HospitalInspections.org

Based on observation and staff interview, the facility failed to install smoke detectors in activity room that were open to the corridor. Findings:

1. A tour of the facility was conducted on 07/10/2024, and the following observations were made:

a. The activity room next to patient room 209 and the room next to the mock apartment did not have a door and was open to the corridor. These two rooms were not equipped with required hard wired smoke detectors to protect the rooms since the two doors have been removed.

2. The Manager of Maintenance/Environmental Services was present during the tour of the facility and acknowledged the observations.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 07/10/2024 at 1:45 p.m. The most recent annual sprinkler inspection document was dated 05/15/2024.

A quarterly sprinkler inspection should have been performed in the first quarter of 2024 and the fourth quarter of 2023, but no documentation was found for the two missing quarterly sprinkler inspections.

2. The Manager of Maintenance/Environmental Services was present during the record review on 07/10/24 and stated the inspection company failed to perform the quarterly inspections for the past year.

Based on record review and interview, the facility failed to conduct the routine inspections of the non-rated corridor doors and pateint room doors throughout the hospital. Findings:

1. The facility records were reviewed on 07/10/2024 at 1:30 p.m., and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The Manager of Maintenance/Environmental Services were interviewed during the record review and she stated they do rountine repairs and inspections, but they did not document the inspections.


Maintenance, Inspection & Testing - Doors
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)