HospitalInspections.org

Based on observation, facility record review and staff interview the facility failed to ensure the main entrance/exit doors to the Bayside unit is maintained in good repair, and is operational as architecturally designed for patient safety.

The findings are:

An observation of the facility conducted with the Director of plan operations beginning at 11:00 AM on 4/12/10, revealed the entrance double door to the Bayside Units are damaged, both doors do not open as Architecturally designed. Upon entering the Bayside unit, one of the double doors was observed to be held shut by a screw.
Upon inquiry, the Director of Plan Operations stated, the entrance/exit double doors are damaged and it prevents the doors from staying locked. The doors will not lock securely if the screw is removed. He further stated the doors cannot be repaired and both doors have to be replaced. The Director acknowledged that in the event of a fire the doors would not open as designed.

Interview with a Registered Nurse during the above observation at 12:25 PM, and review of the patient census report revealed the Bayside Unit had 20 patients on 04/12/10.

Review of the facility environmental record revealed a Maintenance Request dated 02/22/10, that documents, "Door to Bayside Unit not working on its own .Please check door to the entrance of Bayside unit".

The Director stated during an interview on 04/12/10 at 1:15 PM, a request to replace the Bayside unit doors was submitted for approval on 02/18/10 and it was approved on 02/26/10, but the doors have not yet been replaced, as noted on 04/13/2010.

The facility safety inspection record indicates that on 03/16/10, during a fire drill, the Bayside unit doors did not latch properly.