HospitalInspections.org

Based on observation, and staff interview, it was determined the Hospital failed to provide Exit and directional signs.

Findings include:

1. On 12/18/12 at approximately 12:20 p.m., it was observed there were no exit signs in the ICU.

2. During an interview with a maintenance employee on 12/18/12 at 12:20 p.m., he agreed with these findings.

Based on observation, it was determined the hospital failed to maintain and keep the facility free from decorations of highly flammable character in accordance with National Fire Protection Association (NFPA) 101. This has the potential to adversely affect the safety of all hospital staff, patients and visitors.

Findings include:

1. During a tour of the hospital on 12/17/12 at approximately 10:30 a.m., the facility's Christmas decorations were of combustible materials and were covering unit exits and entrances as well as parts of corridors.

2. The Christmas decorations were discussed with the Administrator on 12/17/12 at approximately 11:00 a.m., and he agreed with these findings. He also stated the decorations would be removed that day.

Based on record review and interview, the hospital failed to ensure proper documentation of the generator being exercised under load on a monthly basis.

Findings include:

1. Review of the generator log sheet on 12/17/12 at 10:00 a.m., revealed the facility failed to provide documentation of the Emergency generator being exercised under load on a monthly basis.

2. The maintenance employee stated during an interview on 12/17/2012 at about 10:00 a.m., the tests are done monthly, but he failed to document the test.

Based on observation and staff interview, it was determined not all hospital electrical systems were maintained according to National Fire Protection Association (NFPA) 70 National Electrical Code.

Findings include:

1. During a tour of the hospital laboratory area on 12/17/12 at approximately 1:30 p.m., the ground fault circuit interrupter in the Laboratory bathroom was not working, (wouldn't trip).

2. During a tour on 12/19/12 at approximately 10:15 a.m., in the new born nursery office there was a reciprocal within six (6) feet of a water source and was not on a ground fault circuit interrupter.

3. These findings were discussed with the hospital maintenance staff on 12/19/12 at approximately 11:04 a.m., and they agreed with these findings.