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Based on document review and staff interview it was determined the facility failed to ensure medical records were completed within 30 days of discharge. Five patient medical records were affected. The facility census was 29.


Findings include:


Review of the Report to the Wayne HealthCare Board of Trustees from the Executive Committee of the Medical Staff dated 08/15/18 revealed "Failure by any credentialed member of the medical staff to complete patient medical records (create, sign, date and time) within 30 days of patient discharge or provision of outpatient services, as required in the Rules and Regulations, will result in the following progressive sequence of sanctions intended to motivate timely completion."


During an interview with Staff E on 08/12/19 at 10:45 AM, a request was made to provide the number of delinquent medical records. On 08/12/19 at 12:15 PM, Staff E confirmed the facility had five delinquent medical records.

Based on observation, documentation review and staff interview the facility failed to maintain the integrity of the fire proofing of the steel structure in order to maintain the required building construction and type, failed to perform the annual inspections of emergency and exit lights, failed to ensure sensitivity testing of all smoke detectors, sprinkler heads were properly maintained, failed to inspect, test and maintain fire extinguishers, failed to ensure no penetrations in the smoke barrier, failed to maintain smoke/fire barrier doors, failed to ensure electrical outlets were properly installed and failed to ensure proper medical gas storage (A710) This has the potential to affect all patients receiving services from the facility. The facility census was 29.

Based on observation, documentation review and staff interview it was determined the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA) 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies. This has the potential to affect all patients receiving services from the facility. The facility census was 29.


Findings include:

Please refer to Life Safety Code findings for further details.

K161 Building construction type in regard to spray foam missing from steel support beams
K291 Testing of emergency lights
K345 Sensitivity testing of the smoke detectors
K353 Sprinkler heads not properly maintained
K355 Portable fire extinguishers
K372 Penetrations in the smoke barriers
K374 Failure to maintain smoke/fire barrier doors
K912 Electrical outlets not properly installed in regard to GFCI
K923 Medical gas storage.