HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to ensure required means of egress doors were not equipped with a latch(s) or lock(s) that requires more than one action to open from the egress side.

Findings:

On 2/21/17 at 11:30 a.m., while on tour of the facility three (3) deadbolts were observed to be on each of the six (6) hospital units' treatment room door(s). The safety officer said those rooms are patient treatment rooms but also used as a tornado shelter.

The facility manager acknowledged the padlocks on the each of the treatment room doors for Unit 1 through 6.

Based on observation and staff interview it was determined the facility failed to ensure emergency powered lighting at each exit discharge as required.

Findings:

On 2/21/17 while on tour of the facility it was observed at each of the main buildings' 20 exit discharge(s) and each of the hospital Units 1 through 6 exit discharge(s) did not have emergency powered lighting installed.

The safety officer acknowledged the twenty main exit discharges, and the six (6) hospital units exit discharge areas did not have emergency powered lighting.

Based observation and staff interview it was determined the facility failed to ensure battery powered emergency back up lighting was inspected and maintained as required.

Findings:

On 2/22/17 while on tour of the facility several battery powered emergency lighting devices were observed installed. The monthly and yearly inspection reports were requested to indicate each battery powered emergency lighting was operationally tested for 30 seconds each month, and 90 minutes per year. The battery powered emergency lighting inspection reports were not provided.

The safety officer acknowledged the need for the battery powered emergency lighting to be tested each month and year.

Based on observation and staff interview it was determined the facility failed to ensure protection of their hazardous areas.

Findings:

On 2/22/17 at 1:55 p.m., while on tour of the facility a fuel fired appliance hazardous area room # 514 was observed to have its door propped open, had combustible materials stored inside and did not have self-closing hardware installed on the door.

The safety officer acknowledged the issues observed with the hazardous area room.

Based on staff interview it was determined the facility failed to ensure annual test & balance inspections were completed as required.

Findings:

On 2/21/17 the 2014, 2015 and 2016 annual test & balance inspections were requested and not provided.

The safety officer acknowledged the missing test & balance annual inspections.

Based on record review and staff interview it was determined the facility failed to ensure fire drills were conducted as required.

Findings:

On 2/21/17 on review of facility fire drills revealed night shift staff was only given written exams about fire drill information and did not actively participate in an operational fire drill for their response to be observed/evaluated.

The safety officer acknowledged the need to actually perform a fire drill on third shift.

Based on observation and staff interview it was determined the facility failed to ensure protection from portable heaters.

Findings:

On 2/21/17 while on tour of the facility portable heaters were observed to be located in Unit 1, 3, 4 at the nurse's station. Documentation of the heating element not exceeding 212 degrees Fahrenheit was requested but not provided.

The safety officer acknowledged the three (3) portable heaters.

Based on staff interview it was determined the facility failed to ensure risk assessments for their building systems were conducted and completed as required.

Findings:

On 2/21/17 at 10:35 a.m., the surveyor asked the safety officer for the facility's building systems risk assessments and they were not provided.

The safety officer acknowledged the missing building systems risk assessments.

Based on staff interview it was determined the facility failed to ensure risk assessments for their medical gas systems were conducted and completed as required.

Findings:

On 2/21/17 at 10:35 a.m., the surveyor asked the safety officer for the facility's medical gas systems risk assessments and they were not provided.

The safety officer acknowledged the missing medical gas systems risk assessments.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas storage had precautionary signage in accordance with NFPA, 2012 Edition, Chapter 5.

Findings:

On 2/21/17, the medical gas storage area(s) for hospital unit 1 through 6 were observed to have no precautionary signage on the door.

The safety officer acknowledged there was no signage on the medical gas storage areas for hospital units 1 through 6.

Based on staff interview it was determined the facility failed to ensure the medical gas systems were inspected annually as required.

Findings:

On 2/21/17 the medical gas systems annual inspections were requested for 2014, 2015 and 2016 and were not provided.

The safety officer acknowledged the missing medical gas systems annual inspections.

Based on staff interview it was determined the facility failed to ensure risk assessments for their building systems were conducted and completed in accordance with NFPA 99, Chapter 4.

Findings:

On 2/21/2017, the surveyor asked the safety officer for their building systems risk assessments.

On 2/21/2017, the safety officer acknowledged there were no building system risk assessments completed for their medical gas system and essentail eletrical system.

Based on record review and staff interview it was determined the facility failed to ensure monthly and yearly generator load bank tests were completed as required.

Findings:

On 2/21/17 the monthly and yearly generator load bank inspection reports were requested. On review, it could not be determined how long or if the monthly generator was ran for at least 30 minutes, nor could it be confirmed or determined if the 36 month 4 continuous hour load bank tests were completed.

The safety officer acknowledged the generator vendor reports could not identify run times for the facility generator.