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Based on observations made during the survey for life safety from fire with the facility's Physical Plant Director, it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found from 6/28/16 from 8:30 am until 2:00 pm that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents form 2014, 2015 and first and second quarter of 2016 related to conducted fire drills during the survey for life safety from fire with the facility's Physical Plant Director (employee #30), it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only 12 fire drills performed out of 30 in three years, as required by LSC 2012 19.7.1.2

Findings include:

1.The facility performed on 2014 five during the 7:00 am until 3:00 pm shifts and three during the 11:00 pm until 7:00 am, on 2015 three during the 7:00 am until 3:00 pm shifts, one during the 3:00 pm until 11:00 pm shifts and three during 11:00 pm until 7:00 am shifts and on 2016 two during 7:00 am until 3:00 pm shifts, two during 3:00 pm until 11:00 pm shifts and one during the 11:00 pm till 7:00 am shifts.
Written documents about conducted fire drills from 2014, 2015 and 2016 were reviewed on 6/28/16 at 2:15 pm and it was found that the facility failed to perform at least twelve fire drills during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of a maximum of twenty fire drills during the past thirty months. The facility performed nine fire drills during the 7:00 am till 3:00 pm shifts, four during the 3:00 pm till 11:00 pm shifts and seven during the 11:00 pm till 7:00 am shifts. The facility failed to comply with this regulation due to the lack of ten fire drills (seven during the 3:00 pm till 11:00 pm shifts and four during the 11:00 pm till 7:00 am shifts). Also, no fire drill was performed under the supervision of a qualified safety officer.
Interview with the Safety Officer (employee #30) on 6/28/16 at 2:19 pm reveals that he organize the drills with the different wards supervisors to performed the drills.
During the written documents reviews it was found that the emergency room employees, nursing staff and medical staff never participate in a fire drill. Employee #XX indicates on 6/28/16 at 2:20 pm that because the emergency room always busy and they cannot interrupted the operation.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Director, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to fire extinguisher visibility, decorations hanging from the ceiling and exit stairs with a chair placed on one of the landings, the use of multi-plugs and extension cords in operating suites and there is the need of a fire extinguisher in the medical record department.

Findings include:
1. The medical record department was visited on 6/28/16 from 10:00 am until 11:00 am and provided evidence that one microwave oven and small fridge had electric cables and multi-plugs directly on the floor which creates a tripping and short circuit hazard.

2. A fire extinguisher is needed in the medical record department as observed on 6/28/16 at 11:00 am.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Director, it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found from 6/28/16 from 8:30 am until 2:00 pm that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents form 2014, 2015 and first and second quarter of 2016 related to conducted fire drills during the survey for life safety from fire with the facility's Physical Plant Director (employee #30), it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only 12 fire drills performed out of 30 in three years, as required by LSC 2012 19.7.1.2

Findings include:

1.The facility performed on 2014 five during the 7:00 am until 3:00 pm shifts and three during the 11:00 pm until 7:00 am, on 2015 three during the 7:00 am until 3:00 pm shifts, one during the 3:00 pm until 11:00 pm shifts and three during 11:00 pm until 7:00 am shifts and on 2016 two during 7:00 am until 3:00 pm shifts, two during 3:00 pm until 11:00 pm shifts and one during the 11:00 pm till 7:00 am shifts.
Written documents about conducted fire drills from 2014, 2015 and 2016 were reviewed on 6/28/16 at 2:15 pm and it was found that the facility failed to perform at least twelve fire drills during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of a maximum of twenty fire drills during the past thirty months. The facility performed nine fire drills during the 7:00 am till 3:00 pm shifts, four during the 3:00 pm till 11:00 pm shifts and seven during the 11:00 pm till 7:00 am shifts. The facility failed to comply with this regulation due to the lack of ten fire drills (seven during the 3:00 pm till 11:00 pm shifts and four during the 11:00 pm till 7:00 am shifts). Also, no fire drill was performed under the supervision of a qualified safety officer.
Interview with the Safety Officer (employee #30) on 6/28/16 at 2:19 pm reveals that he organize the drills with the different wards supervisors to performed the drills.
During the written documents reviews it was found that the emergency room employees, nursing staff and medical staff never participate in a fire drill. Employee #XX indicates on 6/28/16 at 2:20 pm that because the emergency room always busy and they cannot interrupted the operation.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Director, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to fire extinguisher visibility, decorations hanging from the ceiling and exit stairs with a chair placed on one of the landings, the use of multi-plugs and extension cords in operating suites and there is the need of a fire extinguisher in the medical record department.

Findings include:
1. The medical record department was visited on 6/28/16 from 10:00 am until 11:00 am and provided evidence that one microwave oven and small fridge had electric cables and multi-plugs directly on the floor which creates a tripping and short circuit hazard.

2. A fire extinguisher is needed in the medical record department as observed on 6/28/16 at 11:00 am.