 3-10-15 revealed no recorded fire alarm in the facility's fire alarm activity log for 10-22-14 despite the fire drill record showing a drill was conducted at 1:05PM that day.

During an interview on 3-10-15 at 2:00PM, Maintenance A and Maintenance B confirmed the findings.

Based on record review and interviews on 3-10-15 at 2:20PM, the facility failed to perform or document the monthly generator load test for 2 of 12 required monthly generator load tests. Not performing the monthly load tests could result in generator failure in a time of need. This practice affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Record review on 3-10-15 revealed no recorded monthly load tests in the facility's monthly generator log for February and June of 2014.

During an interview on 3-10-15 at 2:20PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and interview on 3-10-15 at 2:45PM, the facility failed to maintain a 36 inch clearance between electrical breaker boxes and combustible materials in the nourishment room. Combustibles too close to electric panels are a hazard during a potential power surge. This practice had the potential to affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 2:45PM revealed food carts with combustible materials were up against 2 electrical breaker boxes in the nourishment room.

During an interview on on 3-10-15 at 2:45PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and interview on 3-10-15 at 3:15PM, the facility failed to install an astragal (or smoke stopper) for the set of double smoke doors leading into the trauma unit. Gaps between smoke doors can allow the passage of smoke. This practice had the potential to affect 4 patients in the emergency room area. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 3:15PM revealed the pair of smoke doors near the trauma unit had come out of adjustment which caused a 3/8" gap between the doors.

During an interview on 3-10-15 at 3:15PM, Maintenance A confirmed the finding.

Based on observation and interview on 3-10-15 at 4:00PM, the facility failed to maintain fire separation walls in the computer server room. Failing to maintain fire walls could allow the passage of fire and smoke to other areas. This practice affected no patients due the location of the room but had the potential to affect other service areas and staff. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 4:00PM revealed several holes in the walls of the computer servers room. Many holes and conduits were sealed up with fire caulk but several others were not.

During an interview on 3-10-15 at 4:00PM, Maintenance A confirmed the deficiency.

Based on record review and interviews, the facility failed to activate the fire alarm for 1 of 12 required fire drills. Failing to activate the fire alarm during drills could lead to panicked or poor staff performance during a real fire emergency. This practice affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Record review on 3-10-15 revealed no recorded fire alarm in the facility's fire alarm activity log for 10-22-14 despite the fire drill record showing a drill was conducted at 1:05PM that day.

During an interview on 3-10-15 at 2:00PM, Maintenance A and Maintenance B confirmed the findings.

Based on record review and interviews on 3-10-15 at 2:20PM, the facility failed to perform or document the monthly generator load test for 2 of 12 required monthly generator load tests. Not performing the monthly load tests could result in generator failure in a time of need. This practice affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Record review on 3-10-15 revealed no recorded monthly load tests in the facility's monthly generator log for February and June of 2014.

During an interview on 3-10-15 at 2:20PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and interview on 3-10-15 at 2:45PM, the facility failed to maintain a 36 inch clearance between electrical breaker boxes and combustible materials in the nourishment room. Combustibles too close to electric panels are a hazard during a potential power surge. This practice had the potential to affected all patients. Facility census was 12 patients on 3-10-15.

Findings are:

Observations on 3-10-15 at 2:45PM revealed food carts with combustible materials were up against 2 electrical breaker boxes in the nourishment room.

During an interview on on 3-10-15 at 2:45PM, Maintenance A and Maintenance B confirmed the findings.