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Based on observation and staff interview it was determined the facility failed to ensure emergency lighting is maintained in operating condition in one (1) of two (2) emergency lights tested at the facility's Physical Therapy Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the Physical Therapy Clinic on 3/18/15 at 8:50 a.m. revealed an emergency light unit failed when tested. The unit was located in the front room of the Physical Therapy Clinic, located on the second floor at 210 Charles Street, Sistersville, West Virginia.

2. An interview was conducted with a Physical Therapy Staff member on 3/18/15 at 8:50 a.m., who confirmed the unit did not function when tested.

Based on observation and staff interview it was determined the facility failed to ensure exit signs are displayed in accordance with 7.10, with continuous illumination and served by the emergency lighting system. This deficient practice was identified in two (2) signs in the St. Mary's Express Care Clinic, and two (2) signs in the Physical Therapy Clinic, in Sistersville, West Virginia (WV). This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 8:50 a.m. revealed the exit sign above the front door did not illuminate.

2. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 9:00 a.m. revealed the exit sign at the top of the ramp at the rear door did not illuminate.

3. An interview with maintenance personnel on 3/17/15 at approximately 11:00 a.m. revealed the signs had illuminated when he was in the building before.

4. A tour of the Physical Therapy Clinic at 210 Charles Street, Sistersville, WV on 3/18/15 at approximately 8:50 a.m. revealed the exit signs at both stairwell entries were not illuminated. There were paper exit signs pinned above the doorways leading to the stairwells. There was no back-up lighting to illuminate the signs in the event of a power outage.

Based on record review and staff interview it was determined the facility failed to ensure the fire alarm system is inspected at least annually in accordance with NFPA 72. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. Document review of the fire alarm inspection for the calendar year 2014 and 2015 revealed there was no inspection of the fire alarm system in 2014.

2. An interview with a maintenance representative on 3/16/15 at approximately 10:00 a.m. revealed there was no inspection of the fire alarm system during the calendar year of 2014. He indicated the contracted inspection provider had somehow missed them, and the inspection was completed on 2/20/15.

Based on observation and staff interview it was determined the facility failed to ensure that portable fire extinguishers are inspected and labeled prior to being placed in service in two (2) of two (2) extinguishers located in the St. Mary's Express Care Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 8:45 a.m. revealed two (2) fire extinguishers had not been inspected and labeled prior to being placed in service.

2. An interview was conducted with maintenance personnel on 3/17/15 at approximately 10:30 a.m. and he confirmed the fire extinguishers were not inspected by the contracted inspection company prior to being placed into service. He was under the impression they had up to a year to get the extinguishers inspected.

Based on observation and staff interview it was determined the facility failed to ensure that portable space heaters are not used in health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212° Fahrenheit. This deficient practice was identified at the St. Mary's Express Care Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at 8:50 a.m. revealed a space heater located on a table in the patient waiting area.

2. A tour of the St. Mary's Express Care Clinic on 3/17/15 at 9:00 a.m. revealed a radiant space heater on a table in the hallway, just outside the patient treatment rooms.

3. The above noted observations were confirmed by the Quality Assurance Director on 3/17/15 at the time of the tour.

Based on document review and staff interview it was determined the facility failed to ensure it maintains its generator in accordance with NFPA 110 chapter 8. This failure has the potential to affect all residents, staff and visitors to the facility.

Findings include:

1. Review of the facility's generator testing and maintenance documentation for the calendar year of 2014 revealed no documented credible evidence that the starting battery electrolyte had ever been checked. The documentation provided included a maintenance checklist indicating, "Battery", and this was completed routinely.

2. Review of a note titled, "Sistersville General Hospital Maintenance Service Schedule Emergency Generator for 2014", dated 9/23/14, revealed: "Batteries were weak. Had to get boost start from city officials to get Gen set started. Left running for three hours to charge batteries".

3. An interview was conducted with maintenance personnel on 3/16/15 and he confirmed that electrolyte specific gravity had not been routinely checked. He indicated a new generator set was scheduled for installation beginning the week of 3/16/15 and noted the battery failure was due to a trickle charger failure, which had been replaced.

Based on observation and staff interview it was determined the facility failed to ensure emergency lighting is maintained in operating condition in one (1) of two (2) emergency lights tested at the facility's Physical Therapy Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the Physical Therapy Clinic on 3/18/15 at 8:50 a.m. revealed an emergency light unit failed when tested. The unit was located in the front room of the Physical Therapy Clinic, located on the second floor at 210 Charles Street, Sistersville, West Virginia.

2. An interview was conducted with a Physical Therapy Staff member on 3/18/15 at 8:50 a.m., who confirmed the unit did not function when tested.

Based on observation and staff interview it was determined the facility failed to ensure exit signs are displayed in accordance with 7.10, with continuous illumination and served by the emergency lighting system. This deficient practice was identified in two (2) signs in the St. Mary's Express Care Clinic, and two (2) signs in the Physical Therapy Clinic, in Sistersville, West Virginia (WV). This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 8:50 a.m. revealed the exit sign above the front door did not illuminate.

2. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 9:00 a.m. revealed the exit sign at the top of the ramp at the rear door did not illuminate.

3. An interview with maintenance personnel on 3/17/15 at approximately 11:00 a.m. revealed the signs had illuminated when he was in the building before.

4. A tour of the Physical Therapy Clinic at 210 Charles Street, Sistersville, WV on 3/18/15 at approximately 8:50 a.m. revealed the exit signs at both stairwell entries were not illuminated. There were paper exit signs pinned above the doorways leading to the stairwells. There was no back-up lighting to illuminate the signs in the event of a power outage.

Based on record review and staff interview it was determined the facility failed to ensure the fire alarm system is inspected at least annually in accordance with NFPA 72. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. Document review of the fire alarm inspection for the calendar year 2014 and 2015 revealed there was no inspection of the fire alarm system in 2014.

2. An interview with a maintenance representative on 3/16/15 at approximately 10:00 a.m. revealed there was no inspection of the fire alarm system during the calendar year of 2014. He indicated the contracted inspection provider had somehow missed them, and the inspection was completed on 2/20/15.

Based on observation and staff interview it was determined the facility failed to ensure that portable fire extinguishers are inspected and labeled prior to being placed in service in two (2) of two (2) extinguishers located in the St. Mary's Express Care Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at approximately 8:45 a.m. revealed two (2) fire extinguishers had not been inspected and labeled prior to being placed in service.

2. An interview was conducted with maintenance personnel on 3/17/15 at approximately 10:30 a.m. and he confirmed the fire extinguishers were not inspected by the contracted inspection company prior to being placed into service. He was under the impression they had up to a year to get the extinguishers inspected.

Based on observation and staff interview it was determined the facility failed to ensure that portable space heaters are not used in health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212° Fahrenheit. This deficient practice was identified at the St. Mary's Express Care Clinic. This failure has the potential to affect all patients, staff and visitors to the facility.

Findings include:

1. A tour of the St. Mary's Express Care Clinic on 3/17/15 at 8:50 a.m. revealed a space heater located on a table in the patient waiting area.

2. A tour of the St. Mary's Express Care Clinic on 3/17/15 at 9:00 a.m. revealed a radiant space heater on a table in the hallway, just outside the patient treatment rooms.

3. The above noted observations were confirmed by the Quality Assurance Director on 3/17/15 at the time of the tour.

Based on document review and staff interview it was determined the facility failed to ensure it maintains its generator in accordance with NFPA 110 chapter 8. This failure has the potential to affect all residents, staff and visitors to the facility.

Findings include:

1. Review of the facility's generator testing and maintenance documentation for the calendar year of 2014 revealed no documented credible evidence that the starting battery electrolyte had ever been checked. The documentation provided included a maintenance checklist indicating, "Battery", and this was completed routinely.

2. Review of a note titled, "Sistersville General Hospital Maintenance Service Schedule Emergency Generator for 2014", dated 9/23/14, revealed: "Batteries were weak. Had to get boost start from city officials to get Gen set started. Left running for three hours to charge batteries".

3. An interview was conducted with maintenance personnel on 3/16/15 and he confirmed that electrolyte specific gravity had not been routinely checked. He indicated a new generator set was scheduled for installation beginning the week of 3/16/15 and noted the battery failure was due to a trickle charger failure, which had been replaced.