HospitalInspections.org

Based on observation, the critical access hospital failed to ensure that there was no impediment to closing doors protecting corridor openings.

Failure to ensure that doors protecting corridor openings close and latch risks spread of smoke and fire into the emergency egress corridor.

Findings include:

During a tour of the hospital on 09/14/10, it was found that doors protecting corridor openings in the following locations did not fully close or latch as required:

1) Clinical Services Administrator office door
2) Equipment room door
3) Aide Office door (By nurses' station)
4) Fire/Smoke doors by Heath Information Management Office.

Based on record review and interview, the critical access hospital failed to conduct or document that fire drills were conducted at least quarterly on each shift.

Failure to conduct regular fire drills risks staff being unprepared to respond quickly to a fire emergency.

Findings include:

During review of fire drill documentation on 09/14/10, it was found that there was no documentation of that fire drills had been conducted on the following shifts:

2009 4th quarter, day shift and night shift
2010 1st quarter, night shift
2010 2nd quarter, day shift

Hospital engineering personnel confirmed that no records could be found documenting fire drills conducted during the above shifts.

Based on record review and interview, the critical access hospital failed to ensure that cooking facilities were protected in accordance with 9.2.3, by failing to inspect the fire suppression system on the kitchen grill hood at six-month intervals.

Failure to inspect the kitchen grill hood fire suppression system risks failure of the system in the event of fire.

Findings include:

During review of documentation on 09/14/10, no evidence could be found that the kitchen hood fire suppression system was inspected more frequently than annually. The previous inspection report was dated 10/19/2009. There was no inspection report for 04/2009 or 04/2010. Hospital engineering personnel stated that no further records were available.

Based upon observation, the critical access hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 09/14/10, it was observed that large wheeled recycle paper bin exceeding 32 gallons capacity werelocated in the following locations:

The executive conference room
The recreational treatment program office
The basement level elevator lobby in the assisted living facility, which communicated via the elevator shaft to the hospital swing bed day room

These rooms were not protected as hazardous areas.

Based on observation, the critical access hospital failed to store flammable and combustible liquids in approved containers.

Failure to store combustible liquids in approved containers risks spread of flammable fumes and consequent fire in the hospital.

Findings include:

During a tour of the hospital on 09/14/10, it was observed that at least four gallons of paints and solvents labeled "combustible" were stored on open shelves in a room that also contained a source of potential ignition (the electric compressors for the hospital vacuum system).

Based on observation, the critical access hospital failed to ensure that there was no impediment to closing doors protecting corridor openings.

Failure to ensure that doors protecting corridor openings close and latch risks spread of smoke and fire into the emergency egress corridor.

Findings include:

During a tour of the hospital on 09/14/10, it was found that doors protecting corridor openings in the following locations did not fully close or latch as required:

1) Clinical Services Administrator office door
2) Equipment room door
3) Aide Office door (By nurses' station)
4) Fire/Smoke doors by Heath Information Management Office.

Based on record review and interview, the critical access hospital failed to conduct or document that fire drills were conducted at least quarterly on each shift.

Failure to conduct regular fire drills risks staff being unprepared to respond quickly to a fire emergency.

Findings include:

During review of fire drill documentation on 09/14/10, it was found that there was no documentation of that fire drills had been conducted on the following shifts:

2009 4th quarter, day shift and night shift
2010 1st quarter, night shift
2010 2nd quarter, day shift

Hospital engineering personnel confirmed that no records could be found documenting fire drills conducted during the above shifts.

Based on record review and interview, the critical access hospital failed to ensure that cooking facilities were protected in accordance with 9.2.3, by failing to inspect the fire suppression system on the kitchen grill hood at six-month intervals.

Failure to inspect the kitchen grill hood fire suppression system risks failure of the system in the event of fire.

Findings include:

During review of documentation on 09/14/10, no evidence could be found that the kitchen hood fire suppression system was inspected more frequently than annually. The previous inspection report was dated 10/19/2009. There was no inspection report for 04/2009 or 04/2010. Hospital engineering personnel stated that no further records were available.

Based upon observation, the critical access hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include but are not limited to:

During a tour of the critical access hospital on 09/14/10, it was observed that large wheeled recycle paper bin exceeding 32 gallons capacity werelocated in the following locations:

The executive conference room
The recreational treatment program office
The basement level elevator lobby in the assisted living facility, which communicated via the elevator shaft to the hospital swing bed day room

These rooms were not protected as hazardous areas.

Based on observation, the critical access hospital failed to store flammable and combustible liquids in approved containers.

Failure to store combustible liquids in approved containers risks spread of flammable fumes and consequent fire in the hospital.

Findings include:

During a tour of the hospital on 09/14/10, it was observed that at least four gallons of paints and solvents labeled "combustible" were stored on open shelves in a room that also contained a source of potential ignition (the electric compressors for the hospital vacuum system).