HospitalInspections.org

Based on record review and interview the facility failed to conduct fire drills at various times during the day for each shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 7.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 07/28/14, showed fire drills for the second shift, 7:00 PM to 7:00 AM, were conducted at the following times:
-09/26/14 at 7:45 PM
-11/26/14 at 7:14 PM
-03/29/14 at 7:41 PM
-06/27/14 at 7:05 PM

During an interview on 07/30/14 at 10:45 AM, Staff G, Maintenance Director, stated the second shift fire drills had all been conducted during the 7:00 PM hour of the evening.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Based on observation and interview the facility failed to assure all sprinkler shut off valves are electrically supervised to sound an alarm if the valves are closed. This deficient practice affects all occupants in the facility. The facility census was 7.

Findings included:

Observation and concurrent interview during a tour of the facility, conducted on the morning of 07/29/14, showed the two backflow shut off valves located on the main water supply to the sprinkler system were not electrically supervised so at least a local alarm would sound if the valves are turned.

Staff G, Maintenance Director, confirmed at that time the two backflow shut off valves were not electrically supervised.

Section 19.3.5.1 of the National Fire Protection Association (NFPA 101) states: Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation and interview the facility failed to store flammable/combustible products in approved storage cabinets. This deficient practice affects all occupants in the facility. The facility census was 7.

Findings included:

Observations, during tours of the kitchen conducted on the afternoon of 07/28/14 and morning of 07/29/14, showed a cardboard box containing 16 eight ounce canisters of Sterno brand gelled fuel on a shelf in the dry food storage room of the kitchen and five individual eight ounce canisters on a second shelf.

During an interview on 07/30/14, Staff A, Dietary Manager, confirmed the 20 canisters of Sterno were not stored in an approved cabinet.

Section 4.3.3 of the National Fire Protection Association (NFPA 30) states construction requirements for cabinets for flammable/combustible product storage.

Based on record review and interview the facility failed to conduct fire drills at various times during the day for each shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 7.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 07/28/14, showed fire drills for the second shift, 7:00 PM to 7:00 AM, were conducted at the following times:
-09/26/14 at 7:45 PM
-11/26/14 at 7:14 PM
-03/29/14 at 7:41 PM
-06/27/14 at 7:05 PM

During an interview on 07/30/14 at 10:45 AM, Staff G, Maintenance Director, stated the second shift fire drills had all been conducted during the 7:00 PM hour of the evening.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Based on observation and interview the facility failed to assure all sprinkler shut off valves are electrically supervised to sound an alarm if the valves are closed. This deficient practice affects all occupants in the facility. The facility census was 7.

Findings included:

Observation and concurrent interview during a tour of the facility, conducted on the morning of 07/29/14, showed the two backflow shut off valves located on the main water supply to the sprinkler system were not electrically supervised so at least a local alarm would sound if the valves are turned.

Staff G, Maintenance Director, confirmed at that time the two backflow shut off valves were not electrically supervised.

Section 19.3.5.1 of the National Fire Protection Association (NFPA 101) states: Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation and interview the facility failed to store flammable/combustible products in approved storage cabinets. This deficient practice affects all occupants in the facility. The facility census was 7.

Findings included:

Observations, during tours of the kitchen conducted on the afternoon of 07/28/14 and morning of 07/29/14, showed a cardboard box containing 16 eight ounce canisters of Sterno brand gelled fuel on a shelf in the dry food storage room of the kitchen and five individual eight ounce canisters on a second shelf.

During an interview on 07/30/14, Staff A, Dietary Manager, confirmed the 20 canisters of Sterno were not stored in an approved cabinet.

Section 4.3.3 of the National Fire Protection Association (NFPA 30) states construction requirements for cabinets for flammable/combustible product storage.