HospitalInspections.org

Based upon observations and staff interviews on 12/19/2017 between approximately 1400 to 1530 hours the facility has failed to maintain the patient sleeping room doors. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.


The findings include, but are not limited to:
Found two locks on infusion room door.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 12/19/2017 between approximately 1100 and 1300 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Findings were four doors that did not close and latch properly.
Room 11 door not latching.
Supply room inside the laundry room door not latching.
Purchasing office door not latching.
Soiled utility across from room 105 not latching.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 12/19/2017 between approximately 1200 and 1230 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include, but are not limited to:
Found open electrical junction box in IT server room. (Fixed at time of inspection)

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 12/19/2017 between approximately 1130 and 1200 hours the facility 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:
Four that the facility failed to conduct fire drill in the second quarter for night shift.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 12/19/2017 between approximately 1530 and 1600 hours the facility has failed to provide shelter where oxygen is in stored outside. 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:
Findings wreathe the oxygen manifold system and tanks are unprotected from the weather and needs to be protected from three sides.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 12/19/2017 between 1200 and 1530 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include, but are not limited to:
Found the use of extension cords, unapproved multi plug adapters, and power-strips daisy-chained at the following locations.
Payroll office power-strips daisy-chained.
Medical records office/training room extension cord in use. (Fixed at time of inspection)
Break room unapproved multi plug adapter in use for coffee pots and microwave oven. (Fixed at time of inspection)
Extension cord in use for cooling table in cafeteria.



The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 12/19/2017 between approximately 1500 and 1600 hours the facility has failed to have in place a policy for maintaining and repairing electrical equipment in a safe manner in accordance with NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include, but are not limited to:
Found no policy in place for the testing and repairs of electrical equipment.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 12/19/2017 between 1530 and 1600 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:
The facility does not have guidelines for training and usage of medical gas equipment.


The above was discussed and acknowledged by the facility staff.