HospitalInspections.org

The facility has failed to properly test batteries of required emergency lighting as required. This could allow for batteries to become inoperable and staff not aware. Failure to ensure that batteries are tested as required could result exposing patients, visitors, and staff to unlighted egress paths during a power outage.

The findings include, but are not limited to:

Document review, on August 12, 2014 between the hours of 9:30am and 10:30am, revealed that the staff could not produce documented proof that the 90 minute tests were conducted on the emergency lighting batteries. Interview with maintenance staff member revealed that maintenance staff was not properly informed of process for the 90 minute test.

This finding was observed and discussed with the Plant Manager and Maintenance Staff member.

The facility has failed to ensure that fire drills are conducted a minimum of one fire drill per quarter per shit as required. Failure to conduct the required frequency of fire drills could result in staff not being properly trained and expose patients, visitors, and staff to evacuation delays or other emergency where staff is unaware of their roles.

The findings include, but are not limited to:

During record review on August 12, 2014 between the hours of 9:30am and 10:30am, of the facility's fire drill records for one year prior to the date of survey revealed fire drills were not conducted as required. Interview with Plant Manager and other Hospital staff revealed that the fire drills were indeed conducted, the written paperwork has been temporarily misplaced.

Record review revealed that no fire drills were conducted in:

1. No fire drill records for 1st quarter 2014.
2. No night fire drill records for 2nd quarter of 2014.
3. No fire drills records for 3rd quarter 2014.
4. No fire drills records for 4th quarter 2013.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey.

The facility has failed to provide documentation, and corresponding logs, that the 5 year sensitivity testing had been conducted on the smoke detectors. This could allow for smoke detectors to lose sensitivity and not activate as quickly as required. Failure to conduct required maintenance of the smoke detectors could expose patients, visitors, and staff to a smoke environment without detection.

The findings include, but are not limited to:

During document review on August 12, 2014 between the hours of 9:30am and 10:30am, I observed that no documentation was available for the 5 year sensitivity testing of the smoke detectors for the old system that is a zoned system. Interview with the Plant Manager and other maintenance staff indicated that the testing had just been done, however, the paperwork was not available at the time of survey. No written record could be produced for the nuisance alarms as required to extend the testing to every 5 years.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey tour.

The facility has failed to ensure that the sprinkler system undergoes quarterly inspections as required. This could allow for the system to become inoperable and staff not aware. Failure to inspect and test automatic sprinkler systems could expose patients, visitors, and staff to the threat of fire without an extinguishing system.

The findings include, but are not limited to:

During document review on August 12, 2014 between the hours of 9:30am and 10:30am, I observed that no documentation was available for the 1st quarter of 2014 quarterly inspection of the sprinkler system. Interview with the Plant Manager revealed that the sprinkler company could not come out during the 1st quarter of 2014 due to staff shortages and workload.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey tour.

The facility has failed to provide master alarms to the medical gas piping system as required. This could potentially allow for a malfunction of the system to go undetected by the staff. This could place patients, visitors, and staff at risk of a medical gas leaks or other situations.

The findings include, but are not limited to:

Based upon observations and staff interviews during survey rounds on August 12, 2014 between the hours of 10:30 am and 3:30pm, while accompanied by the Plant Manager and Maintenance Staff Member, I observed that the second master alarm for the medical gas piping system was in the Emergency Department. The second alarm does not satisfy the requirement of being principal working area of the individual responsible for the maintenance of this system.

This finding was observed and discussed with the Plant Manager and the Maintenance Staff Member.

The facility has failed to provide a required emergency stop button for the existing old generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Plant Manager and Maintenance Staff Member, on August 12, 2014 between the hours of 10:30am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

At approximately 10:35am, I observed that the old generators do not have emergency shut off buttons as required.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member, that accompanied me during the entire survey tour.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on August 12, 2014, between the hours of 10:30am and 3:30pm, I observed electrical hazards in the following locations:

1. At 11:05 I observed a refridgerator plugged into a power strip in Medial Records.
2. At 11:30am, I observed soiled utility to have an electrical outlet missing its required cover plate.
3. At 11:40am, I observed the Dr's lounge to have a microwave plugged into a power strip.

These findings were observed and discussed with the Plant Manage and the Maintenance Staff Member that accompanied me during the entire survey.

The facility has failed to ensure that Alcohol Based Hand Sanitizers (ABHS) are separated from electrical sources by at least 6 inches. This could allow for a fire to start with an ignition source so close, and thus put patients, visitors, and staff at risk of fire.

The finding include, but are not limited to:

During the facility survey on August 12, 2014, between the hours of 10:30am and 3:30pm, I observed ABHS too close to electrical units in the following locations:

1. At 11:31am, I observed an ABHS too close to an electrical switch in room A in the Specialty Clinic.
2. At 11:32am, I observed an ABHS too close to an electrical switch in room B in the Specialty Clinic.

These findings were observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey tour.

The facility has failed to properly test batteries of required emergency lighting as required. This could allow for batteries to become inoperable and staff not aware. Failure to ensure that batteries are tested as required could result exposing patients, visitors, and staff to unlighted egress paths during a power outage.

The findings include, but are not limited to:

Document review, on August 12, 2014 between the hours of 9:30am and 10:30am, revealed that the staff could not produce documented proof that the 90 minute tests were conducted on the emergency lighting batteries. Interview with maintenance staff member revealed that maintenance staff was not properly informed of process for the 90 minute test.

This finding was observed and discussed with the Plant Manager and Maintenance Staff member.

The facility has failed to ensure that fire drills are conducted a minimum of one fire drill per quarter per shit as required. Failure to conduct the required frequency of fire drills could result in staff not being properly trained and expose patients, visitors, and staff to evacuation delays or other emergency where staff is unaware of their roles.

The findings include, but are not limited to:

During record review on August 12, 2014 between the hours of 9:30am and 10:30am, of the facility's fire drill records for one year prior to the date of survey revealed fire drills were not conducted as required. Interview with Plant Manager and other Hospital staff revealed that the fire drills were indeed conducted, the written paperwork has been temporarily misplaced.

Record review revealed that no fire drills were conducted in:

1. No fire drill records for 1st quarter 2014.
2. No night fire drill records for 2nd quarter of 2014.
3. No fire drills records for 3rd quarter 2014.
4. No fire drills records for 4th quarter 2013.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey.

The facility has failed to provide documentation, and corresponding logs, that the 5 year sensitivity testing had been conducted on the smoke detectors. This could allow for smoke detectors to lose sensitivity and not activate as quickly as required. Failure to conduct required maintenance of the smoke detectors could expose patients, visitors, and staff to a smoke environment without detection.

The findings include, but are not limited to:

During document review on August 12, 2014 between the hours of 9:30am and 10:30am, I observed that no documentation was available for the 5 year sensitivity testing of the smoke detectors for the old system that is a zoned system. Interview with the Plant Manager and other maintenance staff indicated that the testing had just been done, however, the paperwork was not available at the time of survey. No written record could be produced for the nuisance alarms as required to extend the testing to every 5 years.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey tour.

The facility has failed to ensure that the sprinkler system undergoes quarterly inspections as required. This could allow for the system to become inoperable and staff not aware. Failure to inspect and test automatic sprinkler systems could expose patients, visitors, and staff to the threat of fire without an extinguishing system.

The findings include, but are not limited to:

During document review on August 12, 2014 between the hours of 9:30am and 10:30am, I observed that no documentation was available for the 1st quarter of 2014 quarterly inspection of the sprinkler system. Interview with the Plant Manager revealed that the sprinkler company could not come out during the 1st quarter of 2014 due to staff shortages and workload.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member that accompanied me during the entire survey tour.

The facility has failed to provide master alarms to the medical gas piping system as required. This could potentially allow for a malfunction of the system to go undetected by the staff. This could place patients, visitors, and staff at risk of a medical gas leaks or other situations.

The findings include, but are not limited to:

Based upon observations and staff interviews during survey rounds on August 12, 2014 between the hours of 10:30 am and 3:30pm, while accompanied by the Plant Manager and Maintenance Staff Member, I observed that the second master alarm for the medical gas piping system was in the Emergency Department. The second alarm does not satisfy the requirement of being principal working area of the individual responsible for the maintenance of this system.

This finding was observed and discussed with the Plant Manager and the Maintenance Staff Member.

The facility has failed to provide a required emergency stop button for the existing old generators in an approved location. This could allow for a problem to exist at the generator and staff must go inside the room housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include, but are not limited to:

Observations made during the survey tour and interviews with the Plant Manager and Maintenance Staff Member, on August 12, 2014 between the hours of 10:30am and 3:30pm, revealed that staff was not aware that the generators required remote shut-down switches.

At approximately 10:35am, I observed that the old generators do not have emergency shut off buttons as required.

This finding was observed and discussed with the Plant Manager and Maintenance Staff Member, that accompanied me during the entire survey tour.

The facility has failed to ensure the premises is free of electrical hazards. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of an electrical fire.

The findings include, but are not limited to:

During the survey tour on August 12, 2014, between the hours of 10:30am and 3:30pm, I observed electrical hazards in the following locations:

1. At 11:05 I observed a refridgerator plugged into a power strip in Medial Records.
2. At 11:30am, I observed soiled utility to have an electrical outlet missing its required cover plate.
3. At 11:40am, I observed the Dr's lounge to have a microwave plugged into a power strip.

These findings were observed and discussed with the Plant Manage and the Maintenance Staff Member that accompanied me during the entire survey.