HospitalInspections.org

Based on documentation review and staff interviews, the facility failed to perform or maintain proper documentation for fire drills during the past year. This practice affected all residents. Facility census was 5 residents on 3-17-10.

Findings are:

Observations on 3-17-10 at 5:00PM revealed fire drills were missing from the calendar year 2009 and the first quarter of 2010 (thus far).

During an interview on 3-17-10 at 5:00PM, the facility maintenance staff acknowledged that the facility has been conducting fire drills with regard to 12 hour shifts instead of their 8 hour shifts. As discussed with the facility, it is imperative to perform these drills with regard to the 8-hour shifts to ensure all personnel are trained on how to perform in the event of a fire.

Record review of Gothenburg Memorial Hospital LTC revealed the following:
2009-
1st quarter: (Shifts run Day: 6AM - 2PM, Evening: 2PM - 10PM, Nights: 10PM - 6AM) 12 hour shifts are 7PM to 7AM(Night) / 7AM to 7PM (Day).
1-19-09, 1400: Day shift; 2-28-09 10AM, Day; 3-27-09 4:30PM Evening. (Two days, one evening per 8-hour shift; all days per 12-hour shift)
------------------------
2nd quarter 2009-
4-28-09 5:15PM, Evening; 5-30-09 8:55PM, evening; 6-11-09 midnight, night shift. (Two evenings, one night or two days, one night per 12 hour shift.)
------------------------
3rd quarter 2009-
7-14-09 4:50PM, evening; 8-28-09 7PM, evening; 9-29-09 8PM, evening (all evenings per 8 hour shifts or one day, one split and one night shift per 12 hour shifts)
------------------------
4th quarter 2009-
10-29-09 2:30PM, evening; 11-20-09 9PM, evening; 12-29-09 1030PM, night (Two evenings and one night per 8 hour shifts, one day and two nights for 12 hour shifts.)
-------------------------
1st quarter 2010-
1-29-10 2:30PM, evening; 2-24-10 7:50PM, evening (So far, both are evening shift drills per the 8 hour shifts and one day, one night per 12 hour shift.)

The facility administrator was made aware of this deficiency during the exit interview. He and the maintenance supervisor stated they would perform fire drills as required by the Life Safety Code in the future.

Based on observations and interviews, the facility failed to maintain and inspect the portable fire extinguishers for thepast year. This practice affected all residents as the extinguishers are distributed throughout the facility. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 at 3:45PM revealed the maintenance staff had not been doing their monthly inspections for the portable fire extinguishers as all of the extinguisher's tags were blank where you fill in the month and day that you inspect it. Also, the newer K-Class extinguisher that accompanies the kitchen range hood's fire suppression system missed the annual maintenance when the portable fire extinguisher company was last in the building. That company is Quality Fire Extinguisher Service and the tags on all other extinguishers said maintenance had last been performed in 10-09, the tag on the K-Class extinguisher in the kitchen read 10-08, Central Fire and Safety.

During an interview on 3-17-08 at 3:45 PM, the maintenance staff members stated they did not know about the monthly inspections. Concerning the K-Class extinghisher, that was new to the facility in 10 of '08 and was installed by the company that upgraded the fire suppression system in the range hood. It is because of that reason that Quality Fire Extinguisher Co. missed the maintenance on the extinguisher in 10 of '09 because they were unaware that it existed. The maintenance supervisor stated that he will take it to the extinguisher company to have it maintained and possibly recharged. The administrator was made aware of these deficiencies in the exit interview.

Review of NFPA 10, 4-3.1 found that fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require. NFPA 10, 4-3.4.3 says records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.
NFPA 10, 4-4.1 states that fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on documentation review and staff interview, the facility failed to test generators under load for the first month of this year. This practice affected all residents. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Documentation review on 3-17-10 at 5:20PM revealed a generator load test was missed or not documented for the month of January 2010.

During an interview on 3-17-10 at 5:20PM, the facility maintenance supervisor stated that he cannot recall if he actually missed the load test for the emergency generator or if he just didn't write it down. The rest of the generator logs were also reviewed and discussed and the facility is going to start using a new, more detailed form that will help for generator tests. It was also recommended by this surveyor to put the actual (or exact) times the test is being performed and to make sure that the generator is actually exercised under load for 30 minutes minimum. The maintenance supervisor and administrator assured me that the generator tests will continue to be a priority and anything deemed deficient shall be corrected.

(Two generators total, both diesel fueled.) - Cummins did a full service inspection on 12-22-09.

K147 -(Deficiency "a") Based on observation and interviews, the facility failed to remove all non-approved electrical power taps (surge strips) from the facility for the past year. A non-approved power tap was found to be in the nurses station that is open to the corridor near labor & delivery and the nursery. This practice affected all patient rooms in this affected wing (7 rooms). Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 revealed a non-approved power tap in the nurses station that is open to the corridor near the labor & delivery department and also the nursery. Multi-plug electrical power taps that are non UL listed as Hospital / Medical grade have had a tendency to heat up and start fires in the past at other facilities. This is also prohibited by the NSFM Official Interpretation referenced below.

During an interview on 3-17-10 at 3:30PM, the facility maintenance staff (two members) stated that they thought the prohibited power taps had all been removed but they must have missed that one. During the exit interview at 6:00PM on the same day, the administrator acknowledged the deficiency and surmised that an employee that was unaware of the regulations probably brought that power tap into the facility without permission.

Review of NSFM Official Interpretation08-01 found that general patient care areas are not allowed to have non-hospital grade power taps. General patient care areas include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces per this referenced code interpretation.
All official interpretations were shown to the maintenance staff via computer on 3-17-10 for their future reference.

K147 - (Deficiency "b")
Based on observations and staff interview, the facility failed to install proper covers for exposed electrical equipment for electrical breaker boxes in the boiler room. This practice affected no residents but is a potential hazard to staff. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 at 4:40PM revealed blanks in the electric breaker box labeled "EMBR." Open spaces in electrical boxes are a hazard as it is then possible for someone to be flipping switches and accidentally come in contact with energized electrical parts.

During an interview on 3-17-10 at 4:40PM, the facility maintenance supervisor stated he will be sure to get two dummy plates (blank covers) to remedy this situation.

Record review of NFPA 70, Chapter 2, General Maintenance Requirements found that enclosures shall be maintained to guard against accidental contact with live parts and other electrical hazards.

Based on documentation review and staff interviews, the facility failed to perform or maintain proper documentation for fire drills during the past year. This practice affected all residents. Facility census was 5 residents on 3-17-10.

Findings are:

Observations on 3-17-10 at 5:00PM revealed fire drills were missing from the calendar year 2009 and the first quarter of 2010 (thus far).

During an interview on 3-17-10 at 5:00PM, the facility maintenance staff acknowledged that the facility has been conducting fire drills with regard to 12 hour shifts instead of their 8 hour shifts. As discussed with the facility, it is imperative to perform these drills with regard to the 8-hour shifts to ensure all personnel are trained on how to perform in the event of a fire.

Record review of Gothenburg Memorial Hospital LTC revealed the following:
2009-
1st quarter: (Shifts run Day: 6AM - 2PM, Evening: 2PM - 10PM, Nights: 10PM - 6AM) 12 hour shifts are 7PM to 7AM(Night) / 7AM to 7PM (Day).
1-19-09, 1400: Day shift; 2-28-09 10AM, Day; 3-27-09 4:30PM Evening. (Two days, one evening per 8-hour shift; all days per 12-hour shift)
------------------------
2nd quarter 2009-
4-28-09 5:15PM, Evening; 5-30-09 8:55PM, evening; 6-11-09 midnight, night shift. (Two evenings, one night or two days, one night per 12 hour shift.)
------------------------
3rd quarter 2009-
7-14-09 4:50PM, evening; 8-28-09 7PM, evening; 9-29-09 8PM, evening (all evenings per 8 hour shifts or one day, one split and one night shift per 12 hour shifts)
------------------------
4th quarter 2009-
10-29-09 2:30PM, evening; 11-20-09 9PM, evening; 12-29-09 1030PM, night (Two evenings and one night per 8 hour shifts, one day and two nights for 12 hour shifts.)
-------------------------
1st quarter 2010-
1-29-10 2:30PM, evening; 2-24-10 7:50PM, evening (So far, both are evening shift drills per the 8 hour shifts and one day, one night per 12 hour shift.)

The facility administrator was made aware of this deficiency during the exit interview. He and the maintenance supervisor stated they would perform fire drills as required by the Life Safety Code in the future.

Based on observations and interviews, the facility failed to maintain and inspect the portable fire extinguishers for thepast year. This practice affected all residents as the extinguishers are distributed throughout the facility. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 at 3:45PM revealed the maintenance staff had not been doing their monthly inspections for the portable fire extinguishers as all of the extinguisher's tags were blank where you fill in the month and day that you inspect it. Also, the newer K-Class extinguisher that accompanies the kitchen range hood's fire suppression system missed the annual maintenance when the portable fire extinguisher company was last in the building. That company is Quality Fire Extinguisher Service and the tags on all other extinguishers said maintenance had last been performed in 10-09, the tag on the K-Class extinguisher in the kitchen read 10-08, Central Fire and Safety.

During an interview on 3-17-08 at 3:45 PM, the maintenance staff members stated they did not know about the monthly inspections. Concerning the K-Class extinghisher, that was new to the facility in 10 of '08 and was installed by the company that upgraded the fire suppression system in the range hood. It is because of that reason that Quality Fire Extinguisher Co. missed the maintenance on the extinguisher in 10 of '09 because they were unaware that it existed. The maintenance supervisor stated that he will take it to the extinguisher company to have it maintained and possibly recharged. The administrator was made aware of these deficiencies in the exit interview.

Review of NFPA 10, 4-3.1 found that fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require. NFPA 10, 4-3.4.3 says records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.
NFPA 10, 4-4.1 states that fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on documentation review and staff interview, the facility failed to test generators under load for the first month of this year. This practice affected all residents. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Documentation review on 3-17-10 at 5:20PM revealed a generator load test was missed or not documented for the month of January 2010.

During an interview on 3-17-10 at 5:20PM, the facility maintenance supervisor stated that he cannot recall if he actually missed the load test for the emergency generator or if he just didn't write it down. The rest of the generator logs were also reviewed and discussed and the facility is going to start using a new, more detailed form that will help for generator tests. It was also recommended by this surveyor to put the actual (or exact) times the test is being performed and to make sure that the generator is actually exercised under load for 30 minutes minimum. The maintenance supervisor and administrator assured me that the generator tests will continue to be a priority and anything deemed deficient shall be corrected.

(Two generators total, both diesel fueled.) - Cummins did a full service inspection on 12-22-09.

K147 -(Deficiency "a") Based on observation and interviews, the facility failed to remove all non-approved electrical power taps (surge strips) from the facility for the past year. A non-approved power tap was found to be in the nurses station that is open to the corridor near labor & delivery and the nursery. This practice affected all patient rooms in this affected wing (7 rooms). Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 revealed a non-approved power tap in the nurses station that is open to the corridor near the labor & delivery department and also the nursery. Multi-plug electrical power taps that are non UL listed as Hospital / Medical grade have had a tendency to heat up and start fires in the past at other facilities. This is also prohibited by the NSFM Official Interpretation referenced below.

During an interview on 3-17-10 at 3:30PM, the facility maintenance staff (two members) stated that they thought the prohibited power taps had all been removed but they must have missed that one. During the exit interview at 6:00PM on the same day, the administrator acknowledged the deficiency and surmised that an employee that was unaware of the regulations probably brought that power tap into the facility without permission.

Review of NSFM Official Interpretation08-01 found that general patient care areas are not allowed to have non-hospital grade power taps. General patient care areas include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces per this referenced code interpretation.
All official interpretations were shown to the maintenance staff via computer on 3-17-10 for their future reference.

K147 - (Deficiency "b")
Based on observations and staff interview, the facility failed to install proper covers for exposed electrical equipment for electrical breaker boxes in the boiler room. This practice affected no residents but is a potential hazard to staff. Facility census was 5 residents on date of survey, 3-17-10.

Findings are:

Observations on 3-17-10 at 4:40PM revealed blanks in the electric breaker box labeled "EMBR." Open spaces in electrical boxes are a hazard as it is then possible for someone to be flipping switches and accidentally come in contact with energized electrical parts.

During an interview on 3-17-10 at 4:40PM, the facility maintenance supervisor stated he will be sure to get two dummy plates (blank covers) to remedy this situation.

Record review of NFPA 70, Chapter 2, General Maintenance Requirements found that enclosures shall be maintained to guard against accidental contact with live parts and other electrical hazards.