HospitalInspections.org

Based on findings from interview the two areas used to store closed medical records (MRs) were not maintained as hazardous areas in compliance with NFPA 101, Chapter 13.

Findings include:

-- Per interview with the Director of Medical Records on 1/13/11 at 9:30 a.m., closed MRs for deceased patients and non active patients that are being held the required amount of time prior to disposal, are maintained in boxes in a storage room at the Renal Center and in the attic of the DeTorres building (two separate buildings offsite from the main campus).

-- Per interview with the Director of Facilities Management on 1/13/11 at 10:30 a.m., the rooms where the closed MRs were stored, located in the Renal Center and the DeTorres buildings, were not separated from other areas of the building by fire barriers having at least one hour fire resistant construction, nor were they provided with a sprinkler system as required by NFPA 101 (2000).

Based on findings from observations, numerous smoke detectors throughout the hospital were not installed in conformance with NFPA 72, 11.8.3.5.

Findings include:

--Per observations on 1/11/11 and 1/12/11, numerous smoke detectors were observed installed within a 36 inch horizontal path of ventilation ducts throughout the hospital. The Director of Facilities Management, who was present during the survey, observed and confirmed that the smoke detectors were not installed correctly.

Based on findings from observations, numerous alcohol based hand rub (ABHR) dispensers throughout the hospital were not located in accordance with NFPA 101 and instructions provided in Surveillance and Certification letter S&C-05-33, issued by the Center for Medicare and Medicaid Services on 6/9/05.

Findings:

--Per observations on 1/11/11 and 1/12/11, numerous ABHR dispensers were installed over or adjacent to ignition sources throughout the hospital. The Director of Facilities Management, who was present throughout the survey, observed and confirmed that numerous ABHR dispensers were not installed in acceptable locations.

Based on findings from interview the two areas used to store closed medical records (MRs) were not maintained as hazardous areas in compliance with NFPA 101, Chapter 13.

Findings include:

-- Per interview with the Director of Medical Records on 1/13/11 at 9:30 a.m., closed MRs for deceased patients and non active patients that are being held the required amount of time prior to disposal, are maintained in boxes in a storage room at the Renal Center and in the attic of the DeTorres building (two separate buildings offsite from the main campus).

-- Per interview with the Director of Facilities Management on 1/13/11 at 10:30 a.m., the rooms where the closed MRs were stored, located in the Renal Center and the DeTorres buildings, were not separated from other areas of the building by fire barriers having at least one hour fire resistant construction, nor were they provided with a sprinkler system as required by NFPA 101 (2000).

Based on findings from observations, numerous smoke detectors throughout the hospital were not installed in conformance with NFPA 72, 11.8.3.5.

Findings include:

--Per observations on 1/11/11 and 1/12/11, numerous smoke detectors were observed installed within a 36 inch horizontal path of ventilation ducts throughout the hospital. The Director of Facilities Management, who was present during the survey, observed and confirmed that the smoke detectors were not installed correctly.