HospitalInspections.org

Based upon record review and staff interviews on 09/04/2019 between approximately 0800 to 1300 hours the facility has failed to maintenance the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include:
The facility failed to provide heat survey for type 1 hood system. All fusible links in the hood system were found to 360 degree links. The facility stated that they will order heat tape immediately to begin testing.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 09/05/2019 between approximately 0800 to 1400 hours the facility has failed to properly install and maintain alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential danger to patients, staff, and/or visitors within the facility.
The findings include:
ABHR found to be directly over electrical outlet in OD135A. Maintenance director states that he sees it.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/05/2019 between approximately 0800 to 1400 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:
Light found hanging from fire sprinkler system OC104A. Maintenance Directors states that he will get it fixed. Repaired during inspection
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/04/2019 between approximately 0800 to 1400 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:
Jacket found blocking fire extinguisher in cafeteria/kitchen area. Coat was removed immediately.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/04/2019 between approximately 0800 to 1400 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors.

The findings include:
Facility staff in upstairs kitchen were unable to follow fire drill procedures. When facility staff were asked what they would do if there was a grease fire on the stove they explained that they would throw flour on it. Facility staff were asked where the flour is they said down stairs in the other kitchen. Staff then stated that if flour didn't work they would try to use water. The Maintenance Director immediately began providing staff training to kitchen staff on fire emergencies.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/09/2019 between approximately 0800 to 1030 hours the facility did not complete a matrix to determine if their operating rooms were considered wet locations. Operation rooms are by default considered wet locations and require either GFCI or isolated power. This could potentially endanger patients and staff in the operating room if liquids come in contact with the electrical receptacles.

The findings include:

The facility failed to provide LIM, GFCI, or risk assessment in wet procedure location. (Operating room 1-8) Maintenance director states that he will work on a risk assessment.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/05/2019 between approximately 0800 to 1400 hours the facility failed to keep records or conduct maintenance on their Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system endangering patients, staff, and residents.

The findings include:

Facility failed to conduct testing of LIM. The facility has two operating rooms with LIM's. Maintenance states that they will start documenting testing.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/04/2019 between approximately 0800 to 1400 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

Portable heater found plugged into a multi-plug adapter in room 3E151. Maintenance director corrected the violation during the inspection.

Facility found to have powerstrip plugged into powerstrip 3A141. Maintenance director corrected the violation during the inspection.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 09/05/2019 between approximately 0800 to 1400 hours the facility has failed to maintain security of compressed gas cylinders. This could result in the products of the cylinders traveling throughout the facility which could endanger patients, first-responders, staff, and/or visitors.

The findings include:

Fire pump room found to have 1 unsecured carbon dioxide tank.

Six carbon dioxide tanks found to be unsecured in kitchen.

The above was discussed and acknowledged by the facility staff.