HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to continuously maintain means of egress free of all obstructions for full use. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. Facility census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 9:10 a.m. revealed wheelchairs are blocking the egress path to the fire extinguisher on the wall in the hallway of the emergency room on the first floor.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on observation and staff interview it was determined the facility failed to ensure that delayed-egress locking systems were installed in accordance with National Fire Protection Association (NFPA) 101. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census is twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 10:30 a.m. revealed the exit doors in Dietary service hallway had a turn knob locking device on the exit doors. This device will not let the egress doors work properly to exit the facility.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on observation and staff interview it was determined the facility failed to ensure that electrical wiring and equipment be in accordance with National Fire Protection Association (NFPA) 70. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility census is twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 9:10 a.m. revealed a missing ceiling tile and a junction box with a missing cover plate in a small room across the hall from the emergency room on the first floor.

2. An observation on 08/11/20 from 8:00 a.m. to 6:00 p.m. revealed ceiling tiles throughout the facility with holes and cracks.

3. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on document review and staff interview it was determined the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. During a facility document review conducted on 08/10/20 from 9:30 a.m. to 5:30 p.m. it was revealed a second quarter, afternoon shift fire drill was conducted on 05/16/20 at 7:30 p.m. and a fourth quarter, afternoon shift fire drill was conducted on 11/22/19 at 8:03 p.m. All fire drills must be one (1) hour apart from each other to be in compliance.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on document review and staff interview it was determined the facility failed to ensure maintenance was performed on the emergency reserve bank in accordance with National Fire Protection Association (NFPA) 101. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. A facility document review was conducted on 08/10/20 from 9:30 a.m. to 5:30 p.m. The documentation from Medical Gas System Specialists, Inc. (MEGSS) showed they did an inspection on 8/31/19 on the O2 system at the hospital and found a bad check valve for the emergency reserve bank leaking. On 9/3/19 MEGSS did a work order to repair the bad valve but there was no paper work showing the work had been completed. I found the Director of Maintenance to see if this had been completed and he said that a coupling was leaking and the system needed to be shut down for repairs. As of 8/10/20 the work order was not completed so the maintaining of the O2 system is not in compliance with the requirements of NFPA 101.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on observation and staff interview it was determined the facility failed to ensure a nonflammable medical gas cylinder and the storage requirements were in accordance with National Fire Protection Association (NFPA) 99. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 2:20 p.m. revealed two (2) oxygen cylinders not being stored in a rack or chained to the wall. The cylinders were free standing in the middle of the soiled utility room on the third floor.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.