HospitalInspections.org

Based on a review of the facilities Emergency Preparedness (EP) Plan, it was determined the facility failed to address policies and procedures for sheltering.

Findings include:

1. Interview and documentation review on December 27, 2017, at 11:00 a.m., revealed the EP Plan did not specify a means to shelter in place that includes staff and volunteers who remain in the hospital.

Interview with the Administrator and Staff on December 27, 2017, at 2:00 p.m., confirmed the EP Plan lacked policy and procedures for volunteers and emergency staffing to shelter in place.

Based on documentation review and interview, it was determined the facility failed to ensure that fire drills were held quarterly for each shift, in two of twelve instances.

Findings Include:

1. Review of documentation on December 26, 2017, revealed the following fire drills were not performed:

a) 9:50 a.m., a fire drill was not conducted on the second shift, during the second quarter (April, May, June) of 2017;
b) 9:51 a.m., a fire drill was not conducted on the second shift, during the third quarter (July, August, September) of 2017.

Interview with the Facility Administrator and Staff, on December 27, 2017, at 2:00 p.m., confirmed the second shift fire drills were not conducted.

Based on documentation review and interview, it was determined the facility failed to perform required testing at least annually on the facility piped medical gas system.

Findings Include:

1. Review of documentation on December 26, 2017, at 10:00 a.m., revealed the medical gas system inspection was last inspected on December 4, 2015.

Interview with the Facility Administrator and Staff, on December 27, 2017, at 2:00 p.m., confirmed the most recent medical gas system inspection report was from 2015.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring system requirements in six instances, on three of four floors.

Findings Include:

1. Observation on December 26, 2017, revealed the following electrical wiring deficiencies:

a) 1:30 p.m., a surge protector was connected to an extension cord for power, on the desk, in the center of the basement boiler room;
b) 1:40 p.m., a surge protector was connected to an uninterrupted power supply for power, in the basement main storeroom.

Interview with the Facility Administrator and Staff, on December 27, 2017, at 2:00 p.m., confirmed the misuse of electrical wiring.

2. Observation on December 27, 2017, revealed the following electrical wiring deficiencies:

a) 11:55 a.m., a surge protector was connected to another surge protector for power in the ER nursing station, on the first floor;
b) 11:58 a.m., a coffee maker and a microwave were connected to a surge protector for power, in the first floor EMS room;
c) 1:25 p.m., a refrigerator was connected to a surge protector for power, in the second floor nurse manager office;
d) 1:40 p.m., a surge protector was connected to an uninterrupted power supply for power, in the second floor IT closet.

Interview with the Facility Administrator and Staff, on December 27, 2017, at 2:00 p.m., confirmed the misuse of electrical wiring.