HospitalInspections.org

Based on record review and interview, the facility failed to conduct a full-scale community-based (or a full-scale facility based) exercise, at least annually. This deficiency affects all staff and patients in the facility. Findings include:

1. Review of the facility EP plan on 8/27/19 at 11:02 a.m. showed a lack of evidence that the facility had conducted a full-scale community-based and/or facility-based exercise in the last year.

During an interview on 8/27/19 at 11:03 a.m., staff member C stated the facility had not completed a full-scale community-based or facility-based exercise in the last year. He stated the facility conducted a table top exercise on 5/8/19.

Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5).

Findings include:

1. During an observation on 8/27/19 at 9:16 a.m., the education room was inspected. Several items including boxes were observed obstructing the egress path out of the doors to the public way.

Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

Findings include:

1. During an observation on 8/27/19 at 9:24 a.m., the EMS office was inspected. The door in the office was fitted with a deadbolt lock which created more than one latching mechanism on the door.

2. During an observation on 8/27/19 at 9:34 a.m., the education room was inspected. The door in the room was fitted with a deadbolt lock which created more than one latching mechanism on the door.

3. During an observation on 8/27/19 at 9:37 a.m., the medical records office was inspected. The door in the office was fitted with a deadbolt lock which created more than one latching mechanism on the door.

4. During an observation on 8/27/19 at 10:22 a.m., the service hall storage room was inspected. The door in the room was fitted with a deadbolt lock which created more than one latching mechanism on the door.

5. During an observation on 8/27/19 at 10:40 a.m., room 117 on the Med-Surg hall was inspected. The door in the room was fitted with a deadbolt lock which created more than one latching mechanism on the door.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

Findings include:

1. During an observation on 8/27/19 at 10:05 a.m., the operating room recovery room was inspected. The door in the room was fitted with a non-approved door stop which was being used to hold the door open. The door was fitted with a self-closure.

2. During an observation on 8/27/19 at 10:11 a.m., the Ante utility room was inspected. The door in the room was observed being held open with a non-approved door stop. The door was fitted with a self-closure.

3. During an observation on 8/27/19 at 10:16 a.m., the business office was inspected. The door in the room was observed being held open with a non-approved door stop. The door was fitted with a self-closure.

Based on observations, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.1.2.2, and 7.10.1.5.2.

Findings include:

1. During an observation on 8/27/19 at 9:36 a.m., the basement stairwell was inspected. The area lacked an illuminated exit sign where the path of egress was not obvious.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7. Findings include:

1. During an observation on 8/27/19 at 9:33 a.m., the fire alarm pull station in the education room was found to be blocked from instant access by various items being stored in front of it.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/27/19 at 9:49 a.m., the lab restroom was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

2. During an observation on 8/27/19 at 9:50 a.m., the housekeeping closet by the lab was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

3. During an observation on 8/27/19 at 10:39 a.m., the OB housekeeping closet was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

4. During an observation on 8/27/19 at 10:44 a.m., the crawl space access room in the Med Surg hall was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

5. During an observation on 8/27/19 at 10:45 a.m., the linen closet on the Med Surg hall was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

6. During an observation on 8/27/19 at 10:46 a.m., the housekeeping closet by the nursing station was inspected. A sprinkler head within the room was observed, blocked by a ceiling mounted light fixture.

Based on observation and record review, the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.
b) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.2 and 5.2.1.1.1, 5.3.2.1, and table 5.1.1.2.

Findings include:

1. Review of the facility sprinkler maintenance reports on 8/27/19 showed the facility failed to have the sprinkler system inspected every ninety days, with a ten-day grace period. The 2018 third quarter inspection was conducted on 9/12/18 and the next inspection did not occur until 1/9/19.

2. Review of the facility sprinkler maintenance reports on 8/27/19 showed the facility failed to have the sprinkler system inspected every ninety days, with a ten-day grace period. The 2019 first quarter inspection was conducted on 1/9/19 and the next inspection did not occur until 5/8/19.

3. During an observation on 8/27/19 at 9:22 a.m., the EMS office was inspected. The sprinkler pipe in the room was observed with a grey wire hanging from the sprinkler pipe within the room.

4. During an observation on 8/27/19 at 9:28 a.m., the server room was inspected. A ceiling tile was observed missing from the ceiling fixture within the room.

5. During an observation on 8/27/19 at 9:38 a.m., the medical records storage room was inspected. The sprinkler pipe in the room was observed with several cords attached to and hanging from the sprinkler pipe within the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 8/27/19 at 10:07 a.m., the instrument wash room was inspected. The portable fire extinguisher in the room was found to freestanding within the room and was not secured.

2. During an observation on 8/27/19 at 10:38 a.m., the OB main area was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. Review of facility documents regarding fire drills on 8/27/19, showed there was no documentation for completed fire drills for PM shifts for the fourth quarter of 2018 and the first and second quarters of 2019.

Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 8/27/19 at 9:06 a.m., the clinic nurse's station was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

2. During an observation on 8/27/19 at 9:27 a.m., the server room was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

Based on observation, the facility failed to ensure power strips were used per NFPA 99-2012, and extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 8/27/19 at 9:07 a.m., the doctor office in the clinic was inspected. An unsecured surge protector was observed, dangling from the wall within the room.

2. During an observation on 8/27/19 at 9:08 a.m., the clinical support office was inspected. An unsecured surge protector was observed, dangling from the wall within the room.

3. During an observation on 8/27/19 at 9:23 a.m., the EMS office was inspected. A green extension cord was observed, which was plugged into the outlet on the wall.

4. During an observation on 8/27/19 at 9:32 a.m., the education room was inspected. An unsecured surge protector was observed, dangling from the wall within the room.

Based on observation, the facility failed to ensure that the oxygen storage locations were maintained in accordance with NFPA 99-2012 Edition, Sections 5.1.3.3.2 (10), 11.3.4.1 and 11.3.4.2.

Findings include:

1. During an observation on 8/2719 at 10:24 a.m., the oxygen storage room was observed. The oxygen storage room was located indoors and lacked a cautionary oxygen sign. The sign must include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED
NO SMOKING