HospitalInspections.org

JSPEN

Based on observation and interview, it was determined that the facility failed to provide smoke barrier doors in accordance with regulations in one of four smoke barrier door openings.

Findings include:

Observation on November 27, 2013 at 8:00 am revealed corridor double smoke barrier doors (adjacent to medical records) have vision panel glass that lacks a stamped fire rating. Facility shall verify the glass in the smoke barrier doors are protected with a fire-rated glazing or wired glass panels in steel frames.

Interview with Director of Nursing (DON) on November 27, 2013 at 8:00 am confirmed the facility shall verify the vision panels in the smoke barrier doors are in accordance with regulations.

JSPEN

Based on observation and interview, facility failed to maintain hazardous areas in accordance with regulations in one of eleven fire rated rooms.

Findings include:

Observation on November 27, 2013 at 8:10 am revealed medical records room door (in administration behind front desk) is held open with a wedge.

Interview with DON on November 27, 2013 at 8:10 am confirmed the medical records room door is held open with an unauthorized hold-open device, and the subsequent correction of this item during the time of the survey.

JSPEN

Based on observation and interview, facility failed to maintain readily accessible exits in two of four exits.

Observation on November 27, 2013 between 8:05 am and 8:30 am revealed the following exit discharges have not been cleared of snow and are not readily accessible:
A. M.R.I. exit (8:05 am).
B. O.R. exit (8:30 am).

Interview with DON on November 27, 2013 at 8:30 am confirmed the exit discharges are not maintained clear for instant access.

Based on observation and interview, it was determined the facility failed to maintain one of four smoke barrier door openings within the Lawrence County Surgery Center of Edgewood Surgical Hospital.

Observation on December 5, 2013 at 9:10 am revealed two sets of automatic double smoke barrier doors at the entrance to the sterile area (four doors total), lacked fire-rated or wire glass vision panels in steel frames.

Interview with the DON on December 5, 2013 at 9:10 am confirmed the lack of fire-rated or wire glass vision panels in steel frames.

JSPEN

Based on observation and interview, it was determined that the facility failed to provide smoke barrier doors in accordance with regulations in one of four smoke barrier door openings.

Findings include:

Observation on November 27, 2013 at 8:00 am revealed corridor double smoke barrier doors (adjacent to medical records) have vision panel glass that lacks a stamped fire rating. Facility shall verify the glass in the smoke barrier doors are protected with a fire-rated glazing or wired glass panels in steel frames.

Interview with Director of Nursing (DON) on November 27, 2013 at 8:00 am confirmed the facility shall verify the vision panels in the smoke barrier doors are in accordance with regulations.

JSPEN

Based on observation and interview, facility failed to maintain hazardous areas in accordance with regulations in one of eleven fire rated rooms.

Findings include:

Observation on November 27, 2013 at 8:10 am revealed medical records room door (in administration behind front desk) is held open with a wedge.

Interview with DON on November 27, 2013 at 8:10 am confirmed the medical records room door is held open with an unauthorized hold-open device, and the subsequent correction of this item during the time of the survey.

JSPEN

Based on observation and interview, facility failed to maintain readily accessible exits in two of four exits.

Observation on November 27, 2013 between 8:05 am and 8:30 am revealed the following exit discharges have not been cleared of snow and are not readily accessible:
A. M.R.I. exit (8:05 am).
B. O.R. exit (8:30 am).

Interview with DON on November 27, 2013 at 8:30 am confirmed the exit discharges are not maintained clear for instant access.

Based on observation and interview, it was determined the facility failed to maintain one of four smoke barrier door openings within the Lawrence County Surgery Center of Edgewood Surgical Hospital.

Observation on December 5, 2013 at 9:10 am revealed two sets of automatic double smoke barrier doors at the entrance to the sterile area (four doors total), lacked fire-rated or wire glass vision panels in steel frames.

Interview with the DON on December 5, 2013 at 9:10 am confirmed the lack of fire-rated or wire glass vision panels in steel frames.