HospitalInspections.org

Based on interview and a review of fire drill documentation during the life safety survey completed on 08/25/14, the hospital did not conduct and document fire drills in accordance with CMS regulations.

Findings:

1. Seven of eight drills did not specifically document the day of the drill. The fire drill report only indicates the month and shift the drill was conducted.

2. Fire drill documentation did not include staff names of fire drill participants.

3. Based on an interview with the Director of Plant Operations, all NOC shift drills were conducted as a verbal inservice rather than as a response to a coded drill announcement.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not maintain the fire sprinkler system in accordance with NFPA 13 and per CMS regulations.

Findings:

1. A 4' section of trapped sprinkler piping was observed around ductwork in the air handling equipment room. The trapped section was not equipped with a pendant head or drain plug.

2. The supply of spare sprinkler heads did not include spare upright heads.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not inspect fire extinguishers in accordance with NFPA 10 and per CMS regulations.

Findings:

Portable fire extinguishers throughout the facility did not have documentation of the required monthly visual inspection of each extinguisher.

This observation was made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not maintain loosely hanging vertical fabrics to be flame resistant.

Findings:

1. A 10' decorative fabric window sash in Room 220 did not have labeling that the fabric was either inherently flame retardant or treated to be flame resistant.

2. A fabric window shade/covering on the Community Room west exit door did not have labeling that the fabric was either inherently flame retardant or treated to be flame resistant.

These observations were made in the presence of the Director of Plant Operations.

Based on interview and a review of fire drill documentation during the life safety survey completed on 08/25/14, the hospital did not conduct and document fire drills in accordance with CMS regulations.

Findings:

1. Seven of eight drills did not specifically document the day of the drill. The fire drill report only indicates the month and shift the drill was conducted.

2. Fire drill documentation did not include staff names of fire drill participants.

3. Based on an interview with the Director of Plant Operations, all NOC shift drills were conducted as a verbal inservice rather than as a response to a coded drill announcement.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not maintain the fire sprinkler system in accordance with NFPA 13 and per CMS regulations.

Findings:

1. A 4' section of trapped sprinkler piping was observed around ductwork in the air handling equipment room. The trapped section was not equipped with a pendant head or drain plug.

2. The supply of spare sprinkler heads did not include spare upright heads.

These observations were made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not inspect fire extinguishers in accordance with NFPA 10 and per CMS regulations.

Findings:

Portable fire extinguishers throughout the facility did not have documentation of the required monthly visual inspection of each extinguisher.

This observation was made in the presence of the Director of Plant Operations.

Based on observation during the life safety survey completed on 08/25/14, the hospital did not maintain loosely hanging vertical fabrics to be flame resistant.

Findings:

1. A 10' decorative fabric window sash in Room 220 did not have labeling that the fabric was either inherently flame retardant or treated to be flame resistant.

2. A fabric window shade/covering on the Community Room west exit door did not have labeling that the fabric was either inherently flame retardant or treated to be flame resistant.

These observations were made in the presence of the Director of Plant Operations.