HospitalInspections.org

Based upon observation, document review and interview the facility failed to provide and maintain adequate maintenance of the emergency generator and physical facilities. This could result in potential harm to all patients and staff in the event of a fire or other emergency in which critical life safety and other equipment fails, to operate due to a power outage in which the emergency generator fails to start. Alarms in two operating rooms (OR 1 and OR 2) that were not maintained but removed could result in potential harm to all patients and staff in those rooms


Findings include:

1. On January 29, 2020 at approximately 0900, during a tour of the emergency generator room, observed that the starting batteries for the 750 KW Cummins generator were marked indicating, "New Feb 2018." They appeared to be sealed batteries but staff OO confirmed that there were caps that could be removed to access the individual cells. staff OO also confirmed that the facility was not testing the condition of the batteries on a monthly basis. This is typically accomplished either by checking specific gravity or a battery conductance test, but there was no record of any such tests. The weekly generator test form for December 2019 indicated "OK" for the line item on specific gravity for all four weeks, but there was no documentation recording the actual specific gravity level. Also, the line item for electrolyte levels was "NA" for all four weeks. Note: The facility did not have a separate monthly inspection form.

2. On January 29, 2020 at approximately 1030, during a tour of the operating room (OR) suite, observed that there was no alarm or indicator light when the isolated power panels for OR 1 and OR 2 were tested. It was later explained that the isolated power alarm/displays, which had been mounted inside the operating rooms, had been removed in a recent renovation of wall finishes in those rooms. This was confirmed by staff OO on the day of the survey.