HospitalInspections.org

Based on observation and interview, the facility failed to protect hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2.1.3. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 06/18/18 at 5:00 pm, observation revealed the double corridor door from the ambulance garage did not self-close and latch as the door was held open by the door coordinator.

2. On 06/18/18 at 5:05 pm, observation revealed the cafeteria door near the tray return did not self-close and latch.

3. On 06/18/18 at 5:08 pm, observation revealed the dish room door did not self-close and latch.

4. On 06/18/18 at 5:20 pm, observation revealed the double corridor door from the central supply room did not self-close and latch as the door was held open by the door coordinator.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff N and Staff P.

Based on observation, record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 5.1.1.2 & 5.2.1. This deficient practice could affect all 6 patients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 06/18/2018 at 2:30 pm, document review revealed that the 2017 fourth quarter inspection and testing was missed.

2. On 06/18/2018 at 4:15 pm, observation revealed that a sprinkler in the nursing administration office was not kept free of lint and other foreign material.

3. On 06/18/2018 at 4:52 pm, observation revealed that a sprinkler in the pharmacy medical hood room was not kept free of lint and other foreign material.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff N and Staff P.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect patients using the OR/recovery and Emergency Department suites, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 06/18/2018 at 4:00 pm observation revealed that the double corridor door into the OR/recovery suite did not fully close and latch.

2. On 06/18/2018 at 4:40 pm observation revealed that the double corridor doors into the Emergency Department by observation room
#2 did not fully close and latch.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff N and Staff P.

Based on record review and interview, the facility failed to provide loading and testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition), 19.5.1 and 9.1.3; and NFPA 110 (2010 edition), 8.4.2. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

On 06/05/18 at 4:11 pm, it was noted during a review of the generator, monthly and weekly records, for the last 12 months, that there was no weekly generator inspection reports for 2017, or January through March of 2018. Additionally, there was no record of the 90 minute annual test of the battery powered generator task light.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff N and Staff P.