HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure the participation of all staff in fire drills to familiarize facility personnel with their roles and the proper response in the event of fire. Lack of knowledge of the proper response to a fire is potential for putting the staff and patients at risk in the event of fire.

Findings include:

During the review of document for fire drills conducted during 2018 and 2019, there was no evidence that doctors and surgeons participated in the fire drills.

During an interview with Staff E, Facility Manger, on 06/20/2019 at 1:30 PM, he acknowledged the above finding.

The above finding was brought to the attention of the facility's administrators during the exit conference on 6/21/2018 at 3:00 PM.

Based on observation and staff interview, the facility failed to maintain the minimum distance between bulk oxygen systems and exposures. Exposures include but are not limited to: public sidewalk, parked vehicle and buildings of wood frame construction, etc.
According to NFPA 50 2-2, the minimum distance between bulk oxygen storage container to any public parking or parked vehicles is 10 ft.

Findings include:

During a tour of the facility on 6/21/2019 at 11:00 AM, a car was observed, parked in the "no parking area" around the bulk oxygen tank.

The finding was identified in the presence of Staff E, Facility Manger and Staff F, Director of Environmental Services. Staff F acknowledged the finding.

The above finding was brought to the attention of the facility's administrators during the exit conference on 6/21/2018 at 3:00 PM.