HospitalInspections.org

Based on observation and staff interview on 1-23-15, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 0.

Findings are:
Observations during the facility tour on 1/23/15, from 1:36PM to 4:10PM revealed:
1. A self-closing device was removed from the break room door near the emergency exit stairwell.
2. A self-closing device was removed from the #367 supply closet which had combustibles in it.
3. A self-closing device was removed from the storage room near rest room #302.
4. A self-closing device was removed from the furnace / duct room downstairs.
5.) A self-closing device was removed from supply room #329.

During interviews conducted at the time of observations on 1/23/15, from 1:36PM to 4:10PM, Maintenance A and Maintenance B acknowledged the findings.

Based on record review and interview on 1-23-15, the facility failed to activate the fire alarm for 7 of 9 (non-overnight) fire drills. Failing to sound the fire alarm could affect staff performance during a real fire emergency. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 3:55PM revealed all fire drills had been conducted but the fire alarm activity logs showed the fire alarm was only activated for 2 of the 9 (non-overnight) drills (April and October) in 2014.

During an interview on 1-23-15 at 4:00PM, Administrator A confirmed the deficiency.

Based on record review and interview, the facility failed to perform the biennial smoke calibration test for all smoke detectors of the fire alarm system. Failing to have the smoke calibration tests done could leave the facility with inadequate smoke detection. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 1:45PM revealed the smoke calibration test was due in "12 of 2014" but had not yet been completed.

During an interview on 1-23-15 at 1:45PM, Maintenance A and Maintenance B confirmed the deficiency.

Based on record review and interview on 1-23-15, the facility failed to perform required quarterly tests of the water flow alarm. Failing to test the sprinkler water flow alarm on a regular basis could contribute to a failed alarm signal during a real fire. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 3:20PM revealed no documentation to confirm quarterly fire sprinkler water flow tests were conducted for the past year.

During an interview on 1-23-15 at 3:20PM, Maintenance A confirmed the deficiency.

Based on record review and interview on 1-23-15 at 3:30PM, the facility failed to document the weekly generator inspections for the past year. Not performing weekly inspections could result in generator failure at a time of need. This practice affected all residents. Facility census was 0 on 1-23-15.

Findings are:

Documentation review on 1-23-15 at 3:30PM revealed no required weekly generator inspections were recorded for the past year.

During an interview on 1-23-15 at 3:30PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and interview on 1-23-15 at 1:50PM, the facility failed to use a medical grade power tap (electrical surge strips) in a patient room. Non-approved power taps are at greater risk for fire and electrical overload. This practice had the potential to affect 2 patients. Facility census was 0 patients on 1-23-15.

Findings are:

Observations on 1-23-15 at 1:50PM revealed the IV Therapy room did not have an approved electrical power tap where the TV was plugged in.

During an interview on 1-23-15 at 1:50PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and staff interview on 1-23-15, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 0.

Findings are:
Observations during the facility tour on 1/23/15, from 1:36PM to 4:10PM revealed:
1. A self-closing device was removed from the break room door near the emergency exit stairwell.
2. A self-closing device was removed from the #367 supply closet which had combustibles in it.
3. A self-closing device was removed from the storage room near rest room #302.
4. A self-closing device was removed from the furnace / duct room downstairs.
5.) A self-closing device was removed from supply room #329.

During interviews conducted at the time of observations on 1/23/15, from 1:36PM to 4:10PM, Maintenance A and Maintenance B acknowledged the findings.

Based on record review and interview on 1-23-15, the facility failed to activate the fire alarm for 7 of 9 (non-overnight) fire drills. Failing to sound the fire alarm could affect staff performance during a real fire emergency. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 3:55PM revealed all fire drills had been conducted but the fire alarm activity logs showed the fire alarm was only activated for 2 of the 9 (non-overnight) drills (April and October) in 2014.

During an interview on 1-23-15 at 4:00PM, Administrator A confirmed the deficiency.

Based on record review and interview, the facility failed to perform the biennial smoke calibration test for all smoke detectors of the fire alarm system. Failing to have the smoke calibration tests done could leave the facility with inadequate smoke detection. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 1:45PM revealed the smoke calibration test was due in "12 of 2014" but had not yet been completed.

During an interview on 1-23-15 at 1:45PM, Maintenance A and Maintenance B confirmed the deficiency.

Based on record review and interview on 1-23-15, the facility failed to perform required quarterly tests of the water flow alarm. Failing to test the sprinkler water flow alarm on a regular basis could contribute to a failed alarm signal during a real fire. This practice affected all patients. Facility census was 0 on 1-23-15.

Findings are:

Record review on 1-23-15 at 3:20PM revealed no documentation to confirm quarterly fire sprinkler water flow tests were conducted for the past year.

During an interview on 1-23-15 at 3:20PM, Maintenance A confirmed the deficiency.

Based on record review and interview on 1-23-15 at 3:30PM, the facility failed to document the weekly generator inspections for the past year. Not performing weekly inspections could result in generator failure at a time of need. This practice affected all residents. Facility census was 0 on 1-23-15.

Findings are:

Documentation review on 1-23-15 at 3:30PM revealed no required weekly generator inspections were recorded for the past year.

During an interview on 1-23-15 at 3:30PM, Maintenance A and Maintenance B confirmed the findings.

Based on observation and interview on 1-23-15 at 1:50PM, the facility failed to use a medical grade power tap (electrical surge strips) in a patient room. Non-approved power taps are at greater risk for fire and electrical overload. This practice had the potential to affect 2 patients. Facility census was 0 patients on 1-23-15.

Findings are:

Observations on 1-23-15 at 1:50PM revealed the IV Therapy room did not have an approved electrical power tap where the TV was plugged in.

During an interview on 1-23-15 at 1:50PM, Maintenance A and Maintenance B confirmed the findings.