HospitalInspections.org

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain corridor doors to be positive latching.

Findings:

1. The 2nd stage recovery double corridor doors did not have a means to positive latch when in the closed position.

2. Physical therapy area doors were observed to be obstructed from closing by hand dumbbells that were utilized as door stops.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain smoke barriers to be free from unsealed penetrations.

Findings:

Unsealed penetrations were observed above the lay-in ceiling assembly at the ER Exam Room 1 area smoke barrier, and at the OR area smoke barrier.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the facility did not provide a one hour fire rating for all hazardous areas in the facility.

Findings:

The following hazardous area corridor doors did not close to positive latch as required when allowed to self close: the soiled side laundry room door and the east wing soiled utility room door.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain battery back-up emergency lights in accordance with CMS regulations.

Findings:

The battery back-up emergency light located in the transfer switch area did not function when tested during the survey.

This observation was made in the presence of the maintenance supervisor.

Based on observation and fire systems testing record review during the life safety survey completed on 01/06/2010, the hospital did not test fire alarm equipment in accordance with NFPA 72 and per CMS regulations.

Findings:

1. There was no documentation to verify that quarterly sprinkler flow alarm tests were being conducted.

2. There was no documentation that annual load testing was completed on the fire alarm panel batteries.

These observations were made in the presence of the maintenance supervisor.

Based on observation and fire sprinkler systems testing record review during the life safety survey completed on 01/06/2010, the hospital did not test fire sprinkler system equipment in accordance with NFPA 13 and per CMS regulations.

Findings:

There was no documentation to verify that tamper valves were tested at least semi-annually as required.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not provide portable fire extinguishers at all required locations in accordance with NFPA 10 and per CMS regulations.

Findings:

The commercial kitchen area was not equipped with a K type extinguisher within 30 feet of the cooking equipment as required.

This observation was made in the presence of the maintenance supervisor.

Based on a review of hospital smoking policies during the life safety survey completed on 01/06/2010, the hospital did not have smoking policies addressing supervision of patients who smoke per CMS regulations.

Findings:

Hospital policies did not address supervision criteria for patients who may be classified as prohibited to smoke except when under direct supervision.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not provide exit corridors and exits to be free from obstructions to immediate use per CMS regulations.

Findings:

The south OR corridor exit was observed to be obstructed from immediate use by several IV trees, and various OR equipment.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain oxygen cylinder storage in accordance with NFPA 99.

Findings:

Two unsecured e-tanks were observed in the cylinder storage cage on the loading dock area.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not install Alcohol Based Hand Rub (ABHR) dispensers in accordance with CMS regulations.

Findings:

Numerous ABHR dispensers were observed to be installed immediately above ignition sources, either light switches or electrical wall outlets. Examples include: x-ray area rooms, kitchen area, and ER exam rooms.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain corridor doors to be positive latching.

Findings:

1. The 2nd stage recovery double corridor doors did not have a means to positive latch when in the closed position.

2. Physical therapy area doors were observed to be obstructed from closing by hand dumbbells that were utilized as door stops.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain smoke barriers to be free from unsealed penetrations.

Findings:

Unsealed penetrations were observed above the lay-in ceiling assembly at the ER Exam Room 1 area smoke barrier, and at the OR area smoke barrier.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the facility did not provide a one hour fire rating for all hazardous areas in the facility.

Findings:

The following hazardous area corridor doors did not close to positive latch as required when allowed to self close: the soiled side laundry room door and the east wing soiled utility room door.

These observations were made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain battery back-up emergency lights in accordance with CMS regulations.

Findings:

The battery back-up emergency light located in the transfer switch area did not function when tested during the survey.

This observation was made in the presence of the maintenance supervisor.

Based on observation and fire systems testing record review during the life safety survey completed on 01/06/2010, the hospital did not test fire alarm equipment in accordance with NFPA 72 and per CMS regulations.

Findings:

1. There was no documentation to verify that quarterly sprinkler flow alarm tests were being conducted.

2. There was no documentation that annual load testing was completed on the fire alarm panel batteries.

These observations were made in the presence of the maintenance supervisor.

Based on observation and fire sprinkler systems testing record review during the life safety survey completed on 01/06/2010, the hospital did not test fire sprinkler system equipment in accordance with NFPA 13 and per CMS regulations.

Findings:

There was no documentation to verify that tamper valves were tested at least semi-annually as required.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not provide portable fire extinguishers at all required locations in accordance with NFPA 10 and per CMS regulations.

Findings:

The commercial kitchen area was not equipped with a K type extinguisher within 30 feet of the cooking equipment as required.

This observation was made in the presence of the maintenance supervisor.

Based on a review of hospital smoking policies during the life safety survey completed on 01/06/2010, the hospital did not have smoking policies addressing supervision of patients who smoke per CMS regulations.

Findings:

Hospital policies did not address supervision criteria for patients who may be classified as prohibited to smoke except when under direct supervision.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not provide exit corridors and exits to be free from obstructions to immediate use per CMS regulations.

Findings:

The south OR corridor exit was observed to be obstructed from immediate use by several IV trees, and various OR equipment.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 01/06/2010, the hospital did not maintain oxygen cylinder storage in accordance with NFPA 99.

Findings:

Two unsecured e-tanks were observed in the cylinder storage cage on the loading dock area.

This observation was made in the presence of the maintenance supervisor.