HospitalInspections.org

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Based on observation, interview and document review the hospital failed to properly implement a fire watch while their fire alarm was not fully operational.

Failure to implement a fire watch when the fire alarm is not fully operational places patients, staff, and visitors at risk of injury and/or death.

Findings included:

1. Failure to ensure the life safety from fire requirements were met.

Cross-reference: A709

2. Failure to initiate an approved fire watch in Washington Valley Hospital, twenty-four hours a day, seven days per week: failed to provide dedicated staff to the fire watch, failed to post fire watch signage in the hospital, and failed to notify local fire authority of non-functioning fire alarm system.

Cross-reference: K100

3. Failure to notify fire authority of non-functioning fire alarm system.

Cross-reference: K346

Due to the scope of the deficiencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET.
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