HospitalInspections.org

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed corridor door (administrative coordinators office) was held in the open position by an unapproved device. Findings include:

1. Observation at 1:30 p.m. revealed the corridor door to the administrative coordinator's office was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the environmental services director at the time of the observation confirmed that finding.

B. Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for four randomly observed doors to the corridor (operating room entrance, male operating room lockers, female operating room lockers, and the obstetrics soiled utility room). Findings include:

1. Observation at 2:56 p.m. revealed the corridor doors to the operating room entrance, male operating room lockers, female operating room lockers, and the obstetrics soiled utility room were not provided with positive latching hardware. Interview with the environmental services director at the time of the observation confirmed that finding. She stated those doors had never had latching hardware installed since the original construction of the building.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Two of nine exit doors (radiology and employee entrance) were not readily accessible. Findings include:

1. Observation at 2:20 p.m. revealed the south leaf of the exterior exit doors next to the radiology department had a cable attaching it to the wall of the building preventing it from opening more than a couple of inches. That cable prevented that door from opening in the event of an emergency. Interview with the environmental services director at the time of the observation revealed she was aware of that condition. She stated the cable had been installed to prevent the door from being damaged by the wind

2. Observation at 2:41 p.m. revealed the south leaf of the exterior door to the employee entrance (adjacent to the boiler room) had a kick-down door stop installed on it. That kick-down door stop could become wedged and prevent that door from opening in the event of an emergency. Interview with the environmental services director at the time of the observation revealed she was aware of that condition. She stated she was aware the kick-down was in use but was not aware of the hazard it could present.

Based on observation, testing, and interview, the provider failed to furnish emergency lighting of at least one hour duration. The battery powered emergency lights in the CT room and CT control room did not work. Findings include:

1. Observation and testing at 2:15 p.m. revealed the battery powered emergency lights in the CT room and CT control room did not work when the test button was depressed. Interview with the environmental services director at the time of the observation revealed she did not have testing of those emergency light on the preventive maintenance schedule.

Based on observation and interview, the provider failed to ensure staff were familiar with fire drill procedures. Findings include:

1. Observation during the fire drill at 3:20 p.m. revealed the staff person responding to the simulated fire was not familiar with the facility's fire drill procedure. That staff person had to be instructed to pull the manual pull station to activate the buildings fire alarm system. Interview with the environmental services director at the time of the observation confirmed that finding.

Based on record review and interview, the provider failed to conduct required inspection of the cooking facility's fire extinguishing system. Inspections of the ansul system for the range hood must be conducted not less than every six months. Findings include:

1. Record review revealed the fire extinguishment system for the kitchen hood was last inspected on 7/27/10 and then it had not been inspected again until 2/1/11. That timeframe between inspections exceeded the maximum limit of six months. Interview with the director of environmental services at the time of the observation confirmed that condition. She stated she was unaware of that condition.

I. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Gregory clinic) (building 01) was found not in compliance with LSC requirements for hospitals.

Based on observation and interview, the provider failed to furnish exit signs in locations in accordance with section 7.10 of the Life Safety Code. Findings include:

1. Observation at 12:11 p.m. revealed the door to the vestibule for the north exit did not have an exit sign indicating it was part of the exit path. Further observation revealed when that door was closed the location of the exit for that end of the building was unidentifiable. Interview with the environmental services director at the time of the observation confirmed that finding.

II. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Winner clinic) (building 02) was found not in compliance with LSC requirements for hospitals.

Based on observation, testing, and interview, the provider failed to maintain exit signs with continuous illumination. All of the observed exit signs did not properly function. Findings include:

1. Observation and testing on 3/30/11 at 4:52 p.m. revealed the three combination exit light/signs for the clinic were not functioning when tested for battery operation. Interview with the clinic manager at the time of the observations confirmed that finding. He indicated he was unaware those signs were not functioning.


III. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Fairfax clinic) (building 04) was found not in compliance with LSC requirements for hospitals.

Based on observation and interview, the provider failed to furnish exit signs in locations in accordance with section 7.10 of the Life Safety Code. Findings include:

1. Observation at 12:11 p.m. revealed the door for the east exit did not have an exit sign indicating it was part of the exit path. Further observation revealed the exit sign for that door was placed over an adjacent door leading to the interior of the building. Interview with the environmental services director at the time of the observation confirmed that finding.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring and article 210-8 Ground-Fault Circuit-Interrupter Protection for Personnel. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring in one randomly observed location. Power strips were in use in place of permanent wiring in the emergency room. Findings include:

1. Observation at 2:02 p.m. revealed two power strips were in use in place of permanent wiring in the emergency room. Those power strips were used to power a blood pressure monitor, a piece of diagnostic equipment, and an ophthalmoscope/otoscope charging station. Interview with the environmental services director at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at three randomly observed resident rooms (dialysis room, dialysis waiting room, and patient room 38). Findings include:

1. Observation beginning at 10:30 a.m. revealed ABHR containers were installed adjacent to an electrical source in the dialysis room, dialysis waiting room, and patient room 38. Interview at the time of the observation with the environmental services director confirmed that finding. She stated she would relocate the ABHR containers to acceptable locations as soon as possible.

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed corridor door (administrative coordinators office) was held in the open position by an unapproved device. Findings include:

1. Observation at 1:30 p.m. revealed the corridor door to the administrative coordinator's office was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the environmental services director at the time of the observation confirmed that finding.

B. Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for four randomly observed doors to the corridor (operating room entrance, male operating room lockers, female operating room lockers, and the obstetrics soiled utility room). Findings include:

1. Observation at 2:56 p.m. revealed the corridor doors to the operating room entrance, male operating room lockers, female operating room lockers, and the obstetrics soiled utility room were not provided with positive latching hardware. Interview with the environmental services director at the time of the observation confirmed that finding. She stated those doors had never had latching hardware installed since the original construction of the building.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Two of nine exit doors (radiology and employee entrance) were not readily accessible. Findings include:

1. Observation at 2:20 p.m. revealed the south leaf of the exterior exit doors next to the radiology department had a cable attaching it to the wall of the building preventing it from opening more than a couple of inches. That cable prevented that door from opening in the event of an emergency. Interview with the environmental services director at the time of the observation revealed she was aware of that condition. She stated the cable had been installed to prevent the door from being damaged by the wind

2. Observation at 2:41 p.m. revealed the south leaf of the exterior door to the employee entrance (adjacent to the boiler room) had a kick-down door stop installed on it. That kick-down door stop could become wedged and prevent that door from opening in the event of an emergency. Interview with the environmental services director at the time of the observation revealed she was aware of that condition. She stated she was aware the kick-down was in use but was not aware of the hazard it could present.

Based on observation, testing, and interview, the provider failed to furnish emergency lighting of at least one hour duration. The battery powered emergency lights in the CT room and CT control room did not work. Findings include:

1. Observation and testing at 2:15 p.m. revealed the battery powered emergency lights in the CT room and CT control room did not work when the test button was depressed. Interview with the environmental services director at the time of the observation revealed she did not have testing of those emergency light on the preventive maintenance schedule.

Based on observation and interview, the provider failed to ensure staff were familiar with fire drill procedures. Findings include:

1. Observation during the fire drill at 3:20 p.m. revealed the staff person responding to the simulated fire was not familiar with the facility's fire drill procedure. That staff person had to be instructed to pull the manual pull station to activate the buildings fire alarm system. Interview with the environmental services director at the time of the observation confirmed that finding.

Based on record review and interview, the provider failed to conduct required inspection of the cooking facility's fire extinguishing system. Inspections of the ansul system for the range hood must be conducted not less than every six months. Findings include:

1. Record review revealed the fire extinguishment system for the kitchen hood was last inspected on 7/27/10 and then it had not been inspected again until 2/1/11. That timeframe between inspections exceeded the maximum limit of six months. Interview with the director of environmental services at the time of the observation confirmed that condition. She stated she was unaware of that condition.

I. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Gregory clinic) (building 01) was found not in compliance with LSC requirements for hospitals.

Based on observation and interview, the provider failed to furnish exit signs in locations in accordance with section 7.10 of the Life Safety Code. Findings include:

1. Observation at 12:11 p.m. revealed the door to the vestibule for the north exit did not have an exit sign indicating it was part of the exit path. Further observation revealed when that door was closed the location of the exit for that end of the building was unidentifiable. Interview with the environmental services director at the time of the observation confirmed that finding.

II. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Winner clinic) (building 02) was found not in compliance with LSC requirements for hospitals.

Based on observation, testing, and interview, the provider failed to maintain exit signs with continuous illumination. All of the observed exit signs did not properly function. Findings include:

1. Observation and testing on 3/30/11 at 4:52 p.m. revealed the three combination exit light/signs for the clinic were not functioning when tested for battery operation. Interview with the clinic manager at the time of the observations confirmed that finding. He indicated he was unaware those signs were not functioning.


III. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted on 3/30/11. Avera Gregory Healthcare Center (Fairfax clinic) (building 04) was found not in compliance with LSC requirements for hospitals.

Based on observation and interview, the provider failed to furnish exit signs in locations in accordance with section 7.10 of the Life Safety Code. Findings include:

1. Observation at 12:11 p.m. revealed the door for the east exit did not have an exit sign indicating it was part of the exit path. Further observation revealed the exit sign for that door was placed over an adjacent door leading to the interior of the building. Interview with the environmental services director at the time of the observation confirmed that finding.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring and article 210-8 Ground-Fault Circuit-Interrupter Protection for Personnel. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring in one randomly observed location. Power strips were in use in place of permanent wiring in the emergency room. Findings include:

1. Observation at 2:02 p.m. revealed two power strips were in use in place of permanent wiring in the emergency room. Those power strips were used to power a blood pressure monitor, a piece of diagnostic equipment, and an ophthalmoscope/otoscope charging station. Interview with the environmental services director at the time of the observation confirmed that condition.