HospitalInspections.org

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 3 of 3 residents.


Findings:

During the facility tour on 5/5/21, between the hours of 7:30a-4:00p observation revealed unsealed penetrations in the ceiling of the mechanical room.

Interview with the Administrator revealed the facility was not aware of the unsealed penetrations in the hazardous areas.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 3 of 3 residents.
4 of 4 quarters in 2020-2021 were deficient.

Findings:

During the record review, between the hours of 7:30a-4:00p record review revealed no documentation provided for 1st & 2nd quarter of night shift and 3rd & 4th quarter of day shift.

Interview with Administrator revealed the facility was not aware fire drills were not being held as required.

Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)


Based on visual observation, the facility failed to assure receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months in accordance with NFPA 99 6.3.4. The non hospital-grade receptacles are required to be inspected, tested, and documented annually. The deficient practice has the potential to affect 3 of 3 residents.

Findings:

During the record review, between the hours of 7:30a-4:00p record review revealed non hospital grade receptacles were not being tested as required.

Interview with the Administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the receptacles.