HospitalInspections.org

Based on the findings of the Life Safety Code survey performed between 4/27- 5/11,2016, it was determined that the Condition of Physical Environment was not met as evidence by the following:

K0015 - Interior finish ( carpeting) did not meet the required fire rating;
K0048 - Failure to follow the facility "Evacuation and Relocation Plan"
K0050 - Failure to have fire drills as required for all three shifts;
K0056 - Lack of or improperly spaced automatic sprinkler heads;
K0062 - Lack of documentation for annual ITM of automatic Sprinkler system for 2015 and 2016;
K0067 - Failure to maintain ventilating equipment left from the previously used dryer;
K0069 - Failure to maintain the kitchen mechanical exhaust ventilation system in accordance with code;
K0070 - The use of an electrical space heater into a non compliant strip outlet;
K0130 - Failure to have required signage for stored flammable and combustible liquids;
K0144 - Failure to inspect the emergency generator weekly; and
K0147 - The use of noncompliant electrical appliances

Based on review of records and interview of staff it was determined that the hospital's negative pressure rooms were not checked as required to insure optimal operation as evidenced by:

Negative pressure isolation rooms are scheduled to be checked monthly as part of the hospital's preventative maintenance program (PM). A review of the documentation for the maintenance revealed that the January 2016 form was missing, the April 2016 form was not filled out as pass or fail. Further records were requested and reviewed by the surveyor for October 2015, November 2015, and December 2015. These records all indicated the PM was performed as required.

As a result of this finding, the Facilities Director met with the engineer assigned the task who reported that there was a communication error. The engineer believed that he did not have to submit the paper documents once the hospital went to a new TMA system. The engineer was unable to produce documentation of the January 2016 PM although he said the checks had been performed as required.

A PM log check sheet was developed on 05/04/2016 to resolve this issue in the future but the form failed to address all the PM that needed to be tracked. The Facilities Director identified this and informed the surveyor that he was in the process of developing a more comprehensive tracking tool.