HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure there were no impediments to the closing of the corridor doors, in one location within the facility.

Findings include:

1. Observation on March 17, 2015, at 1:00 PM revealed the 1st floor, Director of Hospice office corridor door, was held open by unauthorized means, a rubber wedge.

Interview with the Director of Quality Management and Assistant Director of Environmental Services on March 17, 2015, at 2:15 PM confirmed the door was held open by a rubber wedge.

Based on observation and interview, it was determined the facility failed to maintain the 1/2-hour fire resistance rating of smoke barrier walls in one location within this facility.

Findings include:

1. Observation on March 17, 2015, at 1:20 PM revealed multiple unsealed penetrations of the smoke barrier wall around communication cables and MC armored cable in the 1st floor General Storage Room.

Interview with the Director of Quality Management and Assistant Director of Environmental Services on March 17, 2015, at 2:15 PM confirmed the unsealed penetrations.

Based on documentation review and interview, it was determined the facility failed to perform required inspections of the kitchen hood/duct.

Findings include:

1. Review of documents on March 17, 2015, between 8:30 AM and 9:45 AM revealed that kitchen hood/duct cleaning inspections were not conducted semi-annually. Documentation provided indicated inspections were performed on 1/14/14 and 12/16/14.

Interview with the Director of Quality Management and Assistant Director of Environmental Services on March 17, 2015, at 2:15 PM confirmed the cleaning was not performed semi-annually.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage and administration areas in one location within this facility.

Findings include:

1. Observation on March 17, 2015, at 12:55 PM revealed a 2" x 2" section of drywall cut out of the Medical Gas Manifold Room enclosure wall, as viewed from above the suspended ceiling, in the 1st floor Administrative Office.

Interview with the Director of Quality Management and Assistant Director of Environmental Services on March 17, 2015, at 2:15 PM confirmed the unsealed penetration.

Based on documentation review and interview, it was determined the facility failed to maintain generator components within this facility.

Findings include:

1. Review of records on March 17, 2015, between 8:30 AM and 9:45 AM revealed documentation was unavailable verifying weekly battery electrolyte/specific gravity testing for the facility diesel generator, storage batteries.

Interview with the Director of Quality Management and Assistant Director of Environmental Services on March 17, 2015, at 2:15 PM confirmed documentation was unavailable.