HospitalInspections.org

Based on observation and interview the facility failed to provide positive latching mechanisms on patient room doors. This deficient practice affects all patients and staff on the unit. The facility census was 15.

Findings included:

1. Observation on the afternoon of 12/12/12 during a tour of the facility showed all 12 patient room doors on the medical surgical unit were provided with closure devices but all 12 patient room doors were not provided with positive latching mechanisms to securely latch the door in the door frame when closed.

2. Staff P, Security/Safety/Maintenance, confirmed at that time the doors were not currently nor have been provided with positive latching mechanisms.

Section 19.3.6.3.2 of the National Fire Protection Association (NFPA 101) states doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction.

Based on document review and interview the facility failed to conduct monthly and annual tests of all battery-powered emergency lighting unit. This deficient practice affects all occupants of the building. The facility census was 15.

Findings included:

Review of the preventive maintenance documentation of fire safety equipment, conducted on the afternoon of 12/11/12, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting unit located in the emergency generator room.

During an interview on 12/12/12 at 1:15 PM, Staff P, Security/Safety/Maintenance, stated that staff had not been testing the battery-powered emergency lighting unit in the generator room on a monthly and yearly basis.

Section 7.9.3 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours.

Bases on observation and interview the facility failed to maintain all means of egress (exit paths) free of obstructions. This deficient practice affects all patients in one of two smoke compartments. The facility census was 15.

Findings included:

1. Observation on 12/12/12 at 2:02 PM during a tour of the facility showed 4 computers on wheels, plugged into electrical outlets for recharging, an 1 medication cart in the corridor, a designated means of egress, adjacent to patient room 105.

2. Staff P, Security/Safety/Maintenance, confirmed at that time those 5 units are placed in that area of the corridor when not in use by the staff due to a lack of space on the unit.

Section 7.1.10.1 of the National Fire Protection Association (NFPA 101) states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.