HospitalInspections.org

Based on tests and observations made during the recertification survey for life safety from fire with the facility's Physical Plant Manager (employee #3), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the treatment room #1 at the gym as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the Occupational Therapist Director (employee #11) on 8/16/16 from 9:00 am until 9:45 am in the following areas:

a. In the Treatment room #1 located at the gym.

Based on observations made during the recertification survey for life safety from fire with the facility's Physical Plant Manager (employee #3), it was determined that the facility failed to ensure that a written plan was found at the nursing station for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 8/16/16 at 9:50 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient ' s room doors, etc.). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on observations during the recertification survey, review of written documents related to smoke detectors located at patient ' s room, it was determined that the facility failed to ensure that it complies with other Code requirements not listed on 2786-R (see 19.7.1.3 on 2012 Code) related to lack of inspections on patient ' s equipment sets and a smoke detector not installed in patient ' s room #211.

Findings include:

1.During record review performed on 8/17/16 it was found that patient ' s brought their own peritoneal dialysis machine and no evidence about being inspected by the facility ' s safety officer as required by the 2012 edition of the Life Safety Code of the NFPA 99 7.6.2.1.10.

2. No evidence was provided related to a log report about the equipment brought by the patients or their relatives to the facility.

3. Patient sleeping room #211 was visited on 8/7/16 at 10:14 am and it was observed that the smoke detector was not installed.