HospitalInspections.org

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the wall of the south stair tower was free of penetrations as required.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that there was a one inch hole in the wall of the south stair tower at the hospital landing that had a wire penetrating the opening that was not sealed.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the smoke barrier wall to the hospital wing from the lobby was not penetrated.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that there was a one inch hole in the smoke barrier wall over the doorway to the nursing wing that was not sealed.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that certain hazardous areas were free of penetrations that may allow smoke and fire to travel out of the areas. Also, a door to the laundry area was found open with no one present.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that the following listed areas had penetrations as listed.
1. The laundry chute room has conduits and cable wires penetrating the ceiling that were not sealed. There also was a loose ceiling tile in the ceiling.
2. There was a bx cable penetrating the wall to the corridor of room S-124, AHU room 2.
3 There is piping penetrating the wall of the laundry on the hallway side that was not sealed.
4. There was piping and conduits penetrating the wall of the laundry on the dryer end of the room.
5. There is a hole in the sewing room wall that adjoins the morgue room that was not sealed.

It was observed that the doors to the laundry area were open with equipment running, and no one in the area.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the new closet in the dining room was provided with sprinkler protection as required. Also the cooler and freezer in the kitchen are not sprinkled as well as the kitchen offices and kitchen compressor room.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that a new closet in the dining room which is sprinkled, was created without providing sprinkler protection for the new room. The walk in cooler and freezer as well as the offices and compressor room in the kitchen area are not equipped with sprinkler protection.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the K extinguisher in the kitchen on the left side of the ranges was easily accessible and mounted properly.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that the K extinguisher was mounted over five feet off of the floor and in a difficult location to access, and installed too close to the burner units of the range to be of use if the fire was on one of the closest burner units.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the tag for the kitchen extinguishing system was being filled out properly during the monthly inspections and that there was not a sign denoting the pull station for the extinguishing system.

The findings include:
On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that the tag for the extinguishing system was not filled out for the month of May, and there was no sign near the gas shut off sign denoting that the pull station was for the hood extinguishing system also.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that there were no hazardous materials stored improperly in the building kitchen area at any time.

The findings include:

On June 4th, 2015, between the hours of 9:00 am and 12:00 pm the Fire Safety Inspector observed that there were two acetylene cylinders stored in the compressor room in the kitchen area. One cylinder was secured in a cart with wheels, and the other cylinder was not secured and standing next to the one in the cart. The cylinder in the cart had a regulator and hose and nozzle attached to the cylinder. The loose cylinder had no attachments to the valve system. In addition, an oxygen cylinder in a cart was stored adjacent to the acetylene cylinders, approximately six feet away. The acetylene cylinders were within one foot of an operating compressor. A large window fan was located in a window approximately ten feet from the acetylene cylinders and eight feet up from the floor. The fan was running at that time. Discussion with the maintenance supervisor revealed that he was told during a previous Joint Commission survey, when the cylinders were found in the maintenance area to move them to the kitchen compressor room because there was an exhaust fan in the kitchen. This surveyor immediately ordered that all of the cylinders in the kitchen be removed to the outside of the building, and properly secured. Should the loose acetylene cylinder have fallen and the valve broken an explosive mixture could have immediately been released. With all of the non explosion proof electrical devices in operation in the area, an immediate ignition and explosion could have occurred. The maintenance supervisor is ordering a separate metal storage unit for the acetylene tanks and reports that the cylinders will be stored outside of the building.

These findings were noted and affirmed by the maintenance supervisor during the survey.

As a follow up to this finding the nurse surveyor on site at the facility on June 10, 2015 checked to determine if the corrective action was still in place for this issue.

Interview with the Maintenance Chief on June 10th at approximately 1230 revealed that the oxygen tank and two acetylene tanks had been moved to a large metal cabinet outside in the maintenance yard. Upon observing the maintenance yard, 30 oxygen tanks without chains or other securing device were noted to be standing freely in one metal cabinet. Additionally, only one acetylene tank was found in another metal cabinet labeled for empty oxygen tanks. It was the only tank in the cabinet.

On June 11, the COO informed the surveyor that he had secured the oxygen tanks with chain which was verified by the surveyor and that another cabinet for acetylene tanks was ordered.

This could have affected 100 percent of the occupants

Based on observation and discussion with the maintenance supervisor, it was determined that the facility failed to ensure that the receptacles in potentially wet locations were ground fault receptacles as required. Also that safe practices were being used for providing electric to certain devices.

The findings include:
On June 4th, 2015, between the hours of 9:00am and 12:00pm the Fire Safety Inspector observed that the following listed areas did not have ground fault receptacles as required.
1. In the sink area of the hospital wing dining room.
2. At the sink in the rahab area at the water fountain.
3. All 110 volt receptacles in the kitchen must be ground fault receptacles.

It was noted that a multi receptacle extension cord was plugged into the wall in the rehab room and run between the door and the door jamb into the adjacent office. This resulted from a lack of receptacles in the office area. Extension cords must not be the primary electrical source for electrical devices.

These findings were noted and affirmed by the maintenance supervisor during the survey.

This could affect 100 percent of the occupants.