HospitalInspections.org

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to residents, staff and/or visitors.

The findings include, but are not limited to:

The facility fails to complete 90 minute emergency light testing. The Maintenance Director states that he has never done 90 minute light testing on his exit signs.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to provide signage where mixed gases is stored. This could result in a unsafe response to a fire which could potentially endanger the residents, staff and/or visitors within the facility.

Central supply gas storage area shall have signage stating "positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening" Maintenance Director states that he can get a sign made and that he didn't know about the requirements.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to properly maintain the medical gas system in the facility. This could result in the system not functioning as designed and prompt 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:

The facility fails to provide medical inventory of all source systems, control valves, alarms, manufactured assemblies and outlets. Maintenance Director states that the facility does not have an inventory.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to properly maintain electrical receptacles as required. This could result in an electrical shock due to arcing endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Facility failed to provide GFCI in wet location of ER. Approximately 6 circuits were found in the operating room that failed to have GFCI protection. Maintenance Director states that he does not have a risk assessment by the facility governing body to identify the operating room as anything of than a wet location. Maintenance Director states that he can add GFCI protection to the outlets.

Based upon record review and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to have annual testing and maintenance conducted on the emergency generator. This could result in a failure of the emergency power system which would leave the facility without egress and work lighting in the event of a power failure which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility failed to conduct a fuel test on the generator fuel as required.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.


Generator room fails to have 2 hour fire rated construction provided. Maintenance Director provided plans that identified the generator room to have a 1 hour fire rating.
7.2.1.1 The room shall have a minimum 2 hour fire rating or be located in an adequate location outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building code

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Multi plug adapter exceed 75 of capacity in the following locations:
Billing office
OR break room
HR assistant office
Nurse Coordinators office
Imaging sleep room
CWCM office


Powerstrip plugged into powerstrip in the following location

Trauma Emergency room Repaired during inspection
Emergency room Exam room 1 Repaired during inspection
Emergency room Exam room 2 Repaired during inspection
Maintenance Director states that he will educate staff about the issue

Extension cord in use in reception area
Maintenance Director states that extension cords are not allowed. Repaired during inspection.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to properly maintain training of individuals who maintain electrical equipment. This could result in an electrical shock due to the lack of education endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility fails to provide continuing training for personnel responsible for the testing, maintenance and use of electrical appliances. The Maintenance Director states that they don't provide continuing education.

Based upon record review and staff interviews on 10/17/2017 between approximately 08:30 and 15:0 hours the facility 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:

Storage is planned so cylinders are used in order of which they are received from supplier. Maintenance Director states he never knew about this requirement


The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on 10/17/2017 between approximately 08:30 and 15:00 hours the facility has failed to provide education of medical gases and cylinders. This could result in the ignition of gases, endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Facility failed to provide continuing education, including safety guidelines and usage requirements of gas equipment.

The Maintenance Director states that's he does not have any documentation in reference continuing education that he can provide at this time.