HospitalInspections.org

Based on fire drill documentation review and interview, it was determined the facility to conduct 8 of 10 required quarterly fire drills for the 1st (day) shift and 2nd (night) shift from January 2010 to March 2011. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 05/26/11 at 1000 revealed there was no documentation of fire drills for the for the 1st (day) shift or 2nd (night) shift for the 2nd, 3rd and 4th quarters in 2010 and for the 1st quarter in 2011.
B. In an interview conducted on 05/26/11 at 1435 the Assistant Director of Plant Operations verified there was no further fire drill documentation available for review.

Based on fire drill documentation review and interview, it was determined the facility to conduct 8 of 10 required quarterly fire drills for the 1st (day) shift and 2nd (night) shift from January 2010 to March 2011. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 05/26/11 at 1000 revealed there was no documentation of fire drills for the for the 1st (day) shift or 2nd (night) shift for the 2nd, 3rd and 4th quarters in 2010 and for the 1st quarter in 2011.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire drill documentation available for review.

Based on fire alarm system inspection documentation review and interview, it was determined the facility failed to perform annual inspection of the building fire alarm system beginning in 2007 to present. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of fire alarm inspection reports on 05/26/11 at 0930 revealed the most recent annual fire alarm system inspection occurred on 10/04/06.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire alarm system inspection documentation available for review.

Based on fire alarm system inspection documentation review and interview, it was determined the facility failed to perform annual inspection of the building fire alarm system beginning in 2007 to present. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of fire alarm inspection reports on 05/26/11 at 0930 revealed the most recent annual fire alarm system inspection occurred on October 4, 2006.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire alarm system inspection documentation available for review.

Based on interview, it was determined the facility failed to perform annual inspection of the building sprinkler system since the initial installation in 2007. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of the sprinkler system could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no sprinkler system inspection documentation available for review.

Based on kitchen hood fire suppression system inspection documentation review and interview it was determined the system had not received annual inspection beginning in 2008. Failure to perform annual inspections had the potential to affect the health and safety of staff, visitors and patients because the ability of the fire suppression system to extinguish a fire under the kitchen hood could not be assured. The failed practice had the potential to affect all staff, visitors, and patients admitted to the facility and three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey. The findings follow:

A. Review of the kitchen hood fire suppression system inspection documentation on 05/26/11 at 1330 revealed the most recent inspection occurred on 08/24/07.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further kitchen hood fire suppression system inspection documentation available for review.

Based on fire drill documentation review and interview, it was determined the facility to conduct 8 of 10 required quarterly fire drills for the 1st (day) shift and 2nd (night) shift from January 2010 to March 2011. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 05/26/11 at 1000 revealed there was no documentation of fire drills for the for the 1st (day) shift or 2nd (night) shift for the 2nd, 3rd and 4th quarters in 2010 and for the 1st quarter in 2011.
B. In an interview conducted on 05/26/11 at 1435 the Assistant Director of Plant Operations verified there was no further fire drill documentation available for review.

Based on fire drill documentation review and interview, it was determined the facility to conduct 8 of 10 required quarterly fire drills for the 1st (day) shift and 2nd (night) shift from January 2010 to March 2011. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 05/26/11 at 1000 revealed there was no documentation of fire drills for the for the 1st (day) shift or 2nd (night) shift for the 2nd, 3rd and 4th quarters in 2010 and for the 1st quarter in 2011.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire drill documentation available for review.

Based on fire alarm system inspection documentation review and interview, it was determined the facility failed to perform annual inspection of the building fire alarm system beginning in 2007 to present. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of fire alarm inspection reports on 05/26/11 at 0930 revealed the most recent annual fire alarm system inspection occurred on 10/04/06.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire alarm system inspection documentation available for review.

Based on fire alarm system inspection documentation review and interview, it was determined the facility failed to perform annual inspection of the building fire alarm system beginning in 2007 to present. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

A. Review of fire alarm inspection reports on 05/26/11 at 0930 revealed the most recent annual fire alarm system inspection occurred on October 4, 2006.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further fire alarm system inspection documentation available for review.

Based on interview, it was determined the facility failed to perform annual inspection of the building sprinkler system since the initial installation in 2007. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of the sprinkler system could not be assured. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. The findings follow:

In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no sprinkler system inspection documentation available for review.

Based on kitchen hood fire suppression system inspection documentation review and interview it was determined the system had not received annual inspection beginning in 2008. Failure to perform annual inspections had the potential to affect the health and safety of staff, visitors and patients because the ability of the fire suppression system to extinguish a fire under the kitchen hood could not be assured. The failed practice had the potential to affect all staff, visitors, and patients admitted to the facility and three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey. The findings follow:

A. Review of the kitchen hood fire suppression system inspection documentation on 05/26/11 at 1330 revealed the most recent inspection occurred on 08/24/07.
B. In an interview conducted on 05/26/11 at 1435, the Assistant Director of Plant Operations verified there was no further kitchen hood fire suppression system inspection documentation available for review.