HospitalInspections.org

K345 Fire Alarm System - Testing and Maintenance
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform its own monthly fire alarm system test.

K700 Operating Features - Other
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records, facility failed to annual community mock drill and after-action written report with feedback for future improvements.
2) Based on review of the records, facility failed to compile a list of contacts for hospital staff and local/state/federal emergency agency to be readily available for use in the event of an emergency.

K711 Evacuation and Relocation Plan
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records, facility failed to include tornado/hurricane event in the written evacuation and relocation plan.
2) Facility's written plan failed to address the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per NFPA 101 Life Safety Code chapters 18/19.7.2.2; 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

K712 Fire Drills
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records, facility failed to provide evidence of fire drills conducted in 2020, 2021, and 2022.
2) Based on review of the records, fire drills performed in 2023 lacked night shift exercise.

K914 Electrical Systems - Maintenance and Testing
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform documented maintenance and testing of hospital-grade receptacles in patient care areas/treatment space.

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the CFO, during the hours of the inspection from 2:30 pm am to 6:45 pm on 06/14/2023, that there were the following issues:
1) Based on review of the records of the generator, facility failed to perform weekly inspections, monthly load tests, four hours load bank exercise of the generator every 36 month.