HospitalInspections.org

1. Based on observation and interview, it was determined the facility was utilizing roller latches on 16 out of 16 patient room corridor doors. The census on the day of the survey was one patient, but the failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. On a tour of the Nursing Unit on 02/11/10 at 1000, roller latches were observed on 16 patient room doors in 1 of 1 Nursing Unit in the facility.
B. In an interview on 02/11/10 at 1030, the Maintenance Director verified the presence of the observed roller latches.

2. Based on observation and interview, it was determined a Soiled Linen Room did not have a 3/4 hour rated fire door and was not self-closing as required for a hazardous area. The census on the day of the survey was one patient, but the failed practice had the potential to affect all patients admitted to the facility. The deficiency was reoccurring . The findings follow:

A. On a tour of the facility on 02/11/10 at 1000 with the Maintenance Director, the door to Soiled Linen Room 207 was observed to be a non fire-rated door. The door did not have an automatic or self closing device.
B. The Maintenance Director confirmed Soiled Linen Room 207 did not have a fire rated door and was not self-closing in an interview on 02/11/10 at 1015.

3. Based on emergency generator log review and interview, it was determined the generator was not exercised under load for 4 out of 13 months in the year 2009 and it could not be determined the generator was exercised under load for 30 minutes for 6 of the previous 13 months or inspected weekly for 14 out of 14 previous months. The census on the day of the survey was one patient, but the failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. A review of the emergency generator logs at 1400 on 02/10/10 revealed the generator was not run under load in January, February, May, and June in the year 2009. There was no documentation of the length of the monthly load exercise beginning in August 2009 to February 2010. There was no documentation of a weekly inspection of the generator in January 2009 to February 2010.
B. In an interview on 02/10/10 at 1500, the Maintenance Director verified the documentation above and there was no further documentation available for review.