HospitalInspections.org

Based on observation and staff interview, the facility does not ensure that the egress pathway is maintained and unobstructed. Failure to maintain the egress pathway may delay evacuation of the area in the event of an emergency.

Findings include:

During the facility tour of the dietary department on 06/08/17 at 01:40 PM, the following was observed:

-The fire door in the marked egress pathway adjacent to the three-bay pot/pan sink, did not close completely and when the door was closed completely, it did not latch. A latching device must be capable of keeping the door fully closed when five pounds of force is applied to the latch edge of the door.
-The marked egress pathway, adjacent to the three-bay pot/pan sink, was obstructed by a cart, a soda recycling bin and a cardboard recycling bin. All components in the marked egress pathway must be continuously maintained for use and free of all obstructions in the event of an actual emergency.

Interview with Staff YY on 06/08/17 at 01:45 PM verified this finding.

Based on observation and staff interview, the facility does not ensure the maintenance of the one-hour and two-hour rated walls. Failure to maintain these walls may result in staff, patients and visitors being exposed to fire and/or smoke in the event of an actual emergency.

Findings include:

During the facility tour on 06/07/17 through 06/09/17, it was observed that penetrations were present in the rated fire and smoke walls in the following areas:

-On 06/07/17, penetrations were noted in the two-hour fire rated wall in the medical staff office, between the 1st and 2nd floors (1½ inch wire chase); in the two-hour fire wall in the VP Patient Care Services/Quality office; and in the one-hour fire wall in the administrative assistant for patient care services office.
-On 06/09/17, penetrations were noted in the one-hour smoke wall in the women's operating room locker room; the rated wall in pharmacy; in the one-hour fire wall of the steam boiler room; above the smoke doors adjacent to bone density, in the one-hour fire walls of the regulated medical waste room, in the two-hour fire wall adjacent to the social worker's office in the Behavioral Health Unit and in the two-hour fire wall in the hospital boiler room.

Interview with Staff F on 06/07/17 and with Staff F and XX on 06/09/17 verified these findings.

Based on observation and staff interview, the facility does not ensure that exit signs are visible in the pathway of egress. Failure to ensure the exit signs are visible may result in staff, patients and visitors not being able exit promptly in the event of an emergency.

Findings include:

During the facility tour on 06/07/17 at 11:00 AM, it was observed that the exit sign located in the egress pathway of the HRF corridor was obstructed and was not visible. This sign was blocked by a larger sign stating "Medical/Surgical Unit".

Interview with Staff F on 06/07/17 at 11:10 AM verified this finding.

Based on observation and staff interview, the facility does not ensure that the fire alarm system is maintained. Failure to maintain the fire alarm system may result in delayed egress in the event of an actual fire emergency.

Findings include:

During the facility tour on 06/09/17 at 12:00 PM, it was observed that the fire alarm control panel was in a trouble alarm.

Interview with Staff WW and XX on 06/09/17 at 12:00 PM revealed they did not have knowledge of why the system was in a trouble alarm, nor did they know how to immediately reset the panel. The panel was able to be reset after approximately 20 minutes.

Interview with Staff F on 06/09/17 at 3:00 PM stated that the night time mechanic had performed maintenance on a smoke head in the nursing home area.

Based on document review and staff interview, the facility does not ensure that all components of the fire alarm system are tested annually. Failure to test all components of the fire alarm system may result in inadequate notification and containment in the event of an actual emergency.

Findings include:

Review of the fire alarm inspection report on 06/08/17 at 08:50 AM did not indicate that the audio/visual devices, the visual devices or the magnetic hold open devices on the fire doors are tested annually.

Interview with Staff F on 06/08/17 at 1:00 PM verified this finding.

Based on observation and staff interview, the facility does not ensure that doors and frames are rated in the rated walls. Failure to provide rated doors and frames may result in premature failure of the assembly.

Findings include:

During the facility tour on 06/07/17 at 10:30 AM and 11:30 AM and on 06/09/17 at 11:30 AM revealed that the doors and frames were not rated. These doors and frames were located adjacent to the medical staff office, adjacent to bone density, and adjacent to the vending machines. It was also observed that the frame was not rated in the two-hour wall assembly of the in the behavioral health unit.

Interview with Staff F on 06/07/17 at 10:35 AM and 11:35 AM and on 06/09/17 at 11:35 AM verified these findings.

Based on observation and staff interview, the facility does not ensure mechanical exhaust fans are operational. Failure to maintain these mechanical exhaust fans may result in inadequate ventilation throughout the facility.

Findings include:

During the facility tour on 06/06/17 at 11:20 AM and on 06/09/17 at 11:30 AM and 11:45 AM, it was observed that the mechanical exhaust in the endoscopy reprocessing room, the regulated medical waste (RMW) room, the janitor's closet/laundry room on the Behavioral Health Unit (BHU) and the janitor's closet adjacent to the hospital boiler room were not operational.

Interview with Staff F 06/06/17 at 2:00 PM and with Staff F and XX on 06/09/17 at 01:30 PM verified these findings.

Based on document review and staff interview, the facility does not ensure that documentation is maintained when the hood filters are replaced in the pharmacy area.

Findings include:

Review of the provided documentation on 06/08/17 at 12:30 PM revealed no evidence as to when the filters were changed on the hood in the pharmacy.

Iinterview with Staff F on 06/09/17 at 09:00 AM verified this finding.

Based on observation and staff interview, the facility does not ensure that two master alarm panels are provided for the medical gas system. Failure to provide two master panels may result in inadequate notification to pertinent staff.

Findings include:

During the facility tour on 06/09/17 at 01:30 PM revealed one master alarm panel is provided for the medical gas system located at the nurse's station on the medical/surgical unit. Master alarm panels must be in separate locations. One alarm must be located in the principal working area of the individual responsible for the maintenance of the medical gas system and one must be located in an area of continuous observation.

Interview with Staff F on 06/09/17 at 2:00 PM verified that the facility has only one master alarm panel.

Based on document review and staff interview, the facility does not ensure that the medical gas system is inspected annually. Failure to inspected the medical gas system at regular intervals may result in problems not being identified promptly.

Findings include:

Review of the medical gas inspection report on 06/09/17 indicated that the most recent inspection of the medical gas system occurred in 2013. Different components of the system are required to be inspected at different intervals.

Interview with Staff F on 06/09/17 at 2:30 PM verified this finding.

Based on observation, document review and staff interview, the facility does not ensure that the medical gas piping is labeled. Failure to label the piping and inspect the system may result in the system failing prematurely.

Findings include:

During the facility tour on 06/07/17 through 06/09/17, it was observed that the medical gas piping is not labeled above the ceiling tiles. Medical gas piping must be labeled a maximum of every 20 feet and at least once in every room. This labeling must be stenciled on the piping or identified with adhesive markers.

Interview with Staff F on 06/09/17 at 2:00 PM verified this finding.