HospitalInspections.org

Based on observation and interview, the facility failed to maintain the backup battery in an EXIT sign. This deficient practice would cause confusion and panic in the event of an emergency. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:
Observation on 9-30-19 at 2:31 pm revealed the EXIT sign by the corridor doors to the ER area failed to light when the test button was pushed.

During an interview on 9-30-19 at 2:31 pm, Administrative Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe. This deficient practice would allow fire, smoke and gasses to migrate into the exit corridors. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:

Observation on 9-30-19 at 2:23 pm revealed the door to the mechanical room failed to fully close and latch within the door frame.

During an interview on 9-30-19 at 2:23 pm, Administrative Staff A confirmed the findings.

Based on observation and interview, the facility failed to maintain doors in corridor openings that were not obstructed. This deficient practice would allow fire, smoke and fire gasses to migrate into the exit corridors. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:

Observation on 9-30-19 at 1:30 pm revealed the north door to the conference room was blocked open by a yellow exercise ball

During an interview on 9-30-19 at 1:30 pm, Administrative Staff A confirmed the finding.

Based on observation and interview, the facility failed to maintain doors in a smoke barrier so they fully closed within the door frame. This deficient practice would allow smoke and fire gases to spread between smoke compartments. The facility has a capacity of 15 beds with a census of 1 on the day of the survey.

Findings are:
Observation on 9-30-19 at 2:01 pm revealed, the smoke doors separating the Lobby zone and the Patient zone failed to fully close within the door frame to be smoke tight.

During an interview on 9-30-19 at 2:01 pm, Administrative Staff A confirmed the doors did not fully close.

Based on record review and interview, the facility failed to conduct an individualized assessment for non-hospital grade receptacles at patient bed locations, including the continuity of the grounding circuit, polarity and retention force. This deficient practice increased the risk of fire from an outlet. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:
Record review on 9-30-19, at 1:20 pm revealed: documentation of annual patient bed location receptacle testing was not provided for review.

During an interview on 9-30-19 at 1:20 pm, Administrative Staff A confirmed the testing documentation was not provided and testing was not implemented.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation and interview, the facility failed to prohibit the use of multi-plug adaptors and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the chances of a fire. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:

Observation on 9-30-19 at 1:42 pm revealed a 6 outlet adaptor plugged into an outlet, with a multi-plug power strip plugged into the 6 outlet adaptor, being used at a desk in the front office area.


During an interview on 9-30-19 at 1:42 pm, Administrative Staff A confirmed the findings.