HospitalInspections.org

Based on random observation, testing, and interview, the provider failed to maintain the smoke tight 20 minute fire rating of corridor wall assemblies for the following doors:
*The west corridor door to the patient care area of the clinic.
*The corridor door to the x-ray room in the hospital.
*The corridor door to the female doctors' sleep room in the hospital.
Findings include:

1. Observation and testing at 4:30 p.m. on 4/25/11 revealed the west corridor door to the patient care area of the clinic would not close and latch into the frame. Closer observation at that time revealed the bolt was stuck in the door and would not latch into the frame. Interview and additional testing at 9:00 a.m. on 4/26/11 with the maintenance supervisor (MS) and director of plant operations (DPO) revealed the door would not latch into the frame. The MS and DPO confirmed that condition.

2. Observation and testing at 3:25 p.m. on 4/26/11 revealed the self-closer to the corridor door of the x-ray room was broken and hung from the door. Interview with the MS and DPO at the time of the observation and testing confirmed that condition. They stated they were not aware the closer was broken but would have it repaired.

3. Observation and testing at 4:00 p.m. on 4/26/11 revealed the corridor door to the female doctors' sleep room would not close and latch into the frame. Closer observation at that time revealed the bolt mechanism of the door knob had been removed and a slide bolt lock had been installed on the inside of the door and frame. Interview with the MS and DPO at the time of the observation and testing confirmed that condition. The MS stated a doctor had requested the bolt mechanism be removed and a slide bolt lock be installed. She asked that this be done so the staff and public did not have access to that room when they were sleeping.

Based on observation, testing, and interview, the provider failed to maintain one of three stair enclosures between floors with construction having at least a one hour fire-resistance rating. The upper level stairwell door by the medical records office was not provided with latching hardware. Findings include:

1. Observation at 9:00 a.m. on 4/27/11 revealed the door to the upper level stair enclosure by the medical records office did not have latching hardware. Closer observation revealed the door knob and bolt mechanism had been removed. The one and three quarter inch solid bonded wood, 20 minute equipvalent, free swinging door had a push plate installed on the corridor side and a grab bar installed on the stairwell side. Interview with the maintenance supervisor and director of plant operations at the time of the observation confirmed that finding. They stated that door had been free swinging for some time, and they were not aware the door should latch.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The corridor door of the large bio-terrorism storage room was blocked open with a plastic tote. Findings include:

1. Observation and testing at 3:45 p.m. on 4/26/11 revealed the corridor door to the large (approximately ten foot by ten foot) bio-terrorism storage room was blocked open with a plastic tote. That room had no automatic sprinkler system. Closer observation revealed the unrated door was not self-closing. Interview with the director of plant operations (DPO) at the time of observation confirmed that finding. He stated staff were aware they should not store anything that would obstruct closing doors. He moved the tote at that time. Continued interview with the DPO revealed that room had been turned into a bio-terrorism storage room when the facility had received a grant for the surplus items a few years ago. He stated he was not aware that room now required a self-closer on the door due to its contents and the capacity of the room.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Three randomly observed doors (two in ultrasound and one in the female doctors' sleep room) were equipped with barrel bolt locks which would impede egress in an emergency. Findings include:

1. Observation at 3:00 p.m. on 4/26/11 revealed both of the egress doors out of the ultrasound room were equipped with barrel bolt locks in addition to positive latching hardware. Interview with the maintenance supervisor (MS) and the director of plant operations (DPO) at the time of the observation confirmed that finding. They stated those locks had been installed to ensure privacy for the patients.

Observation at 4:00 p.m. on that same day revealed a barrel bolt lock had been installed on the inside of the female doctors' sleep room. Interview with the MS and DPO at the time of the observation confirmed that finding. They stated that slide bolt lock had been installed to ensure the female doctors had privacy while they slept.

Barrel bolt locks could impede opening the doors in an emergency.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing performed and documented during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was aware the nursing home required quarterly flow testing but had forgotten about the clinic.

A. Based on observation and interview, the provider failed to maintain the one hour fire resistive rating of hazardous areas in the rehabilitation building. The following items were found out of compliance:
* The self-closing fire door to the basement storage room was propped open.
* A one hour rated door was held open with wire.
* Several penetrations between the basement storage room and main floor were not sealed.
Findings include:

1. Observation at 10:20 a.m. on 4/26/11 revealed the self-closing three hour rated door at the bottom of the basement stairs was held open with a can of concrete sealer and a cinder block. Interview with the maintenance supervisor (MS) and director of plant operations (DPO) at the time of the observation confirmed that finding. They revealed they were aware doors could not be propped open and would relay the finding to the staff. They also stated they had no preventative maintenance to check on doors in the rehabilitation building.

2. Observation at 10:40 a.m. on that same day revealed the self-closing access door from the basement storage room to the crawl space was held open with a piece of wire. Interview with the DPO at the time of the observation confirmed that finding. He stated he was unaware the rated door had been tied open with wire and removed the wire at that time.

3. Random observation from 10:25 a.m. to 11:30 a.m. on that same day revealed several penetrations through the wood joists of the basement ceiling/main floor. Those penetrations were from electrical conduit, communication conduit, plumbing piping, and other unidentifiable conduit and piping. None of the penetrations had been sealed with a fire resistive material to maintain the one hour fire rating of that room. Interview with the DPO at the time of the observation confirmed those findings. He stated he was unaware the penetrations had never been sealed.

B. Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing and documentation performed during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor (MS) at the time of the record review indicated he was aware the nursing home required quarterly flow testing but had forgotten about the clinic.


C. Based on observation, measurement, and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector, so the water discharge was not interrupted. Six randomly observed sprinklers in the medical records storage room in the basement of the rehabilitation building were found obstructed. Findings include:

1. Observation at 10:50 a.m. revealed six sprinklers were obstructed with boxes of medical records in the basement of the rehabilitation building. Measurement at that time revealed the distance between the boxes and sprinkler head ranged from 5 - 10 inches. Interview with the MS and director of plant operations at the time of the observation revealed they were not aware of the obstructed sprinklers. They stated they were aware sprinkler heads could not be obstructed and would have all the boxes removed for the top shelves.

D. Based on observation and interview, the provider failed to maintain proper separation of the soiled linen holding room at the rehabilitation building. A 65 gallon container was used for holding soiled linen and was not provided with one hour fire rated construction or automatic sprinkler protection. Findings include:

1. Observation at 11:15 a.m. on 4/26/11 revealed the rehabilitation building soiled linen room had a 65 gallon soiled linen container that was approximately one third full. The corridor door was a 20 minute rated self-closing door. The room was not provided with automatic sprinkler protection. Interview with the maintenance supervisor and director of plant operations revealed they were not aware the rehabilitation building used that large of a container. They were not aware by storing that large of soiled linen container in that room it created a hazardous storage area.

E. Based on observation and interview, the provider failed to install permanent wiring for the medical records storage room in the basement. Several extension cords and multi-tap adapters were used to provide power to hanging shop lights. Findings include:

1. Observation from 11:20 a.m. to 11:30 a.m. on 4/26/11 revealed five shop lights with fluorescent light bulbs were hanging from the ceiling in the medical records storage room in the basement. Those five shop lights were not hardwired to the buildings electrical system. Extension cords were used to provide power to those shop lights and multi-tap adapters were used to connect the extension cords. Interview with the maintenance supervisor and the director of plant operations at the time of the observations confirmed those conditions. They stated they were not aware those shop lights had been installed in that manner and would have them installed to the buildings electrical system.

Based on random observation and interview, the provider failed to install permanent wiring for the clinic and hospital. Several power strips, extension cords, and multi-tap adapters were found in-use throughout both facilities. Findings include:

1. Random observation from 4:15 p.m. to 5:00 p.m. on 4/26/11 revealed power strips and extension cords in-use in the following areas:
* Procedure room 2.
* Exam room 12.
* A doctor's office.
* The medical records office/storage room.
* The coding and billing office.
Interview at 8:45 a.m. on 4/27/11 with the maintenance supervisor (MS) and the director of plant operations (DPO) confirmed the above findings. They revealed they were aware power strips were only acceptable for computer stations. They were also aware extension cords could not be used as permanent wiring.

2. Random observation from 9:00 a.m. to 4:30 p.m. on 4/27/11 revealed power strips, multi-tap adapters, and extension cords in-use in the following areas:
* The materials management office.
* The guest office.
* The boiler room.
* The plant operations office.
* Emergency bay one and two.
* The health information management office.
* The director of nursing's office.
* The female and male doctors sleep rooms.
* The administrator's office.
Interview with the MS and the DPO at the time of the above observations confirmed the those findings. They revealed they were aware power strips were only acceptable for computer stations. They were also aware multi-tap adapters and extension cords could not be used as permanent wiring.

Based on random observation, testing, and interview, the provider failed to maintain the smoke tight 20 minute fire rating of corridor wall assemblies for the following doors:
*The west corridor door to the patient care area of the clinic.
*The corridor door to the x-ray room in the hospital.
*The corridor door to the female doctors' sleep room in the hospital.
Findings include:

1. Observation and testing at 4:30 p.m. on 4/25/11 revealed the west corridor door to the patient care area of the clinic would not close and latch into the frame. Closer observation at that time revealed the bolt was stuck in the door and would not latch into the frame. Interview and additional testing at 9:00 a.m. on 4/26/11 with the maintenance supervisor (MS) and director of plant operations (DPO) revealed the door would not latch into the frame. The MS and DPO confirmed that condition.

2. Observation and testing at 3:25 p.m. on 4/26/11 revealed the self-closer to the corridor door of the x-ray room was broken and hung from the door. Interview with the MS and DPO at the time of the observation and testing confirmed that condition. They stated they were not aware the closer was broken but would have it repaired.

3. Observation and testing at 4:00 p.m. on 4/26/11 revealed the corridor door to the female doctors' sleep room would not close and latch into the frame. Closer observation at that time revealed the bolt mechanism of the door knob had been removed and a slide bolt lock had been installed on the inside of the door and frame. Interview with the MS and DPO at the time of the observation and testing confirmed that condition. The MS stated a doctor had requested the bolt mechanism be removed and a slide bolt lock be installed. She asked that this be done so the staff and public did not have access to that room when they were sleeping.

Based on observation, testing, and interview, the provider failed to maintain one of three stair enclosures between floors with construction having at least a one hour fire-resistance rating. The upper level stairwell door by the medical records office was not provided with latching hardware. Findings include:

1. Observation at 9:00 a.m. on 4/27/11 revealed the door to the upper level stair enclosure by the medical records office did not have latching hardware. Closer observation revealed the door knob and bolt mechanism had been removed. The one and three quarter inch solid bonded wood, 20 minute equipvalent, free swinging door had a push plate installed on the corridor side and a grab bar installed on the stairwell side. Interview with the maintenance supervisor and director of plant operations at the time of the observation confirmed that finding. They stated that door had been free swinging for some time, and they were not aware the door should latch.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The corridor door of the large bio-terrorism storage room was blocked open with a plastic tote. Findings include:

1. Observation and testing at 3:45 p.m. on 4/26/11 revealed the corridor door to the large (approximately ten foot by ten foot) bio-terrorism storage room was blocked open with a plastic tote. That room had no automatic sprinkler system. Closer observation revealed the unrated door was not self-closing. Interview with the director of plant operations (DPO) at the time of observation confirmed that finding. He stated staff were aware they should not store anything that would obstruct closing doors. He moved the tote at that time. Continued interview with the DPO revealed that room had been turned into a bio-terrorism storage room when the facility had received a grant for the surplus items a few years ago. He stated he was not aware that room now required a self-closer on the door due to its contents and the capacity of the room.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Three randomly observed doors (two in ultrasound and one in the female doctors' sleep room) were equipped with barrel bolt locks which would impede egress in an emergency. Findings include:

1. Observation at 3:00 p.m. on 4/26/11 revealed both of the egress doors out of the ultrasound room were equipped with barrel bolt locks in addition to positive latching hardware. Interview with the maintenance supervisor (MS) and the director of plant operations (DPO) at the time of the observation confirmed that finding. They stated those locks had been installed to ensure privacy for the patients.

Observation at 4:00 p.m. on that same day revealed a barrel bolt lock had been installed on the inside of the female doctors' sleep room. Interview with the MS and DPO at the time of the observation confirmed that finding. They stated that slide bolt lock had been installed to ensure the female doctors had privacy while they slept.

Barrel bolt locks could impede opening the doors in an emergency.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing performed and documented during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was aware the nursing home required quarterly flow testing but had forgotten about the clinic.

A. Based on observation and interview, the provider failed to maintain the one hour fire resistive rating of hazardous areas in the rehabilitation building. The following items were found out of compliance:
* The self-closing fire door to the basement storage room was propped open.
* A one hour rated door was held open with wire.
* Several penetrations between the basement storage room and main floor were not sealed.
Findings include:

1. Observation at 10:20 a.m. on 4/26/11 revealed the self-closing three hour rated door at the bottom of the basement stairs was held open with a can of concrete sealer and a cinder block. Interview with the maintenance supervisor (MS) and director of plant operations (DPO) at the time of the observation confirmed that finding. They revealed they were aware doors could not be propped open and would relay the finding to the staff. They also stated they had no preventative maintenance to check on doors in the rehabilitation building.

2. Observation at 10:40 a.m. on that same day revealed the self-closing access door from the basement storage room to the crawl space was held open with a piece of wire. Interview with the DPO at the time of the observation confirmed that finding. He stated he was unaware the rated door had been tied open with wire and removed the wire at that time.

3. Random observation from 10:25 a.m. to 11:30 a.m. on that same day revealed several penetrations through the wood joists of the basement ceiling/main floor. Those penetrations were from electrical conduit, communication conduit, plumbing piping, and other unidentifiable conduit and piping. None of the penetrations had been sealed with a fire resistive material to maintain the one hour fire rating of that room. Interview with the DPO at the time of the observation confirmed those findings. He stated he was unaware the penetrations had never been sealed.

B. Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing and documentation performed during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor (MS) at the time of the record review indicated he was aware the nursing home required quarterly flow testing but had forgotten about the clinic.


C. Based on observation, measurement, and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector, so the water discharge was not interrupted. Six randomly observed sprinklers in the medical records storage room in the basement of the rehabilitation building were found obstructed. Findings include:

1. Observation at 10:50 a.m. revealed six sprinklers were obstructed with boxes of medical records in the basement of the rehabilitation building. Measurement at that time revealed the distance between the boxes and sprinkler head ranged from 5 - 10 inches. Interview with the MS and director of plant operations at the time of the observation revealed they were not aware of the obstructed sprinklers. They stated they were aware sprinkler heads could not be obstructed and would have all the boxes removed for the top shelves.

D. Based on observation and interview, the provider failed to maintain proper separation of the soiled linen holding room at the rehabilitation building. A 65 gallon container was used for holding soiled linen and was not provided with one hour fire rated construction or automatic sprinkler protection. Findings include:

1. Observation at 11:15 a.m. on 4/26/11 revealed the rehabilitation building soiled linen room had a 65 gallon soiled linen container that was approximately one third full. The corridor door was a 20 minute rated self-closing door. The room was not provided with automatic sprinkler protection. Interview with the maintenance supervisor and director of plant operations revealed they were not aware the rehabilitation building used that large of a container. They were not aware by storing that large of soiled linen container in that room it created a hazardous storage area.

E. Based on observation and interview, the provider failed to install permanent wiring for the medical records storage room in the basement. Several extension cords and multi-tap adapters were used to provide power to hanging shop lights. Findings include:

1. Observation from 11:20 a.m. to 11:30 a.m. on 4/26/11 revealed five shop lights with fluorescent light bulbs were hanging from the ceiling in the medical records storage room in the basement. Those five shop lights were not hardwired to the buildings electrical system. Extension cords were used to provide power to those shop lights and multi-tap adapters were used to connect the extension cords. Interview with the maintenance supervisor and the director of plant operations at the time of the observations confirmed those conditions. They stated they were not aware those shop lights had been installed in that manner and would have them installed to the buildings electrical system.

Based on random observation and interview, the provider failed to install permanent wiring for the clinic and hospital. Several power strips, extension cords, and multi-tap adapters were found in-use throughout both facilities. Findings include:

1. Random observation from 4:15 p.m. to 5:00 p.m. on 4/26/11 revealed power strips and extension cords in-use in the following areas:
* Procedure room 2.
* Exam room 12.
* A doctor's office.
* The medical records office/storage room.
* The coding and billing office.
Interview at 8:45 a.m. on 4/27/11 with the maintenance supervisor (MS) and the director of plant operations (DPO) confirmed the above findings. They revealed they were aware power strips were only acceptable for computer stations. They were also aware extension cords could not be used as permanent wiring.

2. Random observation from 9:00 a.m. to 4:30 p.m. on 4/27/11 revealed power strips, multi-tap adapters, and extension cords in-use in the following areas:
* The materials management office.
* The guest office.
* The boiler room.
* The plant operations office.
* Emergency bay one and two.
* The health information management office.
* The director of nursing's office.
* The female and male doctors sleep rooms.
* The administrator's office.
Interview with the MS and the DPO at the time of the above observations confirmed the those findings. They revealed they were aware power strips were only acceptable for computer stations. They were also aware multi-tap adapters and extension cords could not be used as permanent wiring.