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Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure that addresses the tracking of patients. This affected 112 of 112 patients at the Main Hospital and Expansion, and could result in an ineffective Emergency Preparedness (EP) plan.

Findings:

During document review and interview with the AS, the EP policies and procedures were requested and reviewed.

Main Hospital and Expansion:

1. On 4/4/19 at 2:48 p.m., the records provided failed to include a policy and procedure that addresses a tracking system used for locating patients that have been relocated or who are sheltering in place during an emergency. Upon interview, AS1 confirmed the finding.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for a medical documentation system that secures and maintains patient information and availability of records during an emergency. This affected 112 of 112 patients at the Main Hospital and Expansion, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the AS, the EP policies and procedures were requested and reviewed.

Main Hospital and Expansion:

1. On 4/4/19 at 3:25 p.m., there was no policy and procedure outlining the facility's medical record documentation system to preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records in the event of an emergency. Upon interview, Administrative 1 and 2 confirmed the finding.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for the use of volunteers and other staffing strategies. This affected 112 of 112 patients at the Main Hospital and Expansion, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the AS, the EP policies and procedures were requested and reviewed.

Main Hospital and Expansion:

1. On 4/4/19 at 3:04 p.m., the EP plan failed to provide policy and procedure for arrangements and/or agreements, that addresses staffing strategies and the use of volunteers during emergencies. Upon interview, AS1 confirmed the finding.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for maintaining the emergency power supply system (EPSS) and on-site fuel source during an emergency. This affected 112 of 112 patients at the Main Hospital and Expansion, and could result in an ineffective Emergency Preparedness (EP) plan.

Findings:

During document review and interview with the AS and PO, the EP plan was requested and reviewed.

Main Hospital and Expansion:

1. On 4/4/19 at 2:45 p.m., the facility was observed with two permanent diesel fueled generators with on-site fuel sources. No plans were available for how the facility would keep the EPSS operational during an emergency, unless the facility evacuates. Upon interview, PO1 and AS1, confirmed the finding.

Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by unsecured fixed furniture at one access corridor location. This affected one of three floors at the Main Hospital, and could result in a delay in evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

7.1.10 Means of Egress Reliability.
7.1.10.1* General. Means of egress shall be continuously
maintained free of all obstructions or impediments to full instant
use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall
obstruct exits or their access thereto, egress therefrom, or visibility
thereof.

Findings:

During a facility tour and interview with the PO, the means of egress was observed.

Main Hospital 2nd Floor

1. On 4/2/19 at 12:05 p.m., the exit access corridor by Room 210 was observed. The corridor width measured 8 feet. Two chairs and a table were stationed on one side of the corridor. The furniture was projected approximately 2 feet into the corridor, with corridor clear width at approximately 6 feet. The furniture grouping was unsecured to either the floor or wall. Upon interview, PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain a clear and identifiable path of egress to the public way. This was evidenced by the failure to post exit guidance and directional signs in an exit discharge. This affected one of three floors at the Main Hospital, and could result in egress delay and confusion during an emergency evacuation.

NFPA 101, Life Safety Code, 2012 Edition
19.2.7 Discharge from Exits. Discharge from exits shall be arranged
in accordance with Section 7.7.
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with
Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3,
or 19.2.10.4.

7.7 Discharge from Exits.
7.7.3 Arrangement and Marking of Exit Discharge.
7.7.3.2 The exit discharge shall be arranged and marked to
make clear the direction of egress travel from the exit discharge
to a public way.

7.10.2 Directional Signs.
7.10.2.1* A sign complying with 7.10.3, with a directional indicator
showing the direction of travel, shall be placed in every
location where the direction of travel to reach the nearest exit
is not apparent.

Findings:

During a facility tour and interview with the PO, the exit access, exit, and exit discharge were observed.

Main Hospital 1st Floor

1. On 4/2/19 at 12:30 p.m., the egress discharge path from the designated exit to the Pool Courtyard was observed. The door exited outside into a courtyard enclosed by the building structure and metal security fence. Two paths of travel were available. No directional sign or exit sign on the exit gate were posted. The path leading to the exit gate was not clear and identifiable. Upon interview, PO1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the cooking facilities. This was evidenced by range hood cleaning not being performed on a semi-annual basis (six months) for moderate volume cooking. This affected one of three floors at the Main Hospital, and could potentially result in the uncontrolled spread of a grease fire in the cooking area.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
Chapter 11 Procedures for the Use, Inspection,
Testing, and Maintenance of Equipment
11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing
Systems.
11.2.1* Maintenance of the fire-extinguishing systems and
listed exhaust hoods containing a constant or fire-activated
water system that is listed to extinguish a fire in the grease
removal devices, hood exhaust plenums, and exhaust ducts
shall be made by properly trained, qualified, and certified person(
s) acceptable to the authority having jurisdiction at least
every 6 months.

11.4* Inspection for Grease Buildup. The entire exhaust system
shall be inspected for grease build up by a properly trained,
qualified, and certified person(s) acceptable to the authority having
jurisdiction and in accordance with Table 11.4.
Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume
of Cooking
Inspection
Frequency
Systems serving high-volume cooking
operations, such as 24-hour cooking,
charbroiling, or wok cooking
Quarterly
Systems serving moderate-volume cooking
operations
Semiannually

Findings:

During a facility tour, document review, and interview with the PO, the kitchen hood and cooking area were observed and service records were requested.

Main Hospital 1st Floor

1. On 4/4/19 at 9:50 a.m., the facility was observed with a cooking kitchen equipped with a vent- hood. The current hood cleaning service and inspection was dated 11/20/18, and the previous inspection was dated 1/30/18. The inspections indicated that the hood cleaning was performed every nine months, instead of every six months (semi-annually). Upon interview, PO2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by a Fire Alarm Control Panel (FACP) amber trouble light display and audible alarm silence. This affected three of three floors at the Main Hospital, and one of one floor at the Expansion, and could result in the failure of the fire alarm system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems,
their initiating devices, and notification appliances shall comply
with the requirements of this chapter.

14.2.1.2.2 System defects and malfunctions shall be corrected.

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for
1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance,
tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(
vies)
(16) Other tests as required by the equipment manufacturer ' S
published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system
owner notified, problem corrected/successfully retested,
device abandoned in place)

Findings:

During a facility tour, document review, and interview with the PO, the FAS was observed.

Main Hospital and Expansion:

1. On 4/2/19 at 11:00 a.m., the Main FACP located at the Main Hospital was observed with an amber trouble light, and local data map-fault failure display. The audible alarm silence light was activated. Upon interview, PO1 confirmed the finding, stating that the trouble signal was first noted approximately three weeks ago, and that a vendor had assessed the FAS as functioning and sending signals to the Off-Site Monitoring Company.

All FAS devices tested between 2:30 p.m. and 3:10 p.m. were functional and confirmed received at Off-Site Monitoring, including trouble. The Main FACP continued to display an amber-trouble light data map failure and audible alarm silence light after testing was completed. Upon interview, PO1 confirmed the finding.

2. On 4/4/19 at 2:30 p.m., the document titled, "Time Line of Fire Watch Decision for Trouble Fault" dated 2/25/19 was submitted for review. The report indicated that on 2/25/19 at approximately 10:00 a.m., the FAS read a fault, monitoring service was notified, and within one hour after the FAS trouble display was observed, a technician assessed that the system was not compromised. A work order was submitted at the time. No scheduled follow-up repair date of the system was submitted. Upon interview, PO2 confirmed the finding.

Review of the document titled "Fire Alarm Inspection" dated 12/28/18, indicated all FAS devices passed with-in normal values with inspection.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to provide written protocol to ensure that if the fire alarm system was out of service for more than 4 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected three of three floors at the Main Hospital and one of one floor at the Expansion, and could potentially result in the AHJ not having the ability to exercise oversight if the fire alarm system should become inoperable.

Findings:

During document review and interview with the AS, the interim fire measures and policy were reviewed.

Main Hospital and Expansion

1. On 4/4/19 at 9:45 a.m., the approved Fire Watch policy was reviewed. The policy did not include notification to the Department of Public Health if the fire alarm system was out of service for more than 4 hours in a 24 hour period. Upon interview, AS1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the smoke detectors. This was evidenced by the failure to provide a current smoke detector sensitivity testing. This affected three of three floors at the Main Hospital and one of one floor at the Expansion, and could result in delayed notification or false alarm of a fire due to a malfunctioning smoke detector.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm Code, 2010 Edition
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During a facility tour, document review, and interview with the PO, the smoke detectors were observed, and records were requested for review.

Main Hospital and Expansion

1. On 4/4/19 at 11:00 a.m., the facility was observed with hard wired smoke detectors located in corridors and rooms. The current smoke detector sensitivity report was requested for review. No current or previous reports were available. Upon interview, PO2 confirmed the finding stating that the date of sensitivity testing was unknown.

Based on observation, document review, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by the failure to perform two of four quarterly inspections, paint on a sprinkler, and a missing sprinkler escutcheon. This affected three of three floors at the Main Hospital, and one of one floor at the Expansion, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

4.3 Records
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow alarms and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.
5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.
13.2.6 Alarm Devices.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.

Findings:

During a facility tour, document review, and interview with the PO, the automatic fire sprinkler system was observed, and records were requested for review.

Main Hospital 1st Floor

1. On 4/2/19 at 12:15 p.m., the pendant style sprinkler head located in the Gym, above the entry door, was missing an escutcheon. Upon interview, PO2 confirmed the finding.

2. On 4/2/19 at 12:40 p.m., the pendant style sprinkler head located in the Kitchen, above the rear entry door, had an irregular pattern of white paint on the deflector and frame. Upon interview, PO2 confirmed the finding.

Main Hospital and Expansion

3. On 4/4/19 at 11:15 a.m., the facility was observed fully sprinklered with a wet automatic fire sprinkler system. No records for quarterly inspections were available for the first quarter (January, February, March), and second quarter (April, May, June), 2018. Upon interview, PO2 confirmed the finding.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to provide written protocol to ensure that if the automatic sprinkler system was out of service for more than 10 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected three of three floors at the Main Hospital and one of one floor at the Expansion, and could potentially result in the AHJ not having the ability to exercise oversight if the fire sprinkler system should become inoperable.

Findings:

During document review and interview with the AS, the interim fire measures and policy were reviewed.

Main Hospital and Expansion

1. On 4/4/19 at 9:45 a.m., the approved Fire Watch policy was reviewed. The policy did not include notification to the Department of Public Health if the fire sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, AS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was mounted higher than the maximum allowed height of sixty inches. This affected one of three floors at the Main Hospital, and could result in the inability of staff to readily access the fire extinguisher in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010, edition.
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding
40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater
than 40 lb (18.14 kg) (except wheeled types) shall be installed
so that the top of the fire extinguisher is not more than 3 1/2 ft
(1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom
of the hand portable fire extinguisher and the floor be less
than 4 in. (102 mm).

Findings:

During a facility tour and interview with the PO, the portable fire extinguishers were observed.

Main Hospital 1st Floor

1. On 4/2/19 at 12:35 p.m., the portable ABC fire extinguisher located inside the Kitchen was observed. The extinguisher was mounted to the wall with the top of the operative handle at 63 inches above the floor. The extinguisher weighed less than 40 pounds. Upon interview, PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the integrity of the corridor construction. This was evidenced by an unsealed wall penetration. This affected one of three floors at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a facility tour and interview with the PO, the corridor walls and ceiling were observed.

Main Hospital 2nd Floor

1. On 4/2/19 at 11:55 a.m., there was an approximately six inches in diameter wall penetration located in the Two-West corridor by the phone. Upon interview, PO1 Confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by an obstructed corridor door. This affected one of one floor at the Main Hospital Expansion, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a facility tour and interview with the PO, the corridor doors were observed.

Main Hospital Expansion

1. On 4/2/19 at 12:55 p.m., the corridor door to Patient Quiet Room 2 was observed. A towel was wedged under the bottom of the door, prevented the door from closing and latching. Upon interview, PO2 confirmed the finding.

Based on document review and interview, the facility failed to conduct fire drills one per shift per quarter. This was evidenced by no documentation for the performance of three of twelve fire drills. This affected three of three floors at the Main Hospital and one of one floor at the Expansion, and could result in staff being untrained and unaware of shift-specific roles and responsibilities during an emergency.

NFPA 101 Life Safety Code, 2012 edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.2 All employees shall be periodically instructed and
kept informed with respect to their duties under the plan required
by 19.7.1.1.
19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.
19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.
19.7.1.6 Drills shall be conducted quarterly on each shift to
familiarize facility personnel (nurses, interns, maintenance
engineers, and administrative staff) with the signals and emergency
action required under varied conditions.
19.7.1.8 Employees of health care occupancies shall be instructed
in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.
19.7.2.2 Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed
in the use of and response to fire alarms.
19.7.2.3.2 All health care occupancy personnel shall be instructed
in the use of the code phrase to ensure transmission
of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately
go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
19.7.2.3.3 Personnel hearing the code announced shall first
activate the building fire alarm using the nearest manual fire
alarm box and then shall execute immediately their duties as
outlined in the fire safety plan.

Findings:

During document review and interview with the PO, the fire drill records were requested and reviewed.

Main Hospital and Expansion

1. On 4/3/19 at 3:00 p.m., documentation was not available for a Night Shift fire drill second quarter (April, May, June), and P.M. and Night Shift drills for the fourth quarter (October, November, December) 2018. Upon interview, PO2 confirmed the finding.