HospitalInspections.org

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Based on observations and interviews made during the walk through of the facility, the facility failed to ensure that door openings closed to resist the passage of smoke into an exit corridor. This potentially exposed residents to smoke. Findings:

Observation during the facility tour on 02/04/2014 at 3:37 pm revealed the door to mammogram room was blocked open with a wooden wedge. The room was not occupied at the time.

The above findings were acknowledged at the time by the Biomedical Engineer.The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.

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Based on observation and staff interview the facility failed to ensure fire doors on a self-closer would close and latch to resist fire and smoke passage in the corridor. This could potentially expose patients and staff members to fire and smoke. Findings:

Observation during the facility tour on 02/14/2014 at 3:55 PM revealed the double doors in the corridor by the LTC activities room did not latch in accordance with NFPA 101, 8.3.4.

The above findings were acknowledged at the time by the Biomedical Engineer. The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.

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Based on record review the facility failed to ensure that an effective evacuation plan for patients and residents was updated annually. The lack of a current plan could cause confusion and potentially prevent patients and residents from being evacuated in an emergency and possibly prevent continuation of required medical care. Findings:

Review of the Master Copy of the Facility Emergency Plan on 2/4/2014 at 2:11 pm revealed that the Disaster Plan had not been updated since 2/10/2012. The document had a contact list for employees that was out of date.

Failure to provide hospital personnel with the most recent version of the Disaster Plan could potentially prevent patients and residents from being evacuated to an appropriate facility.

The above findings were acknowledged at the time by the Biomedical Engineer. The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.

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Based on record review, interview, and observation, the facility failed to properly maintain the fire alarm system as required. This deficient practice had the potential to affect patients, staff, and visitors. Findings:

Record review during the tour of the Mountainside Family Health Clinic on 02/04/2014 at 4:00 pm revealed the required annual fire alarm system inspection had not been completed.

Interview with the Biomed Engineer revealed that a new fire alarm panel had been installed approximately three years prior when the modular building was erected.

Observations during the facility tour on 2/4/2014 at 4:05 pm revealed that there was no tag on the fire alarm panel.

The above findings were acknowledged at the time by the Biomedical Engineeer. The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.

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Based on observation the facility failed to ensure the width of exit accesses were clear and unobstructed. This deficient practice had the potential to prevent patients,residents, staff, and visitors from leaving a smoke or fire environment. Findings:

Observation during the facility tour on 02/04/2014 at 3:00 pm revealed 3 wheelchairs, a walker, and a table in the corridor between room 107 and the Nurse's station.

Life Safety Code 101, A.19.2.3.3: "It is not the intent that the required corridor width be maintained clear and unobstructed at all times. Projections into the required width are permitted by the exception to 7.3.2. It is not the intent that 19.2.3.3 supersedes 7.3.2. Also, it is recognized that wheeled items in use (such as food service carts, housekeeping carts, gurneys, beds, and similar items) and wheeled crash carts not in use (because they need to be immediately accessible during a clinical emergency) are encountered in health care occupancy corridors. The health care occupancy's fire plan and training program should address the relocation of these items during a fire. Note that "not in use" is not the same as "in storage." Storage is not permitted to be in open corridors unless it meets one of the exceptions to 19.3.6.1 and is not a hazardous area."

The above findings were acknowledged at the time by the Biomedical Engineer. The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.


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Based on observation and interview the facility failed to ensure that proper humidity levels were maintained in the anesthetizing locations in the operating rooms as required by NFPA 99 (1999 edition) 5-4.1 and 5-4.1.1. This could affect the health and safety of patients and employees in the OR. Findings:

Observation and interviews during the facility walk through on 02/04/2014 at 3:40 pm revealed the humidity monitor in operating room 1 was reading 18 percent and operating room 2 had a monitor that gave a reading of "Low".

The above findings were acknowledged at the time by the Biomedical Engineer. The findings were also acknowledged by the CFO/Administrator during the exit conference on 02/04/2014 at 4:20 pm.

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