HospitalInspections.org

Based on observation and interview, the provider failed to maintain battery pack emergency lighting for two of two required emergency lights (boiler room and generator room). Findings include:

1. Observation on 7/6/22 at 10:30 a.m. revealed a battery pack emergency light in the boiler room.

Interview with the building manager at the time of the observation revealed no monthly or annual testing had been performed on the light. Operation of the light could not be confirmed because it was mounted higher than the tallest ladder could access. The building manager confirmed that finding.

2. Observation on 7/6/22 at 1:20 p.m. revealed the battery pack emergency light for the generator located in the generator room would not illuminate.

Interview with the building manager at the time of the observation confirmed that finding and confirmed this light had not been tested on a monthly or annual basis.

The deficiency affected two of numerous requirements for the emergency lighting system and has the potential to affect all staff and residents within the facility.

Based on document review and interview, the provider failed to conduct the required bi-annual inspection of the kitchen range exhaust ductwork. Findings include:

1. Document review and interview of the building manager and kitchen manager on 6/7/22 at 1:45 p.m. regarding the kitchen range hood system inspections revealed there was no documentation indicating the entire exhaust ductwork had been inspected for cleanliness/grease build-up within the last year.

Interview of the building manager revealed he was unaware of the requirement. The kitchen manager was aware, but was a new contractor at the facility.

The deficiency affected the requirements for inspection and cleaning of the kitchen range hood exhaust system and had the potential to affect all residents and staff in the hospital.