HospitalInspections.org

Based on observation, the hospital does not provide fire safety to patients and staff in compliance with NFPA Life Safety Code 101 related to the door to the medication room in the BHU (Behavioral Health Unit).

Observation during facility tour on 1/12/12 at 2:00 PM revealed the "Dutch door" leading into the medication room of the BHU did not have a latch and an astragal, rabbet or bevel on the upper leaf.

This finding was verified with Staff #19 on 1/12/12.

Based on observation, the hospital does not provide fire safety to patients and staff in compliance with NFPA Life Safety Code 101 related to the storage of medical records.

Findings include:

Observation during facility tour on 1/12/12 at 10:45 AM revealed the medical records storage suite is not separated from the hospital floor with a "one hour fire separation". Furthermore, this suite does not contain smoke detection devices.

This finding was verified with Staff #20 on 1/12/12.

Based on observation, the hospital does not provide fire safety to patients and staff in compliance with NFPA Life Safety Code 101 in regard to exit access in the surgical suite.

Observation during facility tour on 1/10/12 at 2:15 PM revealed that numerous items used in the surgical suite were stored in the "cat walk" exit passageway of the surgical suite, which obstructed the exit width.

This finding was verified with Staff #20 on 1/10/12.

Based on observation, the hospital does not provide compliance with NFPA 99 Standard for Health Care Facilities as required by this regulation in regard to medical gas storage.

Findings include:

Observation during facility tour on 1/12/12 at 11:30 AM revealed medical gas supply headers for nitrogen and nitrous oxide are located and connected in the air handler room adjacent to the surgical suite. Electric panel breaker boxes are mounted next to the headers and are less than 5 feet from the floor and subject to damage from the stored tanks.

This finding was verified with Staff #20 on 1/12/12.

Based on observation, document review and interview, the hospital does not maintain the relative humidity equal to or greater than 35% in Operating Room (OR) #1.

Findings include:

Observation during facility tour on 1/10/12 at 2:30 PM revealed the humidistat in OR #1 registered a reading of 20% humidity. Review on 1/10/12 of the daily humidity records revealed readings for the previous 5 days were also below the required 35%.

Interview with Staff #20 on 1/12/12 revealed the facility is unable to maintain the humidity within the required 35-60%.

Based on observation, the facility does not provide fire safety to patients and staff in compliance with NFPA Life Safety Code 101 in regard to placement of alcohol based hand rub (ABHR) containers over ignition sources.

Findings include:

Observation during facility tour on 1/9/12 at 10:15 AM revealed ABHR containers were mounted over ignition sources in Emergency Department rooms #1 and 6, and ICU room #3.

These findings were verified with Staff #20 on 1/9/12