HospitalInspections.org

Based on observation, the hospital does not maintain fire separations related to closed corridor doors as required for the laboratory corridor door.

Findings include:

Observation during facility tour on 1/24/12 at 11:20 AM revealed the laboratory corridor door located in a one hour fire separation was propped open with a cardboard wedge. This door is a component separating a hazardous area from the corridor.

This finding was verified with Staff #15 on 1/24/12.

Based on document review, the hospital does not test the emergency lights as required to ensure their function.

Findings include:

Review on 1/23/12 at 2:00 PM of the facility's Emergency Light Testing record revealed the facility tested the lights for 60 minutes annually.

This finding was verified with Staff #15 on 1/24/12.

Based on document review and interview, the hospital has not ensured an approved maintenance program for the fire alarm system in accordance with NFPA requirements is in place, as evidenced for the last two quarters of 2011. (3rd and 4th quarters 2011)

Findings include:

Review on 1/23/12 at 2:00 PM of the facility's "Quick Reference Fire Alarm and Suppression System Testing/Maintenance Log" revealed the service contractor had not been to the facility since 6/15/11. Prior to that date, the contractor had been onsite quarterly reviewing components of the system to ensure the complete review was conducted annually. Interview with Staff #15 revealed the company has not been maintaining the system due to lack of payment from the hospital.

Based on document review and interview, the hospital has not ensured an approved maintenance program for the fire suppression system in accordance with NFPA requirements is in place, as evidenced for the last two quarters of 2011. (3rd and 4th quarters 2011)


Findings include:

Review on 1/23/12 at 2:00 PM of the facility's "Quick Reference Fire Alarm and Suppression System Testing/Maintenance Log" revealed the service contractor had not been to the facility since 6/15/11. Prior to that date, the contractor had been onsite quarterly reviewing components of the system to ensure the complete review was conducted annually. Interview with Staff #15 revealed the company has not been maintaining the system due to lack of payment from the hospital.

Based on observation and interview, the hospital does not restrict smoking in patient care areas in accordance with hospital policy.

Findings include:

Observation during facility tour on 1/24/12 at 10:30 AM revealed the odor of cigarette smoke in the bathroom of room #505, ashes on the toilet seat, nicotine stains on the exhaust diffuser and a towel on the floor to block the space between the bottom of the door and floor of the rest room. A concerned patient reported that this is a routine occurrence in this room.

This finding was verified with Staff #15 on 1/24/12, who stated the hospital is a "no-smoking facility".

Based on observation and interview, the hospital does not provide flammable liquid storage in the laboratory in accordance with NFPA requirements.

Findings include:

Observation during facility tour on 1/24/12 at 11:40 AM revealed a 5 gallon carboy of formalin stored on a table in the pathology lab. During interview at that time, Staff #16 revealed formalin is not typically used and the 5 gallon volume was the smallest container available. Staff #16 indicated there is a flammable liquid storage cabinet in the laboratory which has not been used recently, and many of the products in the flammable cabinet had not been used in years.

These findings were verified with Staff #15 on 1/24/12.