HospitalInspections.org

Based on observations and interviews made during the walk-through of the facility, the facility failed to ensure door openings closed to resist the passage of smoke into an exit corridor. This potentially exposed staff, visitors and patients to smoke. Findings:

Observation during the facility tour on 03/16/10 at 2:11 PM revealed the door to dietary kitchen, by the walk-in cooler, did not latch properly when closed.

The above findings were acknowledged at the time by the Engineering Coordinator. The findings were also acknowledged by the CEO/Administrator during the exit conference on 03/16/10.

Based on record review and interview the facility failed to conduct fire drills at least quarterly on every shift. This deficient practice could potentially affect all staff and patients. Findings:

A review of fire drill records on 03/16/10 at 12:45 PM revealed that the night shift did not participate in fire drills in March, April, May or June of 2009. As a result, the night shift did not participate in fire drills in the second quarter of the year.

The above finding was acknowledged at the time by the Engineering Coordinator. The finding was also acknowledged by the CEO/Administrator during the exit conference on 03/16/10.

Based on observation and interview, the facility failed to ensure the fire alarm system was properly maintained. This deficienct practice had the potential to expose patients, staff and visitors to a smoke or fire environment. Findings:

Observations and interview on 03/16/10 at 2:50 PM revealed that the fire alarm panel for the facility fire alarm panel was indicated "Trouble" with the message reading "Dialer is missing or has failed."

Interview with the Facilities Engineer revealed that the monitoring company was receiving calls for the alarm panel so he believed the dialer was working. He also stated that the fire alarm servicing company was aware of the problem and the company had indicated that if the problem was with the fire alarm panel dialer, they could not replace the internal fire alarm panel dialer and they would have to install an external dialer.

These findings were acknowledged by the Engineering Coordinator and the CEO/Administrator at the exit briefing on 03/16/10.

Based on observation and staff interview the facility failed to ensure that the facility's electrical system was maintained in a safe condition. This could potentially expose patients and staff to a loss of electrical power and create a possible electrical fire hazard. Findings:

Observation during the facility tour on 03/16/10 at 2:00 P.M. revealed the electrical vault, located off of the boiler room, had cardboard boxes containing filters for the HVAC system stored in the vault. The vault contained at least one transformer.

According to NFPA 70 (1999 edition) section 450-48 Storage in Vaults, materials shall not be stored in transformer vaults.

The storage in the vault presented a fire hazard.

These observations were acknowledged by the Engineering Coordinator and the CEO/Administrator during the exit briefing on 03/16/10.