HospitalInspections.org

Based on document review and interview the facility failed to follow their fire response plan. This deficient practice increases the risk of injury to all occupants of the facility. The facility census was 11 and licensed for 21 at the time of survey.
Findings are:

Document review between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am found the facility's fire response policy required staff to make an announcement via the paging system of a fire and its location. Review of the Incident Report, authored by the facility, found that staff did not make the announcement described in the fire response policy and that corrective action was actively being taken.

During interview on 4/12/2024 between 9:00 am and 10:30 am Staff identified there was a violation of policy, Staff had identified the cause of the policy noncompliance, and that they were actively taking corrective action at the time of survey.

Based on document review and interview the facility failed to inspect and test Patient Care Related Electrical Equipment (PCREE) as it entered the facility. This deficient practice resulted in a fire incident that affected 1 patient and had potential to affect all occupants of the facility. Facility census was 11 and licensed for 21 at the time of survey.

Findings are:
Document review between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am found the facility did not have record of inspection/testing of the device when it entered the facility, nor any record of periodic testing of the device from any of the facilities it had reportedly been at.

During interview between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am Staff confirmed the lack of testing as the device entered the facility. Facility Staff, Staff at the facility the device originated from, and a manufacturers representative stated that there was no recent inspection/testing documentation as the device had been missing since at least December 2023.