HospitalInspections.org

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the rooms occupants. The deficient practice had the potential to affect 62 of 62 patients.
2 of 10 corridors had doors that were deficient.

Findings:

During the facility tour, between the hours of 7:45 am and 9:30 am, the corridor doors leading to OR1, OR2, OR3, OR4 and the Clinic Waiting Room, were not smoke resistive at the frame.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 2 of 113 residents.
1 of 2 smoke compartments on the 5th floor was deficient.

Findings:

During the facility tour, between the hours of 10:00am and 4:00 pm, it was observed that 5th floor North had opened up the area between two rooms to create a dialysis center. The dialysis area is open to the corridor, with a privacy curtain seperation only, creating a suite. The set of double smoke barrier doors currently do not latch.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 113 of 113 residents.
4 of 4 cabinets are deficient.

Findings:

During the facility tour, between the hours of 10:00 am and 4:00 pm, the metal janitors cabinet on the 2nd, 3rd, 4th and 5th floors were secured with a padlock and hasp. The doors do not have a door knob to latch the doors in a closed position.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 113 of 113 residents.
1 of 8 drills in 2010 is deficient.

Findings:

During the record review, between the hours of 10:00 am and 4:00 pm, documentation for the over night drill for the the first quarter (January-March) of 2010 was not available for review.

Based on visual observation the facility failed to assure that the fire alarm system was installed in accordance with the Life Safety Code and NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 113 of 113 patients.

Findings:

During the facility tour and the record review, between the hours of 10:00 am and 4:00 pm, it was observed that in the emergency department suite, the supply room had been converted into a treatment area (Orthopedic Room). The double doors to the room are propped open and there is no smoke detection provided in that area.