HospitalInspections.org

Based on a tour of the hospital, staff interviews and clinical record review during an investigation related to a building evacuation the facility failed to follow the evacuation policy.
During a review of the incident with the Chief Executive Officer (CEO), Plant Facilities Engineer, Fiscal Director and Chief of Patient Care Services on 1/13/13 it was identified that on 11/21/13 at 4:00 AM a steam pipe in a patient occupied building had broken and steam was vented throughout the building ventilation system causing the fire alarm system to activate. A prerecorded building evacuation message programmed into the alarm system was announced. According to the Plant Facilities Engineer the facility was not aware such an incident would cause a prerecorded evacuation message. Patients were evacuated to the secured courtyard of the building with the exception of four patients (P#201, #202, #203 and #204) with physical disabilities who were taken to designated areas of refuge. According to the hospital CEO the staff did not notify the dispatch center that the 4 patients were located in the areas of refuge as indicated in the facility evacuation policy however the Nursing Supervisor (Registered Nurse #4) was aware of the four patients were located in the areas of refuge.
The facility fire and evacuation response plan indicated during an evacuation upon arrival to their new location staff was to call the dispatch center and report their location.