HospitalInspections.org

Based on observation and interview, it was determined the facility did not maintain one (Emergency Department) of five exit corridors free of obstructions to allow the full width of the corridor for use in the event of emergency exiting. The failed practice had the potential to affect all patients, staff and visitors because the rapid egress of building occupants was impeded by the obstructed corridor. Findings follow:

A. During a tour of the facility on 02/24/2016 at 1045 with the Director of Maintenance, the exit corridor serving the Emergency Department had two wheel chairs obstructing the means of egress.
B. The Director of Maintenance verified the items were obstructing the means of egress corridor at the time of observation.

Based on Generator Log review and interview, it was determined that the facility failed to exercise two of two emergency generators (EGEN 10 and EGEN 20) each month for a minimum of 30 minutes from January 2016 through February 2015 [For EGEN10: no load recorded for 01/18/16, 12/17/15, 11/10/15, (no records available for August, July, June, April, March, or February of 2015); for EGEN 20: no load recorded for 01/09/16 and 10/23/15, (no records available for November, June, May, April, March, or February of 2015)]. The failed practice had the potential to affect patients, visitors, and staff because the ability of the generators to provide power during load conditions was not assured. This is an ongoing deficiency. Findings follow:

A. During review of the Generator Log on 02/23/2016 at 0940, it was determined that two of two generators had not been exercised under load conditions for 30 minutes each month from January 2016 to February 2015:
1. The facility failed to exercise Generator - EGEN 10 under load for 30 minutes every month for nine of twelve months.
2. The facility failed to exercise Generator - EGEN20 under load for 30 minutes for eight of twelve months.
B. During an interview on 02/23/2016 at 1315 with the Maintenance Director and the Administrator it was confirmed the generators had not been exercised under load for 30 minutes each month.

Based on observation and interview, it was determined the facility failed to maintain a minimum of three feet working space in front of one of six electrical panels in the Boiler Room near the southwest corner of the facility, as required by NFPA 70, Section 110.26. The failed practice had the potential to affect all patients, staff and visitors due to the inability of quick access to the electrical equipment in the event of an emergency. Findings follow:

A. On a tour of the facility on 02/24/2016 at 1030 with the Director of Maintenance, a ladder and a 5-gallon bucket was stored in the electrical room in front of one of six electrical panels in the Boiler Room near the southwest corner of the facility which did not allow free access to the electrical panel.
B. At the time of the observation, the Director of Maintenance verified the area in front of the electrical panel was not clear.