HospitalInspections.org
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PENN HIGHLANDS MON VALLEY
REGULAR FIRE AND SAFETY INSPECTIONS
Tag No.: A0715
Based upon a review of facility documents and employee interview (EMP), it was determined that the facility failed to maintain written evidence of regular inspection by local fire control agenies.
Findings include:
On September 12, 2023, a request was made for documentation of fire inspection by the local fire control agency. No documentation was presented following several requests.
On September 12, 2023, a request was made for documentation of the annual fire inspection by the local fire control agency for 2022. No documentation was presented following several requests.
On September 12, 2023, at 11:30am, EMP3 confirmed there was no documentation of annual fire inspection.
On September 13, 2023, at 3:21pm, EMP1 and EMP3 confirmed there is no facility policy regarding regular fire inspections.
FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Tag No.: A0724
Based upon a review of facility documents, and employee interview (EMP), it was determined that the facility failed to ensure a program of routine maintenance for the overbed lighting to ensure that all wires and connectors were safe.
Findings include:
A review of facility documents revealed that on 08/29/2023, at 9:00 pm, a nurse noted smoke and sparks from the end of the fluorescent light on the headwall of a patient room on the 3rd floor, PCU.
During a telephone interview on 08/30/2023, at 10:10 am, EMP 4 explained that the issue with arcing of the overbed light " ...was not from the voltage. The issue is created from wear and tear on the sockets and loose clips." EMP4 also stated that all fluorescent light pins and clips were checked on the 3rd floor, PCU following the incident. EMP1 indicated that a risk assessment will be completed the week of 09/04/2023, for the remaining overbed lights on floor 6, floor 5, and floor 2.
During an interview on 09/12/2023, there was no evidence that risk assessment had been completed to ensure that all wires and connectors were safe. This was confirmed by EMP1 and EMP3 at 9:40am.
On 09/12/2023, there was no clear plan for mitigation of risk and assurance that additional connectors were not loose to prevent electrical arcing. On 09/12/2023, at 9:45 am, EMP4 stated that no risk assessment had been completed to ensure that all wires and connectors were safe following the events of 08/29/2023. EMP4 stated it was not possible to check all 170 lights with current resources. EMP4 stated, "those lenses take some time to
remove."