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Based on observation and review of Drill Critique Forms, the facility failed to provide in-service training for all staff to be familiar with procedures or to provide in-service training as required for all staff to be in compliance. 19-7.1.2 Findings:

For the drill conducted on June 12, 2009, the drill report indicated the fire location was in the Equipment Room, a staff member commented on the critique form that during the drill, he did not know where the room was located. The facility failed to provide documentation that there was a follow-up or in-service training provided for the staff member regarding this incident..

Based on observation, review of records, and interview with staff, the facility failed to maintain the Fire Alarm System in accordance with NFPA 72, 1999 edition, 19.3.4 Findings:

The annual fire alarm system test report was not signed by a representative of the facility for the test conducted on 4-21-10 and there was not a record of a re-acceptance test of the Fire Alarm System after the replacement of the system's mother board on August 27-09.

Based on observation and interview with staff on December 20, 2010 at 2:30 PM, the facility failed to protect anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities.
Findings:
(1) Relative humidity is not maintained equal to or greater than 35%. The Fairview Regional Medical Center Nursing Policy #: SG-0073, Department: Surgery, revised 11-26-07, states that the Relative Humidity will be kept between 50-55%. The Surgery Temperature /Humidity Control Log depicts during January 1-31, 2010 through March 1, 2010, humidity was logged from less than 10% to a high of not greater than 32%. Many days were in the low 20% range.
(2) The facility failed to provide documentation that the OR Room was provided with a supply and exhaust system that is arranged to vent smoke and products of combustion automatically or is tied into the Emergency Power System.

Based on observation, review of records, and interview with staff, the facility failed to test Medical Patient Care Equipment in accordance with NFPA 99, 1999 edition, Chapter 9-2.1. Finding:

The INVIVO) MDE /Morton 6# located in the recovery room, first bay, was not tested within a yearly test cycle and was not removed from service. It was last tested March of 2009.

Based on observation and review of Drill Critique Forms, the facility failed to provide in-service training for all staff to be familiar with procedures or to provide in-service training as required for all staff to be in compliance. 19-7.1.2 Findings:

For the drill conducted on June 12, 2009, the drill report indicated the fire location was in the Equipment Room, a staff member commented on the critique form that during the drill, he did not know where the room was located. The facility failed to provide documentation that there was a follow-up or in-service training provided for the staff member regarding this incident..

Based on observation, review of records, and interview with staff, the facility failed to maintain the Fire Alarm System in accordance with NFPA 72, 1999 edition, 19.3.4 Findings:

The annual fire alarm system test report was not signed by a representative of the facility for the test conducted on 4-21-10 and there was not a record of a re-acceptance test of the Fire Alarm System after the replacement of the system's mother board on August 27-09.

Based on observation and interview with staff on December 20, 2010 at 2:30 PM, the facility failed to protect anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities.
Findings:
(1) Relative humidity is not maintained equal to or greater than 35%. The Fairview Regional Medical Center Nursing Policy #: SG-0073, Department: Surgery, revised 11-26-07, states that the Relative Humidity will be kept between 50-55%. The Surgery Temperature /Humidity Control Log depicts during January 1-31, 2010 through March 1, 2010, humidity was logged from less than 10% to a high of not greater than 32%. Many days were in the low 20% range.
(2) The facility failed to provide documentation that the OR Room was provided with a supply and exhaust system that is arranged to vent smoke and products of combustion automatically or is tied into the Emergency Power System.

Based on observation, review of records, and interview with staff, the facility failed to test Medical Patient Care Equipment in accordance with NFPA 99, 1999 edition, Chapter 9-2.1. Finding:

The INVIVO) MDE /Morton 6# located in the recovery room, first bay, was not tested within a yearly test cycle and was not removed from service. It was last tested March of 2009.