HospitalInspections.org

Based on interview and policy review the facility failed to ensure a policy or procedure was developed to ensure adequate protection when the fire alarm or sprinkler system was impaired The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10.

Findings included:

1. During an interview on 03/13/24 at 8:30 AM, Staff I, Maintenance Lead, stated the facility did not have a policy or procedure when the fire alarm system was out of service that stated to evacuate or implement a fire watch.

2. Review of the facility's policies showed a fire watch policy but did not contain a policy on what to do when the fire alarm was out of service.

Based on interview and policy review the facility failed to ensure fire drill evaluations included simulations of actual fire conditions, documented the time of the drill, or evaluated the proficiency of staff participating in the drills. The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10.

Findings included:

1. During an interview on 03/13/24 at 10:10 AM, Staff I, Maintenance Lead, stated there is no scenario for the drills for staff to respond to and there is not after action report to evaluate staff response to drills or if they reacted appropriately. The time of the drill was not documented.

2. Review of the drill reports showed staff participating were documented by signature. There was a date for the drill, but a time was not documented for the drill to indicate they had been done at various times of the day.

Based on interview and record review the facility failed to ensure the monthly generator test included all information required to be documented which would indicate it had been tested under load. The facility census was five Acute Care patients, three Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of 10.

Findings included:

1. During an interview on 03/13/24 at 10:10 AM, Staff I, Maintenance Lead, stated the monthly generator documentation did not include Hertz or Amps.

2. Review of the monthly generator sheets did not show Hertz or Amps indicated on the documents.