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Tag No.: K0712
Based on document review and staff interview it was determined the facility failed to perform fire drills at unexpected times and under varying conditions. Census is 10.
Findings include:
1. Document review on 06/19/17 at 1:19 p.m. revealed day shift fire drills were performed at 7:03 a.m. on the second quarter, 7:05 a.m. on the third quarter and 7:02 a.m. on the fourth quarter. Evening shift fire drills were performed at 9:05 p.m. on the second quarter and 9:15 p.m. on the third quarter. Midnight shift fire drills were performed at 11:23 p.m. on the third quarter and 11:06 p.m. on the fourth quarter.
2. The Plant Manager was present during the review on 06/20/17 and agreed the fire drills would need to show random times.
Tag No.: K0781
Based on observation and staff interview, the facility failed to prohibit portable space heating devices. Census is 10.
Findings include:
1. A facility tour in the same day surgery area on 06/20/17 at 10:20 p.m. revealed a portable electric space heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit.
2. A facility tour in the infection control classroom on 06/20/17 at 12:47 p.m. revealed a portable electric heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit.
3. A facility tour in the nursing administrator's office on 06/20/17 at 2:08 p.m. revealed a portable electric heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit.
4. A facility tour in the medical records department on 06/20/17 at 2:17 p.m. revealed five (5) portable electric heaters in use. The heaters utilized an element exceeding 212 degrees Fahrenheit.
5. A facility tour in the pharmacy on 06/20/17 at 2:22 p.m. revealed three (3) portable electric heaters in use. The heaters utilized an element exceeding 212 degrees Fahrenheit.
6. The Plant Manager was present during the tours on 06/20/17 and agreed the heaters were not allowed and would be removed.
Tag No.: K0918
Based on document review and staff interview it was determined the facility failed to maintain the emergency generator in accordance with National Fire Protection Association 110. Census is 10.
Findings include:
1. Document review on 06/19/17 at 1:00 p.m. revealed electrolyte testing for both generator batteries was incomplete. Electrolyte testing must be performed and recorded for each cell weekly.
2. Document review on 06/20/17 at 1:39 p.m. revealed no evidence of annual load bank testing for both generators.
3. The Plant Manager was present during the document reviews on 06/20/17 and agreed the generators would need to be compliant with the aforementioned code.
Tag No.: K0921
Based on observation and staff interview it was determined the facility failed to complete electrical testing for portable patient-care related equipment. Census is 10.
Findings include:
1. A facility tour of the Radiology Department on 06/21/17 at 11:00 a.m. revealed there was no evidence of electrical testing.
2. The Plant Manager was present on 06/21/17 and agreed the equipment had not been tested.