HospitalInspections.org

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 15 patients in the med/surg wing. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 3:30 PM showed that the entrance door of room 113 could not be closed and latched. A strip of metal between the carpeted corridor and the patient room had loosed from the floor and jammed under the bottom of the door, preventing it from closing into the jamb tightly enough to latch.

During an interview on 03/12/12 at 3:35 PM, Staff P, Director of Maintenance and Engineering, stated that there is not a preventive maintenance policy or schedule for doors. He stated that maintenance has monthly Preventive Maintenance checklists and randomly checks hardware for function on monthly rounds. He stated that they do not keep a log or records except for repairs.

Based on observation and interview the facility failed to maintain a smoke and fire separation between floors in accordance with 8.2.5 and fill annular spaces around hot water pipes with suitable noncombustible material (concrete, mortar or grout). The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:30 PM showed annular spaces around three six-inch water pipes that penetrated the floor of a closet Radiology uses for storage of supplies. The annular spaces were unfilled and showed the boiler room below.

During an interview on 03/12/12 at 2:40 PM, Staff P, Director of Maintenance and Engineering, acknowledged the spaces and stated that he did have appropriate material to fill them with that would be equivalent to the six inches of reinforced concrete floor.

Based on observation and interview, the facility failed to ensure a clear and unobstructed path to one of nine designated exits of the single story building in accordance with 7.1.10.1. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:45 PM showed a large yellow barrel on wheels in the corridor outside of a room used for Ultrasound studies, directly in the path of egress to an exit access on the southwest side of the building, next to Nuclear Medicine. The barrel, a 44 gallon capacity Rubbermaid brand, "Brute" container, was observed parked in the same spot from 03/12/12 at 2:45 PM through 03/15/12 at 11:00 AM, all the days of the survey. Three other 44 gallon yellow barrels, also labeled and designated for soiled linen were parked in other areas of the building; inside the Physical Therapy department, in the corridor outside of the kitchen (Dietary Manager's office), and in the non-sterile corridor outside of the surgical suite.

During an interview on 03/14/12 at 10:30 AM, Staff Q, Director of Housekeeping and Laundry Services, stated the barrels were in the corridors because there was no place to store the barrels inside the departments. She stated the barrels were emptied daily by the laundry staff.

During an interview on 03/15/12 at 10:00 AM, Staff A, Vice President of Patient Care said there was no policy addressing impediments to the exit egress or path to a safe exit.

Based on interview and record review, the facility failed to show documentation of sensitivity tests performed within the past five years in accordance with that all smoke detectors test all smoke detectors at least annually in accordance with NFPA 72, chapter 10.4.3. This deficient practice affects all visitors, staff and patient census. The facility census was 11.

Findings Include:

1. During an interview on 03/13/12 at 10:00 AM, Staff P, Director of Maintenance and Engineering, stated that maintenance checks smoke detectors quarterly and annually, and they are tested as part of the fire alarm notification system when it is recertified annually. He stated that he did not have documentation of sensitivity tests performed on the smoke detectors and could not remember when they had been tested, but was sure it had been more than five years ago. He stated he does not have a written procedure for testing smoke detectors or a policy to ensure they receive scheduled sensitivity tests every five years from qualified service personnel such as a factory trained and certified or certified by reputable national institute.

Based on observation and interview, the facility failed to properly store soiled linen or trash collection receptacles exceeding 32 gallons capacity in a room designed and protected as a hazardous area in accordance with 7.1.10.1. The facility census was 11.
Findings included:

1. Observation during tours on 03/12/12 at 2:45 PM through 3/15/12 at 11:00 AM showed more than six large 44 gallon capacity Rubbermaid "Brute" waste containers being used throughout the facility for trash and soiled linen. Four of the 44 gallon yellow barrels were constantly unattended and never moved to a room protected as a hazardous area as follows:
-Parked in the corridor outside of ultrasound, (also blocked the path of egress to a designated exit through the Radiology corridor).
-Parked in the corridor outside of the Dietary Manager's office.
-Parked at the end of a dead end corridor, outside of the surgical suite.
-Parked in Physical Therapy, at the end of a partial wall, outside of the toilet.
The other (dark gray color) 44 gallon barrels were observed stored inside of a room or the laundry protected as a hazardous area, or if on the floor, were constantly in use by laundry, housekeeping and dietary services.

During an interview on 03/14/12 at 10:30 AM, Staff Q, Director of Housekeeping and Laundry Services stated the barrels were in the corridors because there was no place to store the barrels inside the departments. She stated the barrels were for soiled linen and emptied daily by the laundry staff.

During an interview on 0315/12 at 10:00 AM, Staff A, Vice President of Patient Care stated there was no policy to address impediments to exit egress (blocked hallways) and no policy on safely storing the large, 44 gallon waste containers.

Based on observation and interview, the facility failed to maintain a clear width and work area in an electrical room in accordance with NFPA 70, 12.5.3 which specifies a working space of at least 30 inches horizontally where rear or side access is required to work on de-energized parts of enclosed equipment and to ensure workers have adequate room to avoid contacting grounded components or incurring injury when retreating. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:00 PM showed three plastic folding tables, two office cubicle dividers, three table lamps, two carpeted box steps and more than 10 pair of children's crutches in an electrical room located in the outpatient corridor.

During an interview on 03/12/12, at 2:00 PM, Staff P, Director of Maintenance and Engineering acknowledged the observation and stated he did not have a blanket policy or procedure that addressed safety in electrical rooms, or safe storage suggestions for different departments in the hospital. He stated he would have the items removed.

Based on observation and interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 to protect the patients, staff and visitors during the unlikely eventual failure of the fire alarm system. The facility is not completely sprinklered and the fire alarm system is zoned, and not fully addressable. The facility census was 11.

Findings included:

1. During an interview on 03/14/12 at 10:30 AM, Staff P, Director of Maintenance and Engineering said the facility does not have a formal written plan for a fire watch if the fire alarm or automatic sprinkler system is out of service for more than four hours and has not identified or trained specific personnel to perform this duty.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 15 patients in the med/surg wing. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 3:30 PM showed that the entrance door of room 113 could not be closed and latched. A strip of metal between the carpeted corridor and the patient room had loosed from the floor and jammed under the bottom of the door, preventing it from closing into the jamb tightly enough to latch.

During an interview on 03/12/12 at 3:35 PM, Staff P, Director of Maintenance and Engineering, stated that there is not a preventive maintenance policy or schedule for doors. He stated that maintenance has monthly Preventive Maintenance checklists and randomly checks hardware for function on monthly rounds. He stated that they do not keep a log or records except for repairs.

Based on observation and interview the facility failed to maintain a smoke and fire separation between floors in accordance with 8.2.5 and fill annular spaces around hot water pipes with suitable noncombustible material (concrete, mortar or grout). The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:30 PM showed annular spaces around three six-inch water pipes that penetrated the floor of a closet Radiology uses for storage of supplies. The annular spaces were unfilled and showed the boiler room below.

During an interview on 03/12/12 at 2:40 PM, Staff P, Director of Maintenance and Engineering, acknowledged the spaces and stated that he did have appropriate material to fill them with that would be equivalent to the six inches of reinforced concrete floor.

Based on observation and interview, the facility failed to ensure a clear and unobstructed path to one of nine designated exits of the single story building in accordance with 7.1.10.1. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:45 PM showed a large yellow barrel on wheels in the corridor outside of a room used for Ultrasound studies, directly in the path of egress to an exit access on the southwest side of the building, next to Nuclear Medicine. The barrel, a 44 gallon capacity Rubbermaid brand, "Brute" container, was observed parked in the same spot from 03/12/12 at 2:45 PM through 03/15/12 at 11:00 AM, all the days of the survey. Three other 44 gallon yellow barrels, also labeled and designated for soiled linen were parked in other areas of the building; inside the Physical Therapy department, in the corridor outside of the kitchen (Dietary Manager's office), and in the non-sterile corridor outside of the surgical suite.

During an interview on 03/14/12 at 10:30 AM, Staff Q, Director of Housekeeping and Laundry Services, stated the barrels were in the corridors because there was no place to store the barrels inside the departments. She stated the barrels were emptied daily by the laundry staff.

During an interview on 03/15/12 at 10:00 AM, Staff A, Vice President of Patient Care said there was no policy addressing impediments to the exit egress or path to a safe exit.

Based on interview and record review, the facility failed to show documentation of sensitivity tests performed within the past five years in accordance with that all smoke detectors test all smoke detectors at least annually in accordance with NFPA 72, chapter 10.4.3. This deficient practice affects all visitors, staff and patient census. The facility census was 11.

Findings Include:

1. During an interview on 03/13/12 at 10:00 AM, Staff P, Director of Maintenance and Engineering, stated that maintenance checks smoke detectors quarterly and annually, and they are tested as part of the fire alarm notification system when it is recertified annually. He stated that he did not have documentation of sensitivity tests performed on the smoke detectors and could not remember when they had been tested, but was sure it had been more than five years ago. He stated he does not have a written procedure for testing smoke detectors or a policy to ensure they receive scheduled sensitivity tests every five years from qualified service personnel such as a factory trained and certified or certified by reputable national institute.

Based on observation and interview, the facility failed to properly store soiled linen or trash collection receptacles exceeding 32 gallons capacity in a room designed and protected as a hazardous area in accordance with 7.1.10.1. The facility census was 11.
Findings included:

1. Observation during tours on 03/12/12 at 2:45 PM through 3/15/12 at 11:00 AM showed more than six large 44 gallon capacity Rubbermaid "Brute" waste containers being used throughout the facility for trash and soiled linen. Four of the 44 gallon yellow barrels were constantly unattended and never moved to a room protected as a hazardous area as follows:
-Parked in the corridor outside of ultrasound, (also blocked the path of egress to a designated exit through the Radiology corridor).
-Parked in the corridor outside of the Dietary Manager's office.
-Parked at the end of a dead end corridor, outside of the surgical suite.
-Parked in Physical Therapy, at the end of a partial wall, outside of the toilet.
The other (dark gray color) 44 gallon barrels were observed stored inside of a room or the laundry protected as a hazardous area, or if on the floor, were constantly in use by laundry, housekeeping and dietary services.

During an interview on 03/14/12 at 10:30 AM, Staff Q, Director of Housekeeping and Laundry Services stated the barrels were in the corridors because there was no place to store the barrels inside the departments. She stated the barrels were for soiled linen and emptied daily by the laundry staff.

During an interview on 0315/12 at 10:00 AM, Staff A, Vice President of Patient Care stated there was no policy to address impediments to exit egress (blocked hallways) and no policy on safely storing the large, 44 gallon waste containers.

Based on observation and interview, the facility failed to maintain a clear width and work area in an electrical room in accordance with NFPA 70, 12.5.3 which specifies a working space of at least 30 inches horizontally where rear or side access is required to work on de-energized parts of enclosed equipment and to ensure workers have adequate room to avoid contacting grounded components or incurring injury when retreating. The facility census was 11.

Findings included:

1. Observation on 03/12/12 at 2:00 PM showed three plastic folding tables, two office cubicle dividers, three table lamps, two carpeted box steps and more than 10 pair of children's crutches in an electrical room located in the outpatient corridor.

During an interview on 03/12/12, at 2:00 PM, Staff P, Director of Maintenance and Engineering acknowledged the observation and stated he did not have a blanket policy or procedure that addressed safety in electrical rooms, or safe storage suggestions for different departments in the hospital. He stated he would have the items removed.

Based on observation and interview the facility failed to provide a plan for the institution of a fire watch in accordance with paragraph 9.6.1.8 to protect the patients, staff and visitors during the unlikely eventual failure of the fire alarm system. The facility is not completely sprinklered and the fire alarm system is zoned, and not fully addressable. The facility census was 11.

Findings included:

1. During an interview on 03/14/12 at 10:30 AM, Staff P, Director of Maintenance and Engineering said the facility does not have a formal written plan for a fire watch if the fire alarm or automatic sprinkler system is out of service for more than four hours and has not identified or trained specific personnel to perform this duty.