HospitalInspections.org

Based on observations made during tour of the facility on 1/16/13, it was determined that the facility failed to ensure staff responsible for patients have access to egress from the facility with regard to the special locking arrangements afforded given the clinical and security needs of the patients. Without all staff having access to egress from the smoke compartments and the building, patients and staff could be trapped in a non-sustainable environment.

The findings include:

While on tour with the facility's director, two staff members were asked if they have their proximity cards to unlock the doors in an emergency; they both stated they are outside-agency personnel who are called sitters for one-on-one care of the patients. They are not issued proximity cards. There are up to six of these sitters in house at any given time. The in-house staff would not have direct responsibility for patients while they are in that capacity. Therefore, they could be locked in a smoke compartment during a fire. After staff intervention, the sitters were inserviced on procedures and issued proximity cards. The staff commited to inservice all sitters coming in and creating a policy and procedure.

Based on observations made during tour of the facility on 1/16/13, it was determined that the facility failed to ensure the fire sprinkler system was installed and maintained in reliable operating condition.

The findings include:

Inspection of the roof revealed a hose valve on the roof for fire department staff to connect to. The pipe was observed to have a saddle on it that was connected to the lightning protection system. All lightning protection connected to the fire sprinkler system is required to be connected below ground level.

Based on a review of the facility records and interview with the staff on 1/15/13, it was determined that the facility failed to ensure the commercial cooking equipment is tested as frequently as required and maintained in reliable operating condition in accordance with NFPA 96.

The findings include:

There was no documentation, at the time of the survey, to show that the exhaust hood was tested and cleaned in the last six months. The facility's director stated this was not performed.

Based on a review of the facility records and interview with the staff on 1/16/13, it was determined that the facility failed to ensure the staff maintaining the emergency back-up generator system are trained in testing and inspection.

The findings include:

When questioned, the facility director and assistant stated they are not familiar with manual testing procedures for the generator system. They further stated that all testing is performed by the internal clock. Both stated they are not trained in the procedure for manual transfer of the transfer switches as required in NFPA 110.

Based on observations made during tour of the facility on 1/16/13, it was determined that the facility failed to ensure staff responsible for patients have access to egress from the facility with regard to the special locking arrangements afforded given the clinical and security needs of the patients. Without all staff having access to egress from the smoke compartments and the building, patients and staff could be trapped in a non-sustainable environment.

The findings include:

While on tour with the facility's director, two staff members were asked if they have their proximity cards to unlock the doors in an emergency; they both stated they are outside-agency personnel who are called sitters for one-on-one care of the patients. They are not issued proximity cards. There are up to six of these sitters in house at any given time. The in-house staff would not have direct responsibility for patients while they are in that capacity. Therefore, they could be locked in a smoke compartment during a fire. After staff intervention, the sitters were inserviced on procedures and issued proximity cards. The staff commited to inservice all sitters coming in and creating a policy and procedure.

Based on observations made during tour of the facility on 1/16/13, it was determined that the facility failed to ensure the fire sprinkler system was installed and maintained in reliable operating condition.

The findings include:

Inspection of the roof revealed a hose valve on the roof for fire department staff to connect to. The pipe was observed to have a saddle on it that was connected to the lightning protection system. All lightning protection connected to the fire sprinkler system is required to be connected below ground level.

Based on a review of the facility records and interview with the staff on 1/15/13, it was determined that the facility failed to ensure the commercial cooking equipment is tested as frequently as required and maintained in reliable operating condition in accordance with NFPA 96.

The findings include:

There was no documentation, at the time of the survey, to show that the exhaust hood was tested and cleaned in the last six months. The facility's director stated this was not performed.

Based on a review of the facility records and interview with the staff on 1/16/13, it was determined that the facility failed to ensure the staff maintaining the emergency back-up generator system are trained in testing and inspection.

The findings include:

When questioned, the facility director and assistant stated they are not familiar with manual testing procedures for the generator system. They further stated that all testing is performed by the internal clock. Both stated they are not trained in the procedure for manual transfer of the transfer switches as required in NFPA 110.