HospitalInspections.org

Based on staff interview and observation, it was revealed the facility failed to provide the hazardous storage areas in the kitchen with self-closing doors kept in closed position, unless held open by a release device complying with 7.2.1.8.2 of National Fire Protection Association (NFPA) 101. Facility census 17.

Findings include:

1. During observation on 08/01/18 between the hours of 9:00 a.m. and 2:00 p.m., it was revealed the facility failed to provide the dry storage areas in the kitchen with self closing doors kept in closed position, unless held open by a release device complying with 7.2.1.8.2 of NFPA 101.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations 08/01/18 at approximately 4:30 p.m.

Based on staff interview and observation, it was revealed the facility failed to provide an exit discharge with a level walking surface that meets the provisions of 7.1.7. With respect to level changes in elevation., the exit discharge was not a hard packed all-weather travel surface in accordance with National Fire Protection Association (NFPA) 101. Facility census 17.

Findings include:

1. During observation on 08/01/18 between the hours of 9:00 a.m. and 2:00 p.m., it was revealed the facility failed to provide an exit discharge on the 700 patient wing next to room 706 in accordance with 7.1.7 of NFPA 101.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator on 08/01/18 at approximately 4:30 p.m.

Based on staff interview and observation, it was revealed the facility failed to inspect and maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25. Facility census 17.

Findings include:

1. During observation on 08/01/18 between the hours of 9:00 a.m. and 2:00 p.m., it was revealed the facility failed to inspect and maintain the automatic sprinkler system in accordance with NFPA 25. The facility had computer wires laying on the sprinkler piping above the ceiling in the 700 patent wing next to room 709, a duct on the sprinkler piping above the ceiling in the operating room corridor next to recovery, on the sprinkler piping above the ceiling next to the Life Safety electrical panel and on the sprinkler piping above the ceiling next to the double doors entering the patient room corridor.

2. The above mentioned deficiency was confirmed with the Director and the Administrator on 08/01/18 at approximately 4:30 p.m.

Based on staff interview and observation, it was revealed the facility failed to provide proper signage for the "K" fire extinguisher located in the kitchen in accordance with National Fire Protection Association (NFPA) 10. Facility census 17.

Findings include:

1. During observation on 08/01/18 between 9:00 a.m. and 4:30 p.m., it was revealed the "K" fire extinguisher located in the kitchen did not have the proper signage in accordance with NFPA 10.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator on 08/01/18 at approximately 4:30 p.m.

Based on staff interview and observation, it was revealed the facility failed to provide covers for electrical junction boxes in accordance with the requirements of National Fire Protection Association (NFPA) 70. Facility census 17.

Findings include:

1. During observation on 08/01/18 between the hours of 9:00 a.m. and 2:00 p.m., it was revealed the facility failed to meet the requirements of NFPA 70 by not having electrical junction box covers on the junction boxes located above the ceiling next to the Life Safety electrical panel and above the ceiling in the housekeeping corridor. Junction box "knock out's" are missing above the corridor ceiling outside the operating room entrance and above the ceiling at the double doors of the kitchen corridor.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator 08/01/18 at approximately 4:30 p.m.

Based on staff interview and the facility document review, it was revealed the facility failed to conduct fire drills in accordance with National Fire Protection Association (NFPA) 101. Facility census 17.

Findings include:

1. During the facility document review conducted 07/31/18 between the hours of 10:30 a.m. and 2:30 p.m., it was revealed the facility failed to conduct a fire drill the evening shift of the 3rd quarter of 2017 in accordance with NFPA 101.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator 08/01/18 at approximately 4:30 p.m.

Based on staff interview and the facility document review, it was revealed the facility failed to conduct inspections on the electrical receptacles located at the head of the patient's beds in accordance with National Fire Protection Association (NFPA) 99. Facility census 17.

Findings include:

1. During the facility document review conducted 07/31/18 between the hours of 10:30 a.m. and 2:30 p.m., it was revealed the facility failed to conduct testing of the electrical receptacles located at the head of the patient's beds in accordance with NFPA 99.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator 08/01/18 at approximately 4:30 p.m.

Based on staff interview and observation, it was revealed the facility failed to provide a remote annunciator outside the generator room readily observed by personnel in accordance with National Fire Protection Association (NFPA) 99. Facility census 17.

Findings:

1. During observation on 08/01/18 between the hours of 9:00 a.m. and 2:00 p.m., it was revealed the facility failed to provide a remote annunciator outside the generator room readily observed by personnel in accordance with NFPA 99.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator 08/01/18 at approximately 4:30 p.m.

Based on staff interview and the facility document review, it was revealed the facility failed to conduct electrical safety inspections on fixed and portable patient care electrical equipment in accordance with National Fire Protection Association (NFPA) 99. Facility census 17.

Findings include:

1. During the facility document review conducted 07/31/18 between the hours of 10:30 a.m. and 2:30 p.m., it was revealed the facility failed to conduct electrical safety inspections on fixed and portable patient care electrical equipment in accordance with NFPA 99.

2. The above mentioned deficiency was confirmed with the Director of Plant Operations and the Administrator 08/01/18 at approximately 4:30 p.m.