HospitalInspections.org

Based on record review and interview with the Administrator, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients. The program did not incorporate provisions for Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions

The findings included:

On 10-24-18 at 3:00 PM. while reviewing the facility EP, there was no policy or procedures for alternate sources of energy to maintain temperatures to protect patient health and safety and sanitary storage of provisions in the event of a loss of the system. Concurrent with the review, the Administrator said that the facility was in the process of installing an alternate power source that would meet the needs to maintain temperatures to protect sanitary storage of provisions.

Based on a review of the facility records and interviews with the Maintenance Director (MD) and Maintenance Supervisor (MS), the facility failed to maintain the automatic fire alarm system (AFAS) in accordance with NFPA 101 (2012) and NFPA 72 (2010). This in the event of fire, this could prevent the smoke detectors from operating and notifying the occupants of the emergency.

The findings included:

On 10-24-18 between 9:00 AM and 11:00 AM, during document review of the AFAS records. It was revealed that the facility failed to maintain the AFAS smoke duct detectors. The AFAS smoke duct detector pressure testing frequency requirements were not met. In an interview, the MD and MS acknowledged the findings.

per NFPA 101 (2012 edition) Chapter 9.6.1.3
per NFPA 72 (2010 edition) Chapter 14.4, 14.4.2.2, Table 14.4.2.2.14 (g) (6)

Based on observations during the fire safety tour of the facility and interview with the Maintenance Director (MD) and Maintenance Supervisor (MS), the facility failed to maintain the automatic fire sprinkler system (AFSS) in accordance with NFPA 101 (2012 edition) and NFPA 25 (2011 edition). This could delay or deny extinguishment of a fire.

The findings included:

On 10-24-18, between 11:00 AM and 2:30 PM, during the tour of the facility with MD and MS, observation of the AFSS showed corroded ceiling pendant sprinklers in the Kitchen.
1. dish room has 2 of 2 corroded sprinklers
2. preparation room has 4 of 6 corroded sprinklers
An interview was conducted with the MD and MS concurrent with the observations and they confirmed the findings.

per NFPA 101 (2012 edition) 9.7.5
per NFPA 25 (2011 edition) 5.2.1.1.1

Based on a review of the facility records and interviews with Maintenance Drector (MD) and Maintenance Suprvisor (MS), the facility failed to maintain the Fire Dampers in accordance with NFPA 101 (2012 edition). In the event of a fire, this could delay or deny protection to the occupants in an emergency situation.

The findings included:

On 10-24-18 between 9:00 AM and 11:00 AM, during document review of the facility's fire damper inspection records, it was revealed that the facility could not provide an inspection report for damper testing. In an interview, the MD and MS acknowledged the findings.

per NFPA 101 (2012 edition) Chapter(s) 21.5.2.1, 9.2.1
per NFPA 90A (2012 edition) Chapter 5.4.8.2
per NFPA 105 (2010 edition) Chapter(s) 6.5.2

On 10-24-18, between 11:00 AM and 2:30 PM, during the tour of the facility with MD and MS, it was found that the exhaust fans in the patients' rest rooms located on the B-unit (Addition) were not operational. An interview was conducted with the MD and MS concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 9.2.2, 4.6.12, 4.6.12.1
per NFPA 91 (2010 Edition) 6.5.1

Based on a review of the facility records and interviews with the Maintenance Director (MD) and Maintenance Supervisor (MS), the facility failed to protect the fire barriers in accordance with NFPA 101 (2012 edition) and NFPA 80 (2010 edition). In the event of a fire, this condition could put occupants attempting to shelter or evacuate in an unsafe environment.

The findings included:

On 10-24-18 between 9:00 AM and 11:00 AM, during document review with the MD and MS of the annual fire door inspection records. It was revealed that the facility could not provide documentation for annual fire door inspections. An interview was conducted with the MD and MS concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 edition) Chapter 8.3.3.1
per NFPA 80 (2010 edition) Chapter 5.2.1