HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barrier walls in two instances within the facility.

Findings include:

1. Observation on March 12, 2015, at 10:45 AM revealed:

a. 10:45 AM - The 1st floor smoke barrier door located on the Medical Storage room lacked a self -closing device.

b. 10:55 AM - The 1st floor cross corridor smoke barrier door located near the Medical Records room did not close entirely when released from the hold open magnet.

Exit interview with facility representative #1 on March 12, 2015, between 12:50 PM and 1:00 PM confirmed the smoke barrier door deficiencies.

Based on observation and interview, it was determined the facility failed to ensure exit access corridors were maintained clear and unobstructed within the facility.

Findings include:

1. Observation on March 12, 2015, at 12:05 PM revealed several linen carts stored in the corridor located in the lower level Clean Linen Process room.

Exit interview with facility representative #1 on March 12, 2015, between 12:50 PM and 1:00 PM confirmed the items stored in the corridor.

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the emergency generator in two instances within the facility.

Findings include:

1. Documentation review on March 12, 2015, at 8:35 AM revealed the weekly electrolyte level checks were not performed on the emergency generator batteries for the entire past year.
Exit interview with facility representative #1 on March 12, 2015, between 12:50 PM and 1:00 PM confirmed the lack of documentation.
2. Observation on March 12, 2015, at 9:05 AM revealed the generator location had not maintained a minimum of 30 inches of working space around the unit.

Exit interview with facility representative #1 on March 12, 2015, between 12:50 PM and 1:00 PM confirmed the lack of working space.