HospitalInspections.org

Based upon record review and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:

During a review of the records it was noted that the facility failed to provide a fire drill for the night shift during the first quarter of 2104.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The facility failed to maintain 18" of clearance below sprinkler heads in the Medical records office, Nurse managers office and the supply room under the air handler. All storage removed while surveyor was on site.

2. The annual report from Cascade Fire Safety stated the last calibration for the gauges was 8/31/1979. The gauges must be replaced or calibrated every 5 years.

The above was discussed and acknowledged by the Facilities Director.

Based upon record review and observation on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The fire extinguisher next to the vending machines was blocked by a wheelchair. Wheelchair was removed while surveyor was on site.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to properly maintain the storage of medical gas in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Three oxygen cylinders were observed to be unsecured in the main oxygen room. The cylinders were secured while surveyor was on site.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The emergency battery powered light was not working in the main generator room. Fixed while surveyer was on site.
2. The generators (two) were observed to not have remote manual stops.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

The above was discussed and acknowledged by the Facilities Director.

Based upon record review and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:

During a review of the records it was noted that the facility failed to provide a fire drill for the night shift during the first quarter of 2104.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The facility failed to maintain 18" of clearance below sprinkler heads in the Medical records office, Nurse managers office and the supply room under the air handler. All storage removed while surveyor was on site.

2. The annual report from Cascade Fire Safety stated the last calibration for the gauges was 8/31/1979. The gauges must be replaced or calibrated every 5 years.

The above was discussed and acknowledged by the Facilities Director.

Based upon record review and observation on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The fire extinguisher next to the vending machines was blocked by a wheelchair. Wheelchair was removed while surveyor was on site.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to properly maintain the storage of medical gas in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Three oxygen cylinders were observed to be unsecured in the main oxygen room. The cylinders were secured while surveyor was on site.

The above was discussed and acknowledged by the Facilities Director.

Based upon observations and staff interviews on 1/22/2015 between approximately 0900 and 1300 hours Ocean Beach Hospital has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The emergency battery powered light was not working in the main generator room. Fixed while surveyer was on site.
2. The generators (two) were observed to not have remote manual stops.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

The above was discussed and acknowledged by the Facilities Director.