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The facility has failed to ensure that the original fire rated construction of the building has been maintained. Failure to maintain fire separation construction could allow for smoke, heat, and fire to quickly spread through the building, and thus place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

During the facility tour on November 16, 2017 between the hours of 11:00am and 1:00pm, I observed penetrations in fire barriers in the following location:

1st floor electrical closets north of lab wall has penetrations in the ceiling that would allow fire,smoke, and heat to travel to floor above.

Interview with Maintenance Director revealed that maintenance staff was not aware of this breach in fire resistive construction.

The above was discussed and acknowledged by the Maintenance Staff.

Based upon observations and staff interviews on November 16, 2017 between approximately 11:00am and 1:00pm, the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.
The findings include, but are not limited to:
Above the basement mechanical room door there is a penetration that is not sealed completely.
The above was discussed and acknowledged by the Maintenance staff.

The facility has failed to ensure that hospital grade and non hospital grade receptacles are tested required. Failure to test electrical receptacles could allow for an electrical fire to start and place patients, visitors, and staff at risk of an electrical fire.

The findings include, but are not limited to:

Document review on November 16, 2017 between the hours of 9:00am and 11:00am, revealed that staff has not been testing the electrical receptacles as required. There were no records maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.

Interview with maintenance staff revealed that they were unaware of this requirement.

The above was discussed and acknowledged by the Maintenance Staff.

The facility has failed to conduct inspections of Patient-Care Related Electrical Equipment as required. This could allow for the electrical item to become inoperable and staff unaware, and thus place patients, visitors, and staff at risk of electrical shock or electrical hazard.

The findings include, but are not limited to:

Record review of the facilities policies and procedures, on November 16, 2017 between the hours of 9:00am and 11:00am, revealed the following deficiencies for Patient-Care Related Electrical equipment:

1. Interview with staff revealed that the facility is not conducting testing of Patient-Care Related Electrical Equipment.

2. Interview with staff revealed that there is not a plan in place for staff responsible for testing this equipment to receiving continuing education on maintenance and use of electrical equipment.

3. There is no policy in place for a defined periodic testing, maintenance, and repair of Patient-Care Related Electrical Equipment.

The above was discussed and acknowledged by the Maintenance Staff.

Based on observation and staff interview on November 16, 2017 between 9:00am and 11:00am, the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:

Records could not be provided of staff continuing education of medical gases and cylinders. Interview with staff revealed they were unaware of this requirement.

The above was discussed and acknowledged by the Maintenance Staff.