HospitalInspections.org

Based upon observations and staff interviews on 02/07/18 at 1430 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

The emergency department restraint room door fails to latch.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 02/07/18 at 1200 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.
The findings include, but are not limited to:
There is no documentation of a current hood cleaning.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 at 1350 hours the facility has failed to provide smoke detection in all spaces open to the corridor. This could result in the late notification to people within the facility of smoke and fire.

The findings include, but are not limited to:

There are no smoke detectors in the west wing doctors' sleep room.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 at 1115 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
There is no documentation of quarterly sprinkler testing for 1st quarter of 2017.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 at 1355 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
Both west wing electrical rooms have CO2 fire extinguishers without tags.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 between approximately 1315 to 1330 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

1. Cross corridor smoke door by patient room 119 and PT has gap greater then 1/2".
2. West wing electrical room across from room 118 has excessive gap greater then 1/4".

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 at 1435 hours the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

Emergency Department east corridor smoke doors fail to close completely and has an excessive vertical gap.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/07/18 at 1225 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected.

The findings include, but are not limited to:

There are no documents of inspection and testing for piped systems.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 at 1630 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system.

The findings include, but are not limited to:

There is no documentation of testing of hospital grade receptacles at patient bed locations.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 between approximately 1120 to 1125 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1. No emergency battery back-up lights in the ATS room.
2. Annual fuel quality test not completed.
3. Weekly inspections missed for the last 2 weeks of January 2018 and the first week of February.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/07/18 between approximately at 1345 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include, but are not limited to:

Oxygen storage room in west wing is not posted.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/07/18 at 1130 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:

There is no documentation of continuing education or a policy to provide continuing education for staff who handle medical gas.


The above was discussed and acknowledged by the facility staff.