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Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 15 of 15 residents.


Findings:

During the facility tour on 12/11/2019, between the hours of 9:30a-3:30p observation revealed the exit discharge from the swing bed hall did not exit provide a hard packed all-weather travel surface to the public way.

Interview with Maintenance revealed the facility was not aware that the exit discharge did not continue to the public way.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour on 12/11/2019, between the hours of 9:30a-3:30p observation revealed no sprinkler protcetion behind laundry. Observation also revealed there was not freeze protection located in the riser room.

Interview with Maintenance revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected, tested and maintained in accordance with the requirements of NFPA 25. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour and record review on 12/11/2019, between the hours of 9:30a-3:30p observation revealed no monthly or quarterly inspection were being performed and documented.

Interview with Maintenance revealed the facility was not aware that the monthly and quarterly inspections had not been conducted on the automatic sprinkler system.

Based on visual observation the facility failed to assure that the fire extinguishers were installed in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect 15 of 15 residents.

Findings:

During the facility tour on 12/11/2019, between the hours of 9:30a-3:30p observation revealed the fire extinguishers located by room 118, cross hall, by medical records office, ER, and by DON office were mounted to high.

Interview with Maintenance revealed the facility was not aware that the fire extinguishers were mounted to high.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour and record review on 12/11/2019, between the hours of 9:30a-3:30p observation revealed the central alarm system at the nurses station appeared to be in alarm. Record review also revealed the system was last inspected 2/1/2018.

Interview with Maintenance revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system or the system was in alarm.

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 non hospital grade receptacles were tested and documented in accordance with NFPA 99 6.3.4. The non hospital grade receptacles are required to be tested and documented. The deficient practice has the potential to affect 15 of 15 residents.

Findings:
During a facility tour and record review on 12/11/2019, between the hours of 9:30a-3:30p observation and record review revealed non hospital grade receptacles were not tested annually and not documentation provided at time of inspection.

Interview with the Maintenance revealed the facility was not aware the non hospital grade receptacles required annual testing.

The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6. before being put into service and after any repair or medication. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility ' s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuing training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8


Based on visual observation, the facility failed to assure electrical equipment testing and maintenance requirements in accordance with NFPA 99. The patient-care related electrical equipment (PCREE) is required to be tested in accordance testing intervals established with policies and protocols. The deficient practice has the potential to affect 15 of 15 residents.

Findings:
During the facility tour on 12/11/2019, between the hours of 9:30a-3:30p observation revealed there was no establilshed testing policies and protocols for the PCREE and there was no recorded testing of equipment.

Interview with the Maintenance revealed the facility was not aware the PCREE was required to be tested and records kept of testing.