HospitalInspections.org

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on one of six building levels.

Findings include:

Observation on March 25, 2015 at 10:20 am revealed level one clean linen room door 1207 lacked positive latching due to the following:
A. Door was held open with a wire loop.
B. Door lacked positive latching with the self-closure.

Interview with Facility Diresctor (FD) on March 25, 2015 at 10:20 am confirmed the clean linen room door lacked positive latching.

Based upon observation and interview, the facility failed to maintain the exit egress components as per regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:35 pm revealed facility was utilizing a padlock as a locking device on ground level, outside X-ray film storage door (old incinerator room).

Interview with Facility Director (FD) on March 25, 2015 at 1:35 pm confirmed the storage room door had an unauthorized lock.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually and 30 seconds monthly in accordance with regulations at two of two generator locations.

Findings include:

Document review on March 26, 2015 at 10:20 am revealed facility lacked the following documentation on the emergency pack battery lighting located in both generator locations:
A. Monthly 30 second test.
B. Annual 1-1/2 hour drain test.

Interview with FD on March 26, 2015 at 10:20 am confirmed the lack of battery lighting documentation testing.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually, and 30 seconds monthly in accordance with regulations in all operating room locations.

Findings include:

Document review on March 26, 2015 at 10:20 am revealed facility lacked documentation to indicate an annual 1-1/2 hour drain test was performed on the emergency pack battery lighting located in all the operating rooms.

Interview with FD on March 26, 2015 at 10:20 am confirmed the lack of battery lighting documentation testing.

Based upon document review and interview, facility failed to maintain exit and directional signs in accordance with regulations in all areas of the building.

Findings include:

Document review on March 26, 2015 at 10:30 am revealed facility lacked documentation that all exit signs had a monthly visual inspection performed since January 2015.

Interview with FD on March 26, 2015 at 10:30 am confirmed the lack of exit sign monthly visual documentation.

Based upon review of documentation and interview, the facility failed to perform fire drills as directed by regulations on one of three work shifts.

Findings include:

Document review on March 26, 2015 at 9:50 am revealed facility lacked documentation that a fire drill was performed during the third shift, third quarter of 2014.

Interview with FD on March 26, 2015 at 9:50 am confirmed the lack of fire drill documentation.

Based on observation and interview, the facility failed to ensure the portable fire extinguishers were maintained in accordance with regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:40 pm revealed ground level O. R. fire extinguisher was blocked with a cart.

Interview with FD on March 25, 2015 at 1:40 pm confirmed the fire extinguisher was blocked with a cart.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations on one of six building levels.

Findings include:

Observation on March 25, 2015 at 10:30 am revealed level one main medical gas storage location (dock area) had three unsecured medical gas cylinders.

Interview with FD on March 25, 2015 at 10:30 am confirmed the unsecured medical gas cylinders.

Based upon observation and interview, the facility failed to maintain the piped-in medical gas system in accordance with regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 2:00 pm revealed a printer cart was placed in front of the ground level O. R. medical gas shut off valves to room #1.

Interview with FD on March 25, 2015 at 2:00 pm confirmed the medical gas shut off valves were blocked.

Based upon observation, document review and interview, the facility failed to maintain the piped-in medical gas system in accordance with regulations for one of one piped-in medical gas system.

Findings include:

1. Observation on March 25, 2015 at 9:19 am revealed second floor Emergency Department medical gas shut-off valves across from room #6 are no longer in service. Facility lacked a "not in use" sign on the panel box.

Interview with FD on March 25, 2015 at 9:19 am confirmed the medical gas shut-off valves lacked a "not in use" sign.

2. Document review on March 26, 2015 at 10:10 am revealed last annual medical gas inspection (July 1, 2014) noted deficiencies with shut-off valves, outlets and inlets.

Interview with FD on March 26, 2015 at 10:10 am confirmed the medical gas inspection deficiencies.

Based upon observation, documentation review and interview, it was determined that the facility failed to comply with regulations for two of two emergency generators.

Findings include:

1. Observation on March 25, 2015 at 9:18 am revealed the following concerns for the emergency generator remote annunciator panels located in the second floor Emergency Department:
A. A blanket warmer was blocking both remote annunciator panels.
B. Emergency generator #1 remote annunciator panel did not alarm an audible, nor visual signal when tested.

Interview with FD on March 25, 2015 at 9:18 am confirmed the above remote annunciator issues.

2. Documentation review on March 26, 2015 at 10:00 am revealed last generator inspection (February 16, 2015) noted Kohler #2 generator needs new batteries due to age.

Interview with FD on March 26, 2015 at 10:00 am confirmed the above generator issue.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:45 pm revealed ground floor Pre-Care Screening area office had a microwave oven plugged into an extension cord.

Interview with FD on March 25, 2015 at 1:45 pm confirmed the microwave oven was not plugged directly into an electrical outlet.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of six building levels.

Findings include:

Observation on March 25, 2015 between 9:25 am and 9:50 am revealed the following electrical concerns:
A. Second floor E. D. Manager office had a surge protector suspended off the ground by the devices that are plugged into it (9:25 am).
B. Second floor last office of Administrative suite was utilizing an extension cord (9:50 am).

Interview with FD on March 25, 2015 at 9:50 am confirmed the above electrical concerns.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on one of six building levels.

Findings include:

Observation on March 25, 2015 at 10:20 am revealed level one clean linen room door 1207 lacked positive latching due to the following:
A. Door was held open with a wire loop.
B. Door lacked positive latching with the self-closure.

Interview with Facility Diresctor (FD) on March 25, 2015 at 10:20 am confirmed the clean linen room door lacked positive latching.

Based upon observation and interview, the facility failed to maintain the exit egress components as per regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:35 pm revealed facility was utilizing a padlock as a locking device on ground level, outside X-ray film storage door (old incinerator room).

Interview with Facility Director (FD) on March 25, 2015 at 1:35 pm confirmed the storage room door had an unauthorized lock.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually and 30 seconds monthly in accordance with regulations at two of two generator locations.

Findings include:

Document review on March 26, 2015 at 10:20 am revealed facility lacked the following documentation on the emergency pack battery lighting located in both generator locations:
A. Monthly 30 second test.
B. Annual 1-1/2 hour drain test.

Interview with FD on March 26, 2015 at 10:20 am confirmed the lack of battery lighting documentation testing.

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually, and 30 seconds monthly in accordance with regulations in all operating room locations.

Findings include:

Document review on March 26, 2015 at 10:20 am revealed facility lacked documentation to indicate an annual 1-1/2 hour drain test was performed on the emergency pack battery lighting located in all the operating rooms.

Interview with FD on March 26, 2015 at 10:20 am confirmed the lack of battery lighting documentation testing.

Based upon document review and interview, facility failed to maintain exit and directional signs in accordance with regulations in all areas of the building.

Findings include:

Document review on March 26, 2015 at 10:30 am revealed facility lacked documentation that all exit signs had a monthly visual inspection performed since January 2015.

Interview with FD on March 26, 2015 at 10:30 am confirmed the lack of exit sign monthly visual documentation.

Based upon review of documentation and interview, the facility failed to perform fire drills as directed by regulations on one of three work shifts.

Findings include:

Document review on March 26, 2015 at 9:50 am revealed facility lacked documentation that a fire drill was performed during the third shift, third quarter of 2014.

Interview with FD on March 26, 2015 at 9:50 am confirmed the lack of fire drill documentation.

Based on observation and interview, the facility failed to ensure the portable fire extinguishers were maintained in accordance with regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:40 pm revealed ground level O. R. fire extinguisher was blocked with a cart.

Interview with FD on March 25, 2015 at 1:40 pm confirmed the fire extinguisher was blocked with a cart.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations on one of six building levels.

Findings include:

Observation on March 25, 2015 at 10:30 am revealed level one main medical gas storage location (dock area) had three unsecured medical gas cylinders.

Interview with FD on March 25, 2015 at 10:30 am confirmed the unsecured medical gas cylinders.

Based upon observation and interview, the facility failed to maintain the piped-in medical gas system in accordance with regulations on one of four building levels.

Findings include:

Observation on March 25, 2015 at 2:00 pm revealed a printer cart was placed in front of the ground level O. R. medical gas shut off valves to room #1.

Interview with FD on March 25, 2015 at 2:00 pm confirmed the medical gas shut off valves were blocked.

Based upon observation, document review and interview, the facility failed to maintain the piped-in medical gas system in accordance with regulations for one of one piped-in medical gas system.

Findings include:

1. Observation on March 25, 2015 at 9:19 am revealed second floor Emergency Department medical gas shut-off valves across from room #6 are no longer in service. Facility lacked a "not in use" sign on the panel box.

Interview with FD on March 25, 2015 at 9:19 am confirmed the medical gas shut-off valves lacked a "not in use" sign.

2. Document review on March 26, 2015 at 10:10 am revealed last annual medical gas inspection (July 1, 2014) noted deficiencies with shut-off valves, outlets and inlets.

Interview with FD on March 26, 2015 at 10:10 am confirmed the medical gas inspection deficiencies.

Based upon observation, documentation review and interview, it was determined that the facility failed to comply with regulations for two of two emergency generators.

Findings include:

1. Observation on March 25, 2015 at 9:18 am revealed the following concerns for the emergency generator remote annunciator panels located in the second floor Emergency Department:
A. A blanket warmer was blocking both remote annunciator panels.
B. Emergency generator #1 remote annunciator panel did not alarm an audible, nor visual signal when tested.

Interview with FD on March 25, 2015 at 9:18 am confirmed the above remote annunciator issues.

2. Documentation review on March 26, 2015 at 10:00 am revealed last generator inspection (February 16, 2015) noted Kohler #2 generator needs new batteries due to age.

Interview with FD on March 26, 2015 at 10:00 am confirmed the above generator issue.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of four building levels.

Findings include:

Observation on March 25, 2015 at 1:45 pm revealed ground floor Pre-Care Screening area office had a microwave oven plugged into an extension cord.

Interview with FD on March 25, 2015 at 1:45 pm confirmed the microwave oven was not plugged directly into an electrical outlet.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of six building levels.

Findings include:

Observation on March 25, 2015 between 9:25 am and 9:50 am revealed the following electrical concerns:
A. Second floor E. D. Manager office had a surge protector suspended off the ground by the devices that are plugged into it (9:25 am).
B. Second floor last office of Administrative suite was utilizing an extension cord (9:50 am).

Interview with FD on March 25, 2015 at 9:50 am confirmed the above electrical concerns.