HospitalInspections.org

Based on record review, policy review, and interview, the facility failed to ensure fire drills were conducted on the second shift for three of the last four quarters (second quarter 2023 and third and fourth quarters 2022). The facility census was one Acute Care patient and three Swing Bed patients for a total patient census of four.

Findings included:

1. Review of the fire drill records showed no second shift drills for:
- July to September of 2022;
- October to December 2022; and
- March to May 2023.

2. Review of the facility policy titled "Fire", dated 09/05/19, showed fire drills were to be held at least quarterly for each shift.

3. During an inteview on 07/11/23 at 1:07 PM, Staff A, Chief Executive Officer, confirmed there were no night shift drills done for those three quarters.

Based on record review and interview the facility failed to ensure that a test of the medical gas system was completed annually. The facility census was one Acute Care patient and three Swing Bed patients for a total patient census of four.

Findings included:

1. Record review of the facility's documents for building systems did not show a test of the medical gas system.

2. During an interview on 07/11/23 at 9:45 AM, Staff B, Maintenance lead, stated there was no test of the medical gas system.

Based on record review and interview the facility failed to ensure a policy and test of the electrical outlets was done at the facility. The facility census was one Acute Care patient and three Swing Bed patients for a total patient census of four.

Findings included:

1. Record review of the facility testing documents did not show a test of electrical outlets.

2. During an interview on 07/11/23 at 9:45 AM, Staff B, Maintenance lead, stated all outlets in the hospital should be hosptal grade and that would need to be verified and there was no policy on testing of outlets.