HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the Emergency Preparedness plan was reviewed and updated at least every two years. The hospital census was six.

Review of the hospital's Emergency Preparedness plan, on 06/11/25 at 8:30 AM, showed there was no documentation that the Emergency Preparedness plan had been reviewed and updated at least every two years.

During an interview on 06/11/25 at 8:55 AM, Staff R, Chief Nursing Officer (CNO), stated that she was responsible for the Emergency Preparedness plan. She had updated part of the Emergency Preparedness plan but did not update the entire plan. She was unsure of the last time the Emergency Preparedness plan had been reviewed and updated. No updates had been made within the last two years.

Based on observation and interview, the hospital failed to install exit signage in the kitchen area. This failure had the potential to affect all hospital occupants that used the kitchen area. The hospital census was six.

Observation during the Life Safety Code tour on 06/10/25 between 8:30 AM and 2:10 PM, showed there were no exit signs located in the kitchen area to identify the route of exit in the event of an emergency.

During an interview on 06/10/25 at 2:10 PM, Staff L, Maintenance Director, stated that exit signs shoud be in kitchen area and he was unsure why there were no exit signs.

The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, states:
- 7.10.2 Directional Signs.
- 7.10.2.1 A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
- 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.