HospitalInspections.org

Based upon observations and staff interviews on August 1, 2024 between approximately 0930 to 1500 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patients, staff, and/or visitors.
The findings include:

The facility was unable to provide documentation showing both the monthly 30 second and 90 minute annual testing of the emergency lighting from the past 12 months.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 1, 2024 between approximately 0930 to 1500 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.
The findings include:

1. The facility was unable to provide documentation showing the Fire Alarm system has been tested and maintained within the past 12 months.

2. In physical therapy the fire alarm pull station is obstructed.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 1, 2024 between approximately 0930 to 1500 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

The facility laboratory door from inside the laboratory has penetrations.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 1, 2024 between approximately 0930 to 1500 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place patients, staff, and visitors of electrical shock or ham.

The findings include:

The facility could not provide documentation indicating they have conducted polarity, grounding and tension testing of all hospital grade electrical receptacles within the 6 feet of patient care locations at intervals defined by documented performance data. Last documented report is from June 2023.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 1, 2024 between approximately 0930 to 1500 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

1. There is an extension cord plugged into a power strip in the clinical information office.

2. There is an extension cord plugged into a power strip in the clinic nurse manager desk space.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 1, 2024 between approximately 0930 to 1500 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:

Facility failed to provide annual training on the risks associated with the handling and use of medical gas equipment.

The above was discussed and acknowledged by the facility staff.