HospitalInspections.org

Based upon observations and staff interviews conducted on 2/26/2020, it was determined that the facility failed to have a Fire Alarm System that was functioning throughout the hospital.

The Findings include:

It was observed on 2/26/2020 at 11:47 am that the fire alarm control panel was in trouble.

An interview was conducted with the Chief Operating Officer at the time of the observation and she stated that the system had been in trouble because of the hurricane damage on the 3rd floor and that the facility was on fire watch since the system was not functioning properly. The COO stated that the facility will be on fire watch until system is repaired.

Based upon observations and staff interviews conducted on 2/25/2020, it was determined that the facility failed to have a functioning sprinkler system.

The Findings Include:

It was observed on 2/25/2020 at 12:19 pm that the sprinkler system had trouble lights on.

-Falla en el sistema (system failure)
-bateria #2 disponible (battery not available)
-Fall de cargador #2 (charger fail #2)
-Bomba e Demanda (pump not available)

An interview was conducted with the Chief Operating Officer and she stated that the system was in trouble and that the system had not been functioning since 7/22/2019 because of mechanical issues with one of the pumps. The jockey pump was being replaced and the system should be pressurized and functional soon.

It was observed that the 2 batteries for the fire pump system had corrosion build up on their terminals (both positive and negative) and one of the cables had corrosion near the terminal connection. The terminals and cables should be maintained with no corrosion so that the battery can properly charge and the cable does not fail/break.

The facility was on fire watch and would continue to be until all of the fire systems were fixed.

It was observed on 2/25/2020 at 12:35 pm that there were 3 corroded sprinkler heads in the generator room.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Officer and they stated that they would have the sprinkler heads replaced as soon as possible and possibly before the system was pressurized and that they would check sprinkler heads throughout the facility to assure that they were in proper working condition.

It was observed in the kitchen area at 2:21 pm that there were 6 sprinkler heads with paint on them 9 sprinkler heads that were corroded and 2 sprinkler heads in the dish room that were obstructed by light fixtures.

An interview was conducted with the COO and the Hospital Safety Officer and they stated that the heads and they stated that the heads with paint would be cleaned or replaced, the corroded heads would be replaced and the obstructed sprinkler heads would have the lights moved so that they would not obstruct the sprinkler heads in the event that they would be activated in a fire emergency.

It was observed on 2/26/2020 at 12:30 pm that there 8 dusty sprinkler heads and 3 corroded sprinkler heads in the laundry room area.

An interview was conducted with the COO and the Hospital Safety Officer at the time of the observation and they stated that the dusty heads would be cleaned and put on a cleaning schedule and the corroded heads would be replaced.

It was observed on 2/26/2020 at 12:35 pm that there were 11 corroded sprinkler heads on the loading dock outside and in back of the laundry room.

An interview was conducted at the time of the observation with the COO and Hospital safety office and they stated that the corroded heads would be replaced as soon as possible.

Based upon observations and staff interviews conducted from 2/25/2020-2/27/2020, it was determined that the facility failed to properly document the inspection of the portable fire extinguishers.

The Findings Include:

It was observed from 2/25-2/27/2020 that the portable fire extinguishers were inspected and signed off on each month but no specific date was recorded on the inspection tag. By not documenting the exact date that the fire extinguishers were inspected it is possible for the fire extinguishers not to be inspected for an extended time period, for example if the fire extinguishers were inspected on March 1st they could be left un-inspected until April 30th and fire extinguishers should be inspected every 30 days.

An interview was conducted on 2/252020 at 12:20 pm with the Chief Operating Officer an the Hospital Safety Officer and they stated that they used to put the exact date on the inspections and then they changed about 15 months ago and just put the month and year on the inspection ticket and not the exact date. They stated that they would rectify the issue by going back to using the exact date that the inspection of each fire extinguisher was conducted.

Based upon record review and staff interviews conducted on 2/26/2020, it was determined that the facility failed to conduct fire drills at varying times and failed to conduct fire drills on all shifts.

The Findings Include:

Record review on 2/26/2020 revealed that fire drills were conducted on the following days and times:

Quarter 1
2/12/20 3:43 pm
2/17/20 10:19 am
1/29/20 3:07 pm
1/27/20 8:43 am
12/11/19 3:22 pm

Quarter 2
11/8/19 11:04 am
10/30/19 6:20 am
9/6/19 11:53 am

Quarter 3
8/6/19 6:20 am
7/23/19 12:00 pm
6/28/19 9:12 pm

Quarter 4
May 2019 no fire drill conducted
4/29/2019 2:57 pm
3/15/19 11:48 am

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2/22/19 3:05pm
1/29/19 1:47 pm

Record review revealed that the facility was not doing at least 1 fire drill per shift, per quarter.

Quarter 1 had no drill on the night shift 12am to 8 am or the 4 pm to 12 am shift and the drills that were conducted on the 8 am to 4 pm shift did not vary in their times 3 of the drills occurring in the 3 o'clock area and this quarter only covered the 8 am to 4 pm shift.

Quarter 2 had no drill on the 4pm to 12 am shift and did not vary the times on the 8 am to 4 pm shift having 2 drills in the 11 o'clock hour.

Quarter 3 did not vary the time of the 12 am to 8 am shift by having the fire drill occur at the same time as the prior quarter 6:20 am

Quarter 4 had no fire drill occur in May and no fire drills occur on the 4 pm to 12 am shift or the 12 am to 8 am shift.

An interview was conducted with the Hospital Safety Officer on 2/26/2020 at 3:20 pm and he stated that going forward he would assure that 1 fire drill per shift per quarter would occur and that the times during each shift would vary so that staff would not be expecting a drill at any particular time.

Based upon observations and staff interviews conducted on 2/25/2020, it was determined that the fire/emergency exit doors to the generator room were not functioning because they were damaged by the hurricane.

The Findings Include:

It was observed on 2/25/2020 at 12:32 pm that the fire/emergency exit doors were open, because as you looked at them from the outside, the door on the right was bent in such a way that it would not close because it was bent.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Office and they stated that the door had been bent and damaged by the hurricane and that the doors are on order but not in stock and that they will install them as soon as they come in.

Based upon observations and staff interviews conducted on 2/25/2020, it was determined that the facility failed to maintain the VICC emergency generator by allowing a water leak to be ongoing and allow water into the VICC generator.

The Findings Include:

It was observed on 2/25/2020 at 1:18 pm that there was a leak in the top/roof of the VICC generator. There was a pool of water inside the generator.

An interview was conducted at the time of the observation with the Hospital Safety Officer and he stated that the leak had bee going on for a while and whenever it rains water gets into the VICC generator. He stated that he would have the leak fixed as soon as possible to assure that the generator was not put at risk from the water getting into it from the leak.

Based upon observations and staff interviews conducted on 2/26/2020, it was determined that the facility failed to properly utilized power strips appropriately and utilized extension cords when they should not be utilized.

The Findings include:

It was observed on 2/26/2020 at 11:03 am that there were 2 extension cords daisy chained and the 2nd cord in the daisy chain had a food warmer plugged into it causing an unsafe electrical condition. Extension cords should not be utilized in this fashion only for temporary use in equipment like vacuum cleaners and floor waxers where the cords are utilized only for the time the equipment is being used and then the cords are removed.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Officer at the time of the observation and they stated that the extension cords should not be used for this equipment and that they would be removed as soon as possible.

It was observed on 2/26/2020 at 11:06 am that there was a power strip in use in the gift shop area and it was hanging in the air by its cord with a microwave oven plugged into it crating an unsafe electrical condition.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Officer at the time of the observation and they stated that the power strip should not be hanging in the air in that manner and that they would have it corrected immediately.

It was observed on 2/26/2020 at 11:09 am that in the Cashiers office in the gift shop area that there were 2 power strips daisy chained with equipment plugged into the 2nd power strip in the daisy chain causing an unsafe electrical condition.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Officer at the time of the observation and they stated that the power strips should not be used in this fashion and that the situation would be corrected immediately and staff would be inserviced so that this would not occur in the facility.

Based upon observations and staff interviews conducted on 2/25-2/26/2020, it was determined that the facility failed to properly store and utilize oxygen tanks in a safe manner.

The Finding Include:

It was observed on 2/25/2020 at 12:46 pm that the backup 12 H tank oxygen containers were not secured to keep them in place and not fall, the oxygen tanks were free standing and had no base or chain (or any device) to keep them from falling or moving. The area was not maintained and the ground the oxygen tanks were on was uneven ground with plants growing under the tanks causing a potential the the tanks would be unsteady and have the potential to fall since they were not secured in any fashion while being hooked up to the oxygen gas system.

An interview was conducted with the Chief Operating Officer and the Hospital Safety Officer and they stated that they would secure the oxygen tanks so that they would not be able to fall over and cause a potential hazard and that they would clean away the plants and maintain the area in the future and get bases for the tanks to stop the potential for them falling over.

It was observed on 2/26/2020 at 12:50 pm that there were 6 H tank oxygen cylinders and 3 H tank compressed air cylinders in the gas storage room that were not secured in any fashion nor were the tanks in bases that would stop them from falling over.

An interview was conducted with the Hospital Safety Officer and he stated that he would assure that the tanks are secured and not able to fall over and cause a hazard and that he would look into getting bases for the tanks so that they would not fall over.