HospitalInspections.org

Based on record review and interview the facility failed to ensure training for new staff, individuals providing services under arrangement, and volunteers on the emergency preparedness plan.

Findings:

Record review of the facility's initial emergency preparedness training curriculum documentation showed it did not contain the facility's emergency preparedness plan as required.

On 08/12/19 at 2:15 pm the surveyor asked staff B for documentation of the facility's initial emergency preparedness training in-service for the facility staff/volunteers and individuals providing services under contract. The surveyor asked staff B if the initial training contained the emergency preparedness plan along with the emergency preparedness policies/procedures to include the communication plan and she stated no. Staff B stated they will incorporate the facility emergency preparedness plan in addition to the emergency preparedness policies/procedures.

Based on observation and interview the facility failed to ensure doors could be opened with one action as required.

Findings:

On 08/12/19 at 5:12 pm the surveyor observed deadbolt locks on corridor room B15, the preop door and physical therapy corridor doors.

On 08/12/19 at 5:12 pm the surveyor asked staff A why there were deadbolts on the corridor doors which would take two actions to open. Staff A stated the deadbolts were on the doors within the facility since he has started. Staff A stated they would have them changed with a lock that will only take one action to open the door to be in compliance.

Based on observation and interview, the facility failed to ensure a hazardous area was properly protected/separated from other use spaces.

Findings:

On 08/12/19 at 5:45 pm the surveyor observed seven penetrations in the ceiling of the Magnetic Resonance Imaging (MRI) room housing the computers. The surveyor observed combustible corrugated boxes, and a plastic trash receptacle stored within the computer hazardous area where it is prohibited to store combustible items.

On 08/12/19 at 5:45 pm the surveyor asked staff A why there were penetrations and combustible items stored within the MRI computer room. Staff A stated the staff servicing the computers failed to remove the combustible items but they will make sure they are in-serviced again to have the items removed with penetrations filled too.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 08/12/19 at 4:16 pm one ABC class and one K class fire extinguisher was observed in the kitchen with no placards posted next to them to indicate the hood fire protection suppression system shall be activated prior to using the fire extinguisher as required.

On 08/12/19 at 6:06 pm the surveyor asked staff A why there was no placard on the fire extinguisher in the kitchen. Staff A stated he would get the appropriate placard for the fire extinguisher installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure corridor doors did not have penetrations cut into them which would allow fire and smoke to spread into the protected emergency egress pathway.

Findings:

On 08/12/19 at 3:20 pm the surveyor observed one corridor pharmacy door with a square area cut out of it which would allow fire and smoke to spread throughout the facility.

On 08/14/19 at 3:20 pm the surveyor asked staff A why the corridor pharmacy door had an area cut into it and he stated he did not know. Staff A stated they would get the door repaired or replaced.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 08/12/19 at 3:54 pm the surveyor stated to staff A the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff A stated they would add that to the fire drill documentation from this point on.