HospitalInspections.org

Based upon observations and staff interviews on 02/22/2018 between approximately 1315 to 1430 hours the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.
The findings include, but are not limited to:
Former tub room in old hospital wing is now being used for storage and has a non-latching door with louvers in the bottom.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/22/2018 between approximately 1315 to 1430 hours, the facility has failed to maintain openings in corridor walls and only have allowed openings. This could lead to the rapid spread of fire and smoke throughout the facility.

The findings include, but are not limited to:

Tub room in old hospital wing is being used for storage and its door does not latch and has a transfer grille in the bottom.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/22/2018 between approximately 1130 to 1315 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.
The findings include, but are not limited to:
There is no documentation for 1st and 2nd quarter NOC Shift for 2017.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/22/2018 at between 1130 hours and 1600 hours, the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system.

The findings include, but are not limited to:
There is no documentation of annual testing of receptacles at patient bed locations.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/22/18 between 1130 hours and 1430 hours, the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1. Annual fuel quality test not completed.
2. No battery back-up emergency lighting in the hospital ATS room.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/22/2018 between approximately 1130 to 1315 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

There is no written policy for testing, repairs and modification of electrical equipment.

The above was discussed and acknowledged by the facility staff.

Based on record review and staff interview on 02/22/2018 between 1130 and 1430 hours, the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:

There is no documentation available to review concerning the education and training of personnel in oxygen application, maintenance and handling.

The above was discussed and acknowledged by the facility staff.