HospitalInspections.org

Based upon observations and staff interviews on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.
The findings include:

The TCU electrical room wall has penetrations.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.
The findings include:

1. The facility was unable to provide the most recent smoke detector sensitivity testing report.

2. The fire alarm pull station outside the OR is blocked by a fold down desk area with chairs.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1. The Fire Department Connection on the building does not have a sign.
2. The storage closet by the OR has a fire sprinkler escutcheon missing.
3. The storage room across from the soda machines has storage too close to fire sprinklers.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

The fire extinguisher in the laboratory is installed too high and is inaccessible.

The fire extinguisher outside the OR is obstructed by storage.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The following doors have penetrations:

1. Acute care West and East side doors have penetrations.
2. The TCU toilet shower combo room door has penetrations.
3. The TCU medical prep door frame has penetrations.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger residents/patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.
The findings include:

The ER electrical panel is obstructed by storage.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, residents, staff and/or visitors.
The findings include:

Facility failed to complete an evening shift fire drill the 4th quarter of 2023.

At the PEAK Fitness Physical Therapy there have been no fire drills completed in the prior year.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on May 29 and 30, 2024 between approximately 1230 to 1700 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include:

Weekly inspections are not completed on the emergency generator.

The above was discussed and acknowledged by the facility staff.