HospitalInspections.org

Based on observation, it was determined the facility failed to maintain doors to resist the passage of smoke in one of three janitor closets..

The findings included:

1. Observation of the janitor closet by patient room 306 on 8/13/12 at 10:30 AM revealed the latch had been covered with foam tape to prevent the door from closing and locking .


2. The findings were acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.

Based on observation, it was determined the facility failed to maintain sprinkler heads.

The findings included:

1. Observations of patient room 302 on 8/13/12 at 10:50 AM revealed the sprinkler head in the toilet room did not have an escutcheon ring.

2. Observation of the vacant washer room on 8/13/12 at 10:00 AM revealed 2 of 2 sprinkler heads with a buildup of lint.

3. Observation of the bulk linen storage room on 8/13/12 at 11:20 AM revealed 2 of 3 sprinkler heads with a build up of lint.

4. The findings were acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.

Based on observation, it was determined the facility failed to maintain egress to all exits and public ways.

The findings included:

1. Observation of the exit across from the administrators office on 8/13/12 at 9:30 AM revealed 1 of 10 discharge paths obstructed with a shrub to a public way.

2. Observation of the exit door to the courtyard at 10:20 AM revealed 1 of 10 exit doors obstructed with a set of wheelchair scales stored 6 feet from the exit doors.

3. The findings were acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.

Based on observation, it was determined the facility failed to keep oxygen cylinders in a secure condition to prevent damage.

The findings included:

1. Observation of the occupational therapy room on 8/13/12 at 9:00 AM revealed 1 of 8 oxygen cylinders not secured.

2. The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.

Based on observation, it was determined the facility failed to maintain rated ceilings.

The findings included:

1. Observation of patient room 314 on 8/13/12 at 10:00 AM revealed a penetration around the sprinkler head to the rated ceiling in the center of the room.

2. Observation of the bulk linen room on 8/13/12 at 11:25 AM revealed a penetration around the smoke detector through the rated ceiling.

3. The findings were acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.

Based on observation, it was determined the facility failed to install ground fault interrupting circuits (GFIC) within 6 feet of sinks.

The findings included:

1. Observation of the occupational therapy room on 8/13/12 at 9:05 AM revealed 1 of 2 electrical receptacles was not a GFIC.

2. The findings were acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 8/13/12.