HospitalInspections.org

Based upon observation and interview, hospital staff failed to ensure that the automatic sprinkler system was maintained as designed.

Findings:

On 1/25/12 at 1300 hours during the tour of the hospital with administration and facilities staff, it was observed that sprinkler heads in the clean section of the Sterile Processing department did not have escutcheons in place. During an interview with the the Security Director on 1/25/12 at 1530 hours he acknowledged that several sprinkler heads in the Sterile Processing department were missing escutcheons.

Based upon observation and interview hospital staff failed to ensure the proper inspection of portable fire extinguishers.

Findings:

On 1/25/12 at 1500 hours during a tour of the hospital with the facilities manager it was observed that a portable fire extinguisher outside the chlorine dioxide water treatment room did not have an inspection tag. The Director of Security acknowledged during interview on 1/25/12 at 1530 hours that the fire extinguisher outside the chlorine dioxide water treatment room did not have an inspection tag.

Based upon observation and interview hospital staff failed to store medical gases in a manner which ensures the safety of patients, staff and visitors.

Findings:

On 1/24/12 at 1400 hours during a tour of the hospital with administration and facilities staff, it was observed that there were 14 full size "E" oxygen cylinders being stored in the hallway of the medical imaging department. This oxygen storage was not enclosed within a one hour separation as required. During an interview with the Medical Imaging Director and administation on 1/24/12 at 1400 hours, he acknowledged that oxygen greater than 3,000 cu. ft was being stored without being enclosed in a one hour separation.