HospitalInspections.org

Based on observations and interviews with facility staff it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

The findings include:

During the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer it was observed that the following doors have been removed:

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, personal inform the surveyor that their are nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.


NFPA 101 (2000 edition)

Based on observations made during tour and staff interveiw of the facility on 09/06/11 & 09/07/11 it was determined that Larkin Community Hospital failed to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside.

Findings include:

It was observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

Based on a review of fire drill reports and staff interview it was determined that Larkin Community Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the residents and staff, and other building occupants.

The findings include:

During the Life Safety survey conducted on 09/06/11 & 09/07/11 fire drill reports for 2010 & 2011 were reviewed with the Plant Operations Manager and the Facilities Safety Officer.

It was revealed that:

There was no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for RACE or PASS meant. Further interview of ICE staff none knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition)

It is required that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Based on observations and interviews with facility staff it was determined that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

The findings include:

During the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer it was observed that the following doors have been removed:

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, personal inform the surveyor that their are nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.


NFPA 101 (2000 edition)

Based on observations made during tour and staff interveiw of the facility on 09/06/11 & 09/07/11 it was determined that Larkin Community Hospital failed to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside.

Findings include:

It was observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

Based on a review of fire drill reports and staff interview it was determined that Larkin Community Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the residents and staff, and other building occupants.

The findings include:

During the Life Safety survey conducted on 09/06/11 & 09/07/11 fire drill reports for 2010 & 2011 were reviewed with the Plant Operations Manager and the Facilities Safety Officer.

It was revealed that:

There was no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for RACE or PASS meant. Further interview of ICE staff none knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition)

It is required that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.