HospitalInspections.org

Based on observation and interview, the facility does not provide fire safety to patients and staff.

Findings include:

-Observation during facility tour on 8/13/10 at 11:20 AM revealed one of two corridor entrance doors to the laboratory maintained in the open position. The laboratory is considered a hazardous area. Hazardous areas must be separated from the facility with a one hour fire resistive rating or sprinklered. In addition to being held open, the door has no fire resistive rating. Interview with Staff #45 revealed that this door is maintained open for access to the employee time clock.

These findings were verified with Staff #1 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.

Based on observation, the facility does not provide a clear path of egress in the operating suite.

Findings include:

-Observation during facility tour on 8/9/10 at 2:00 PM revealed the sub-sterile corridor adjacent to Operating Room 4 was obstructed with surgical tables and supplies, which were stored on both sides of the corridor. The path of egress was less than 44 inches in clear width.

This finding was verified with Staff #27 on 8/9/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on observation and interview, the facility does not maintain the functionality of fire protection sprinklers in the laundry collection room.

Findings include:

-Observation during tour of the laundry chute collection room on 8/9/10 at 11:55 AM revealed that two sprinkler heads were obstructed by light fixtures.

This finding was verified with Staff #2 on 8/9/10.

Based on observation, the facility does not maintain the secure storage of oxygen tanks, and the separation of useable and empty oxygen tanks.

Findings include:

-Observation during facility tour on 8/9/10 at 10:00 AM revealed that both full and used oxygen tanks were stored together in a rack located in the store room of the Intensive Care Unit.

-Observation during facility tour on 8/9/10 at 10:30 AM with Staff #1 revealed an oxygen tank unsecured on the floor of the clean supply room in the emergency department.

-Observation during facility tour on 8/9/10 at 10:45 AM revealed that both full and used oxygen tanks were stored together in two different racks and unsecured on top of boxes in the storage room located on the S4 medical/surgical unit. Staff #5 was unable to determine which oxygen tanks were full or used.

-Observation during facility tour on 8/9/10 at 11:00 AM revealed four racks of both full and used oxygen tanks stored together in the storage room on the S3 psychiatric unit.
-This finding was verified with Staff #6 on 8/9/10.

-Observation during facility tour on 8/9/10 at 11:00 AM revealed four E size oxygen tanks stored on the floor behind the information desk in the main lobby.
-This finding was verified with Staff #2 on 8/9/10

-Observation during facility tour on 8/9/10 at 11:15 AM with Staff #19 revealed an oxygen tank unsecured on the floor of the small clean utility room on the H2 obstetrics unit.

-Observation during facility tour on 8/11/10 at 11:30 AM revealed two E size oxygen tanks stored on top of the desk in the Gastro Prep Room #191.

This finding was verified with Staff #32 on 8/11/10.

-Observation during facility tour on 8/12/10 at 10:55 AM revealed one E size oxygen tank stored unsecured on the floor of the gastro recovery room.

This finding was verified with Staff #32 on 8/12/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on observation and interview, the facility does not maintain the laboratory fume hoods.

Findings include:

-Observation during facility tour on 8/13/10 at 11:30 AM revealed strong organic chemical odors in the slide preparation room within the laboratory suite.

- Interview with Staff #45 revealed there is a preventive maintenance (PM) program conducted by the Biomedical Department for maintaining the hood ventilation systems. Follow-up contact with the Facilities Department and Biomedical Department revealed the hoods are not on a PM program.

These findings were verified with Staff #1 on 8/13/10.

Based on observation and interview, the facility does not provide fire safety to patients and staff.

Findings include:

-Observation during facility tour on 8/13/10 at 11:20 AM revealed one of two corridor entrance doors to the laboratory maintained in the open position. The laboratory is considered a hazardous area. Hazardous areas must be separated from the facility with a one hour fire resistive rating or sprinklered. In addition to being held open, the door has no fire resistive rating. Interview with Staff #45 revealed that this door is maintained open for access to the employee time clock.

These findings were verified with Staff #1 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.

Based on observation, the facility does not provide a clear path of egress in the operating suite.

Findings include:

-Observation during facility tour on 8/9/10 at 2:00 PM revealed the sub-sterile corridor adjacent to Operating Room 4 was obstructed with surgical tables and supplies, which were stored on both sides of the corridor. The path of egress was less than 44 inches in clear width.

This finding was verified with Staff #27 on 8/9/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on observation and interview, the facility does not maintain the functionality of fire protection sprinklers in the laundry collection room.

Findings include:

-Observation during tour of the laundry chute collection room on 8/9/10 at 11:55 AM revealed that two sprinkler heads were obstructed by light fixtures.

This finding was verified with Staff #2 on 8/9/10.

Based on observation, the facility does not maintain the secure storage of oxygen tanks, and the separation of useable and empty oxygen tanks.

Findings include:

-Observation during facility tour on 8/9/10 at 10:00 AM revealed that both full and used oxygen tanks were stored together in a rack located in the store room of the Intensive Care Unit.

-Observation during facility tour on 8/9/10 at 10:30 AM with Staff #1 revealed an oxygen tank unsecured on the floor of the clean supply room in the emergency department.

-Observation during facility tour on 8/9/10 at 10:45 AM revealed that both full and used oxygen tanks were stored together in two different racks and unsecured on top of boxes in the storage room located on the S4 medical/surgical unit. Staff #5 was unable to determine which oxygen tanks were full or used.

-Observation during facility tour on 8/9/10 at 11:00 AM revealed four racks of both full and used oxygen tanks stored together in the storage room on the S3 psychiatric unit.
-This finding was verified with Staff #6 on 8/9/10.

-Observation during facility tour on 8/9/10 at 11:00 AM revealed four E size oxygen tanks stored on the floor behind the information desk in the main lobby.
-This finding was verified with Staff #2 on 8/9/10

-Observation during facility tour on 8/9/10 at 11:15 AM with Staff #19 revealed an oxygen tank unsecured on the floor of the small clean utility room on the H2 obstetrics unit.

-Observation during facility tour on 8/11/10 at 11:30 AM revealed two E size oxygen tanks stored on top of the desk in the Gastro Prep Room #191.

This finding was verified with Staff #32 on 8/11/10.

-Observation during facility tour on 8/12/10 at 10:55 AM revealed one E size oxygen tank stored unsecured on the floor of the gastro recovery room.

This finding was verified with Staff #32 on 8/12/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.