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OLIVIA HOSPITAL & CLINIC
Sprinkler System - Installation
Tag No.: K0351
Based on observation and staff interview, the facility failed to install the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1 and 9.7.1.1 and NFPA 13 (2010 edition), The Standard for the Installation of Sprinkler Systems, section 8.5.5.3.1. This deficient finding could have an isolated impact on the residents within the facility.
Findings include:
On 03/13/2024 between 8:45 AM and 12:00 PM, it was revealed by observation that there was no sprinkler head installed in the maintenance director's office.
An interview with the Maintenance Director verified this deficient finding at the time of discovery.
Fire Drills
Tag No.: K0712
Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, and 4.7.4. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 03/13/2024 between 8:45 AM and 12:00 PM, it was revealed by a review of available documentation that the facility was not varying the times of the fire drills throughout the year on each shift.
An interview with the Maintenance Director verified this deficient finding at the time of discovery.
Fundamentals - Building System Categories
Tag No.: K0901
Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 03/13/2024 between 8:45 AM and 12:00 PM, it was revealed by a review of available documentation that the NFPA 99 Risk Assessment for Chapter 5 had not been completed for this facility.
An interview with the Maintenance Director verified this deficient finding at the time of discovery.
Gas Equipment - Qualifications and Training
Tag No.: K0926
Based on a review of available documentation and staff interview, the facility failed to implement medical gas training for staff per NFPA 99 (2012 edition), Health Care Facilities Code, section 11.5.2.1. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 03/13/2024 between 08:45 AM and 12:00 PM, it was revealed by review of available documentation that the facility was unable to provide documentation showing that training for personnel concerned with the application and maintenance of medical gases and others who handle medical gases are receiving continuing education for the safety guidelines and usage requirements for medical gases and their cylinders.
An interview with the Maintenance Director and Director of Quality and Safety verified this deficient finding at the time of discovery.