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BEAVER COUNTY MEMORIAL HOSPITAL
Fire Drills
Tag No.: K0712
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 07/01/19 at 12:38 pm the surveyor stated to Staff H the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff H stated they would add that to the fire drill documentation.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.
Findings:
Record review showed the annual fire rated door assembly inspections for 2018 were not completed and the documentation did not exist.
On 07/01/19 at 12:42 pm the surveyor asked Staff H for the annual fire rated door assembly inspections. Staff H stated the inspection was not done for 2018 and the documentation does not exist.
Fundamentals - Building System Categories
Tag No.: K0901
Based on record review and interview the facility failed to ensure the building system risk assessments were completed.
Findings:
Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed. They do not exist.
On 07/01/19 at 12:35 pm the surveyor asked Staff H for the EES and Medical Gas building system risk assessments, and Staff H stated he would check. Staff H came back a time later and stated they do not have the EES and medical gas building system risk assessments. Staff H stated they will get them completed.