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Based on record review and interview, the facility failed to document a fire scenario and evaluation of the quarterly fire drills conducted. There was no print out from the monitoring company that the signal was received during the drill.
This deficient practice had the potential for staff not to respond accordingly in the event of an actual fire.
Findings:
A review of the hospital wide quarterly fire drills conducted from 2015 to the 2nd quarter of 2016 indicated no documentation of a fire scenario. There was no evaluation and no print out from the monitoring company that the signal was received for each drill.
During an interview on August 1, 2016, at 4:10 p.m., the director of facility services could not explain why there was no fire scenario documented.

NFPA 110, 1999 Edition, Standard for Emergency and Standby Power Systems
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on observation, interview and record review, the facility failed to document electrolyte levels for the generator batteries.

Findings:

During a tour of the facility on August 1, 2016, at 4:35 p.m., the generator located on the east side of the building had two batteries with 6 openings each with a removable cover. Each opening had a solution.
At 5 p.m., the generator on the west side of the building had two batteries with 6 openings each with a removable cover. Each opening had a solution.
A review of the weekly generator checks indicated no documentation of electrolyte levels.
At the same time, during an interview, the director of facility services, after reviewing the generator log stated, there was no documentation of electrolyte levels.

Based on observation and interview, the facility failed to ensure a precautionary sign was posted where the medical gases were stored.
Findings:

During a tour of the facility on August 1, 2016, at 4:40 p.m., the medical gas storage enclosure was located at the back of the building facing the ambulance entrance to the emergency room.
There was a sign on the gate that read " No smoking within 50 feet " There was no precautionary sign posted readable from a distance of 5 feet to indicate medical gases were stored in the enclosure. The precautionary sign should read "Caution, Oxidizing Gas(es) Stored Within. No Smoking."
At the same time, during an interview, the director of facility services could not explain why there was no precautionary sign posted.

Based on record review and interview, the facility failed to document a fire scenario and evaluation of the quarterly fire drills conducted. There was no print out from the monitoring company that the signal was received during the drill.
This deficient practice had the potential for staff not to respond accordingly in the event of an actual fire.
Findings:
A review of the hospital wide quarterly fire drills conducted from 2015 to the 2nd quarter of 2016 indicated no documentation of a fire scenario. There was no evaluation and no print out from the monitoring company that the signal was received for each drill.
During an interview on August 1, 2016, at 4:10 p.m., the director of facility services could not explain why there was no fire scenario documented.

NFPA 110, 1999 Edition, Standard for Emergency and Standby Power Systems
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on observation, interview and record review, the facility failed to document electrolyte levels for the generator batteries.

Findings:

During a tour of the facility on August 1, 2016, at 4:35 p.m., the generator located on the east side of the building had two batteries with 6 openings each with a removable cover. Each opening had a solution.
At 5 p.m., the generator on the west side of the building had two batteries with 6 openings each with a removable cover. Each opening had a solution.
A review of the weekly generator checks indicated no documentation of electrolyte levels.
At the same time, during an interview, the director of facility services, after reviewing the generator log stated, there was no documentation of electrolyte levels.

Based on observation and interview, the facility failed to ensure a precautionary sign was posted where the medical gases were stored.
Findings:

During a tour of the facility on August 1, 2016, at 4:40 p.m., the medical gas storage enclosure was located at the back of the building facing the ambulance entrance to the emergency room.
There was a sign on the gate that read " No smoking within 50 feet " There was no precautionary sign posted readable from a distance of 5 feet to indicate medical gases were stored in the enclosure. The precautionary sign should read "Caution, Oxidizing Gas(es) Stored Within. No Smoking."
At the same time, during an interview, the director of facility services could not explain why there was no precautionary sign posted.