HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier door openings.

Findings include:

1. Observation on April 23, 2014, at 1:35 PM revealed the double doors to the Receiving Area, near the exterior exit, needed a coordinator adjustment to properly close in the frame.

Interview with Director of Maintenance on April 23, 2014, at 1:35 PM confirmed the doors would not close smoke tight.

Based on observation and interview, it was determined the facility failed to ensure that doors to hazardous areas would properly close and latch.

Findings include:

1. Observation on April 23, 2014, at 12:55 PM revealed the automatic closer on the Dry Storage room door in the kitchen was disabled.

Interview with the Facility Representative on April 23, 2014, at 12:55 PM confirmed the closer was disabled.

2. Observation on April 23, 2014, at 1:50 PM revealed the door on the Soiled Utility Room in the O.R. suite needed a latch adjustment to close in the frame.

Interview with the Facilty Representative on April 23, 2014, at 1:50 PM confirmed the door lacked positive latching.

3. Observation on April 23, 2014, at 1:55 PM revealed the double doors on the Soiled Holding Room near the ER Manager's office lacked positive latching.

Interview with the Facility Representative on April 23, 2014, at 1:55 PM confirmed the doors would not latch in the frame.

Based on observation and interview, it was determined the facility failed to ensure that exit access was being maintained readily accessible.

Findings include:

1. Observation on April 23, 2014, at 1:10 PM revealed that the door on the patient restroom in Wound Care was equipped with a dead-bolt, requiring a two-step operation to exit the restroom.

Interview with the Facility Representative on April 23, 2014, at 1:10 PM confirmed the dead bolt did not release upon activation of the lockset.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in accordance with the regulations.

Findings include:

1. Observation on April 23, 2014, at 2:10 PM revealed the spare sprinkler cabinet in the Pump Room lacked the minimum number of required spare sprinklers and sprinkler head wrench.

Interview with the Facility Representative on April 23, 2014, at 2:10 PM confirmed there were only five spare sprinklers and no wrench.

Based on observation and interview, it was determined the facility failed to properly store trash receptacles greater than 32-gallon capacity when left unattended.

Findings include:

1. Observation on April 24, 2014, at 8:45 AM revealed a recycling bin with a capacity greater than 32 gallons being stored in the Pharmacy.

Interview with the Facility Representative on April 24, 2014, at 8:45 AM confirmed the wheeled bin was stored outside of a protected hazardous storage area and exceeded the allowable capacity.

Based on observation and interview, it was determined the facility failed to store medical gas in accordance with the regulations.

Findings include:

1. Observation on April 23, 2014, at 1:52 PM revealed an unsecured "E" size oxygen cylinder in a Storage Room, across the corridor from the Director of Housekeeping Office.

Interview with the Facility Representative on April 23, 2014, at 1:52 PM confirmed the oxygen cylinder was not secured.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier door openings.

Findings include:

1. Observation on April 23, 2014, at 1:35 PM revealed the double doors to the Receiving Area, near the exterior exit, needed a coordinator adjustment to properly close in the frame.

Interview with Director of Maintenance on April 23, 2014, at 1:35 PM confirmed the doors would not close smoke tight.

Based on observation and interview, it was determined the facility failed to ensure that doors to hazardous areas would properly close and latch.

Findings include:

1. Observation on April 23, 2014, at 12:55 PM revealed the automatic closer on the Dry Storage room door in the kitchen was disabled.

Interview with the Facility Representative on April 23, 2014, at 12:55 PM confirmed the closer was disabled.

2. Observation on April 23, 2014, at 1:50 PM revealed the door on the Soiled Utility Room in the O.R. suite needed a latch adjustment to close in the frame.

Interview with the Facilty Representative on April 23, 2014, at 1:50 PM confirmed the door lacked positive latching.

3. Observation on April 23, 2014, at 1:55 PM revealed the double doors on the Soiled Holding Room near the ER Manager's office lacked positive latching.

Interview with the Facility Representative on April 23, 2014, at 1:55 PM confirmed the doors would not latch in the frame.

Based on observation and interview, it was determined the facility failed to ensure that exit access was being maintained readily accessible.

Findings include:

1. Observation on April 23, 2014, at 1:10 PM revealed that the door on the patient restroom in Wound Care was equipped with a dead-bolt, requiring a two-step operation to exit the restroom.

Interview with the Facility Representative on April 23, 2014, at 1:10 PM confirmed the dead bolt did not release upon activation of the lockset.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in accordance with the regulations.

Findings include:

1. Observation on April 23, 2014, at 2:10 PM revealed the spare sprinkler cabinet in the Pump Room lacked the minimum number of required spare sprinklers and sprinkler head wrench.

Interview with the Facility Representative on April 23, 2014, at 2:10 PM confirmed there were only five spare sprinklers and no wrench.

Based on observation and interview, it was determined the facility failed to properly store trash receptacles greater than 32-gallon capacity when left unattended.

Findings include:

1. Observation on April 24, 2014, at 8:45 AM revealed a recycling bin with a capacity greater than 32 gallons being stored in the Pharmacy.

Interview with the Facility Representative on April 24, 2014, at 8:45 AM confirmed the wheeled bin was stored outside of a protected hazardous storage area and exceeded the allowable capacity.

Based on observation and interview, it was determined the facility failed to store medical gas in accordance with the regulations.

Findings include:

1. Observation on April 23, 2014, at 1:52 PM revealed an unsecured "E" size oxygen cylinder in a Storage Room, across the corridor from the Director of Housekeeping Office.

Interview with the Facility Representative on April 23, 2014, at 1:52 PM confirmed the oxygen cylinder was not secured.