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BROWN COUNTY COMMUNITY TREATMENT CTR
PHYSICAL ENVIRONMENT
Tag No.: A0700
Based on observation, interview and review of maintenance records on April 18, 2023, the facility did NOT construct, install and maintain the building systems to ensure life safety to patients.
42 CFR 482.41 Condition of Participation: Physical Environment is NOT MET
Findings include:
The facility was found to contain the following deficiencies.
Hospital
K 0353 Sprinkler System - Maintenance and Testing
K 0355 Portable Fire Extinguishers
K 0712 Fire Drills
Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
LIFE SAFETY FROM FIRE
Tag No.: A0709
Based on observation, interview and review of maintenance records on April 18, 2023, revealed that the facility did NOT construct, install and maintain the building systems to ensure life safety to patients.
42 CFR 482.41(b) Standard: Life Safety from Fire was NOT MET
Findings include:
The facility was found to contain the following deficiencies.
Hospital
K 0353 Sprinkler System - Maintenance and Testing
K 0355 Portable Fire Extinguishers
K 0712 Fire Drills
Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Tag No.: A0724
Based on observation and interview the facility failed to ensure the eyewash station in the Laboratory department was on a preventative maintenance schedule to assure it is functioning properly and maintained in a safe operating condition in 1 of 1 Lab Departments observed in a total of 1 plumbed (a permanent fixture that is connected to a constant water source) eyewash station in the facility.
Findings:
On 4/18/2023 at 1:40 PM during a tour of the lab with Lab Tech H, a plumbed eyewash station was observed. In an interview on 4/18/2023 at 1:45 PM when Lab Tech H was asked about checking the eyewash station for proper temperature and functioning stated, "I turn it on every now and then and if I think the water temperature isn't right I call maintenance to come check it." When asked if Maintenance routinely checks the eyewash station Lab Tech H stated, "No, only if I call them."
On 4/19/2023 at 1:30 PM in an interview with DON (Director of Nursing) A, DON A stated that he/she checked with the Maintenance Department and they do not routinely check or provide preventative maintenance to the eyewash station. "I guess we probably should."