HospitalInspections.org

Based on observation and interview, the facility failed to ensure to maintain a one-hour rated fire separation between a soiled linen room/hazardous area that exceeded 50 square feet and a corridor that served as a protected egress to a designated exit in accordance with 19.3. This failure to secure a rated fire door exposes the corridor if there was a fire in the room and has the potential to affect all staff, visitors and patients. The facility census was 84.

Findings included:

1. Observation on 10/30/14 at 8:58 AM of the soiled utility room at the Barry Road facility showed the one hour fire rated door propped open with a trash container. The corridor door of the room was connected to a self closing device to ensure air pressure in the room remained at a negative airflow, and to provide continuous separation between the room and the corridor.

2. During an interview, on 10/30/14 at 9:00 AM, the Director of Maintenance at Barry Road acknowledged the finding and stated that the door should not be propped open.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, 4.3.1.1.2 and 4.3.5.2.1 with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, and become unguided projectiles with enough force to penetrate a brick or concrete wall and cause injury or death to staff and patients. The facility census was 84.

Findings included:

1. Observation on 10/28/14 at 10:45 AM in the Barry Road facility showed approximately 90 H-sized cylinders of compressed gases chained in four groups of twenty or more each. Approximately 30 of the free-standing cylinders had caps attached were chained in a group against one wall. Three more groups of 20 cylinders apiece, each group bound with a single chain, were connected to the manifolds of the facility's medical gas system, which rendered them vulnerable to damage if one or more were tipped over during change-outs.

2. During an interview on 10/24/14 at 10:45 AM, the Director of Maintenance at Barry Road and the Director of Maintenance at Smithville, acknowledged the finding and stated that they did not know they needed to be individually secured.

Based upon observation and interview, the facility failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. The deficient practice, the storage of flammables in the same compartment where paper and plastic combustible products are stored, potentially affects the safety of all staff and patients. The facility census was 84.

Findings included:

1. Observations on 10/27/14 at 3:30 PM in the Barry Road facility's kitchen dry goods storage room showed two partially used cases of Sterno, (a flammable gelatin of glycol and propylene in a can used for warming casseroles or dutch ovens) in a small closet in the kitchen.

2. Observation on 10/28/14 at 1:00 PM in the Smithville facility's kitchen showed a case of Sterno, with six cans remaining, on an open countertop of the kitchen's food preparation area.

3. During an interview on 10/28/14 at 1:30 PM, the Director of Food Services (Smithville) acknowledged the finding and stated that she had already received word that they would have to find a safer place to store it.

4. During an interview on 10/28/14 at 1:30 PM, the Director of Maintenance, stated that he did not think they had a policy that addressed the safe storage of flammable products.

Based on observation and interview, the facility failed to ensure to maintain a one-hour rated fire separation between a soiled linen room/hazardous area that exceeded 50 square feet and a corridor that served as a protected egress to a designated exit in accordance with 19.3. This failure to secure a rated fire door exposes the corridor if there was a fire in the room and has the potential to affect all staff, visitors and patients. The facility census was 84.

Findings included:

1. Observation on 10/30/14 at 8:58 AM of the soiled utility room at the Barry Road facility showed the one hour fire rated door propped open with a trash container. The corridor door of the room was connected to a self closing device to ensure air pressure in the room remained at a negative airflow, and to provide continuous separation between the room and the corridor.

2. During an interview, on 10/30/14 at 9:00 AM, the Director of Maintenance at Barry Road acknowledged the finding and stated that the door should not be propped open.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, 4.3.1.1.2 and 4.3.5.2.1 with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, and become unguided projectiles with enough force to penetrate a brick or concrete wall and cause injury or death to staff and patients. The facility census was 84.

Findings included:

1. Observation on 10/28/14 at 10:45 AM in the Barry Road facility showed approximately 90 H-sized cylinders of compressed gases chained in four groups of twenty or more each. Approximately 30 of the free-standing cylinders had caps attached were chained in a group against one wall. Three more groups of 20 cylinders apiece, each group bound with a single chain, were connected to the manifolds of the facility's medical gas system, which rendered them vulnerable to damage if one or more were tipped over during change-outs.

2. During an interview on 10/24/14 at 10:45 AM, the Director of Maintenance at Barry Road and the Director of Maintenance at Smithville, acknowledged the finding and stated that they did not know they needed to be individually secured.

Based upon observation and interview, the facility failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. The deficient practice, the storage of flammables in the same compartment where paper and plastic combustible products are stored, potentially affects the safety of all staff and patients. The facility census was 84.

Findings included:

1. Observations on 10/27/14 at 3:30 PM in the Barry Road facility's kitchen dry goods storage room showed two partially used cases of Sterno, (a flammable gelatin of glycol and propylene in a can used for warming casseroles or dutch ovens) in a small closet in the kitchen.

2. Observation on 10/28/14 at 1:00 PM in the Smithville facility's kitchen showed a case of Sterno, with six cans remaining, on an open countertop of the kitchen's food preparation area.

3. During an interview on 10/28/14 at 1:30 PM, the Director of Food Services (Smithville) acknowledged the finding and stated that she had already received word that they would have to find a safer place to store it.

4. During an interview on 10/28/14 at 1:30 PM, the Director of Maintenance, stated that he did not think they had a policy that addressed the safe storage of flammable products.