HospitalInspections.org

This facility is in compliance with Emergency Preparedness regulations at E41 [483.73(e)].

Based on observation and staff interview, the facility failed to use electrical wiring in a way that would not create a fire hazard. This condition increased the potential to cause a fire.

Findings are:
Observation on 8/22/24, at 12:17 pm revealed:
1. A fan was plugged into a power strip in Sleep Studies 2.
2. Three fans were plugged into a power strip in the Sleep Studies Control Room.

In an interview on 8/22/24, at 12:17 pm, Maintenance A acknowledged the findings.

NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed
the branch-circuit ampere rating. An individual branch
circuit shall be permitted to supply any load for which it is
rated. A branch circuit supplying two or more outlets or
receptacles shall supply only the loads specified according
to its size specified in 210.23(A) through (D) and as summarized
in 210.24 and table 210.24.

Based on record review and staff interview, the facility failed to document cleaning inside and behind the dryer, and inside the dryer duct in the Laundry. This deficient practice would increase the potential for a fire from the buildup of lint in the dryer and in the ductwork venting to the outside.

Findings are:
Record review on 8/22/24, at 11:10 am revealed no documentation to verify routine cleaning was conducted in and around the Laundry dryer, and documentation of at least annual inspection/cleaning of the dryer duct.

During an interview on 8/22/24, at 11:10 am, Maintenance A confirmed the annual inspection/cleaning was not conducted, but stated routine cleaning of the dryer was conducted, but not documented.

NFPA 211, 2010, 13.2 Annual Inspection. Chimneys, fireplaces, and vents shall be inspected at least once a year in accordance with the requirements of Section 14.2. Exception: Type B and Type BW gas venting systems. 13.2.1 Cleaning, maintenance, and repairs shall be done if necessary.
NFPA 101, 2012, 19.1.1.3.1 All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly for each shift under varying conditions. This practice would not provide the necessary training for staff to respond effectively in the event of a fire.

Findings are:
Record review on 8/22/24, at 10:40 am revealed:
1. A fire drill was not conducted for the 1st and 3rd shifts in the 1st quarter of 2024.
2. Fire drill times where not varied by 1-hour for the 2024 1st shift 4/29 at 2:45 pm, and 7/12 at 2:30 pm.
3. Fire drill times where not varied by 1-hour for the 2024 2nd shift 5/31 at 3:02 pm, and 8/21 at 3:10 pm.
4. Fire drill times where not varied by 1-hour for various shifts in 2023.


In an interview on 8/22/24, at 10:40 am, Maintenance A acknowledged the findings.