HospitalInspections.org

Based upon observations and staff interviews on June 25, 2024 between approximately 1030 to 1230 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

The cross-corridor fire doors near central supply failed to close and latch when the doors were released from their hold open devices.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.
The findings include:

The facility could not provide documentation indicating the forward flow inspection had been completed in the last year.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 1030 to 1230 hours the facility has failed to properly maintain fire/smoke barriers within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

There was an unsealed penetration found in the basement IT room.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on June 25, 2024 between approximately 0900 to 1030 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

The facility could not provide documentation indicating the Won door has had its annual testing.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place patients, staff, and visitors of electrical shock or harm.

The findings include:

The facility could not provide documentation indicating that periodic testing on hospital grade receptacles had been completed or provide annual testing.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patient, staff, and/or visitors within the facility.

The findings include:

The facility could not provide documentation indicating weekly inspections are being performed on the generator.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 1030 to 1230 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

The facility is using a power-strip in place of permanent wiring found 1st floor room 1135 housekeeping room.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on June 25, 2024 between approximately 0900 to 1030 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include:

The facility could not provide documentation indicating guidelines, documentation of training for usage of medical gas equipment.

The above was discussed and acknowledged by the facility staff.