HospitalInspections.org

Based on record review and interview the facility failed to ensure training for new staff, individuals providing services under arrangement, and volunteers on the emergency preparedness plan.

Findings:

Record review of the facility emergency preparedness training documentation
did not contain the intial in-service training for new staff, volunteers and
individuals providing services under contract.

On 08/05/19 at 1:47 pm the surveyor asked the facility human resource director for documentation of the training in-service for facility staff/volunteers and individuals providing services under contract and gave her a sample list of 23 facility employees to pull their training records. The surveyor stated they could have it for the surveyor in the morning would be great. The human resource administrator stated they would get the files pulled.

On 08/06/19 at 11:43 am the chief operating officer was asked for the emergency preparedness initial training documentation files for the sample of 23 staff the surveyor picked from the facility staff roster yesterday. The chief operating officer stated they did not have documentation showing the staff were trained on the facility's emergency preparedness plan as they have not done it. The training documentation does not exist for any staff.

Based on observation and interview, the facility failed to ensure each exit discharge had emergency generator powered or battery powered backed-up emergency lighting installed as required.

Findings:

On 08/05/19 at 1:20 pm each of the facility's six designated exit discharges from the facility were observed to have lighting fixtures on normal power. The following exit discharges did not have emergency powered lighting: main entrance/exit, exit near patient room 106, exit near laboratory, exit near Emergency Room, exit near medical records.

On 08/05/19 at 1:20 pm the maintenance supervisor was asked if any of the exit discharge lighting fixtures would illuminate when the emergency generator came on. The maintenance supervisor stated he did not know and could not confirm which existing light fixtures would illuminate under emergency generator power.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 08/06/19 at 1:22 pm one K class fire extinguisher and one ABC class fire extinguisher was observed in the kitchen with no placards posted next to them to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 08/06/19 at 1:22 pm The maintenance supervisor stated they would get the appropriate placard for the fire extinguisher which was installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure fire extinguishers were installed properly as required.

Findings:

On 08/05/19 at 2:24 pm the surveyor observed a fire extinguisher in the kitchen installed with the top of the handle over five feet from the floor.

On 08/05/19 at 2:24 pm the surveyor asked the maintenance supervisor why the fire extinguisher was installed so high. The maintenance supervisor stated he did not know why but will get it reinstalled lower to be in compliance.

On 08/06/19 at 8:36 am the surveyor observed a fire extinguisher installed in the mechanical room with the top of the handle over five feet from the floor.

On 08/06/19 at 8:36 am the maintenance supervisor stated they will move the fire extinguisher to a lower position to meet compliance.

Based on observation and interview the facility failed to ensure corridor doors did not have penetrations cut into them which would allow fire and smoke to spread into the protected emergency egress pathway.

Findings:

On 08/05/19 at 4:41 pm the surveyor observed one corridor door with a vent hole cut into the bottom half of the corridor door with a metal louver vent covering the cut out area.

On 08/05/19 at 4:45 pm the surveyor asked the maintenance supervisor why the corridor door had a penetration cut into it with metal vent installed. The maintenance supervisor stated he did not know and the door had been that way since he started a year ago. The maintenance supervisor stated he will repair the door to be in compliance.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 08/05/19 at 3:54 pm the surveyor stated to the maintenance supervisor the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. The maintenance supervisor stated they would add that to the fire drill documentation.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 and 2018 were not completed and the documentation did not exist.

On 08/05/19 at 2:33 pm the surveyor asked the maintenance supervisor for the annual fire rated door assembly inspections. Staff S stated the inspection was not completed for 2017, 2018 and the documentation does not exist.

Based on observation and interview, the facility failed to ensure that space heaters used in non-sleeping staff areas had heating elements which did not exceed 212 degrees Fahrenheit as required in NFPA 101, 2012 Edition, Chapter 19.7.8.

Findings:

On 08/05/18 at 2:27 pm a space heater was observed in the on call sleep room near the CT machine.

On 08/05/18 at 2:30 pm the surveyor asked the maintenance supervisor what room the space heater is in. The maintenance supervisor state it is the on call sleep room. The maintenance supervisor was asked why there was a space heater in a sleeping staff's room as it is prohibited by fire code. The maintenance supervisor stated it will be removed to be in compliance.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed. They do not exist.

On 08/05/19 at 2:35 pm the surveyor asked the maintenance supervisor for the EES and Medical Gas building system risk assessments. The maintenance supervisor stated he was not aware of the requirement but would ensure they would be completed.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles for 2017, 2018 and 2019 as required.

On 08/05/19 at 11:27 am the surveyor asked the maintenance supervisor why the impedance testing has not been completed. The maintenance supervisor stated he did not know but will get the impedance inspection testing scheduled.

Based on observation and interview the facility failed to ensure electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking as required.

Findings:

On 08/06/19 at 2:45 pm the surveyor observed hospital grade electrical receptacles and regular electrical receptacles in patient care rooms with no distinctive colors or markings identifying them from the life safety or critical branch.

On 08/06/19 the surveyor asked the maintenance supervisor which of the electrical receptacles were the emergency power receptacles and/or from the life safety/critical branch. The maintenance supervisor stated he did not know but he would find out. The surveyor explained the electrical receptacles are required to have a distinctive color or marking to identify them.