HospitalInspections.org

K100 Emergency Preparedness Plan and Drills
Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) There was no records to show a disaster drill was conducted in the year 2016. Please consult Federal Register Vol. 81, No. 180, pages 63859-64044, for the current regulatory text regarding emergency preparedness plan and drills.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) There were construction material and rubbish stored in the Boiler Room.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) The electrical Life Safety Panel, which housed the Fire Alarm breaker label was fading and thus not immediately legible.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) The cabinet containing spare sprinkler heads was not replenished. There was only 3 sprinkler heads remaining out of the 6 slots.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) The respiratory room was converted to a hazardous material storage. However, there was still existing medical air inside the room, without a plated cover to prevent improper use. The ceiling was not built up to deck. There were unsealed penetrations.
2) There was a hand washing sink in the laundry room without running water.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) There was no date recorded to indicate when old filters were being replaced.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) Based on a review of the fire drill records, fire drills were not held at unexpected times under varying conditions. Staff indicated there was two shifts: a day shift which spanned from 7:00 AM to 7:00 PM and a night shift which spanned from 7:00 PM to 7:00 AM. In the year 2016, there was only one fire drill conducted for the night shift - held at 7: 25 PM, which doesn't constitute a true night shift fire drill due to the time at which it was held.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) In room 122A, there was a refrigerator for the storage of medications, plugged into a normal power outlet instead of the critical branch of the essential electric system.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) There was no battery backup light at the generator location.
2) The path of access to the generator was not cleared of construction debris and rubbish.

The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) Power strips were in use at the nurse station area. Hospital did not procure waiver to indicate its use was approved.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) There was no record to show that facility was conducting receptacle testing in patient care areas.

The Standard:
A record shall be maintained of the tests required by this chapter and associated repairs or modification. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2012: 6.3.4.2.1.1
At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2012: 6.3.4.2.1.2
Electrical receptacle tests were not being performed in patient care areas. NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data.

Findings:
The inspector observed, while accompanied by the Facilities Director, during the hours of the inspection from 8:30 AM to 12:00 PM on 03/02/17, that there were the following issues:
1) The operating rooms area were not able to be surveyed due to perimeter containment barrier as a result of a fire that started in the imaging suite of the Emergency Department (ED) a week prior to this survey, which resulted in major damages such as water damage, smoke dispersion throughout the hospital, defunct air handling units serving the ED area due to fire, etc. Staff indicated that it will takes 6 to 8 months to rebuild the Emergency Department.