HospitalInspections.org

Based on record review and interview, the facility failed to provide policies and procedures for the use of volunteers.

The findings include;

Based on record review and interview with the maintenance director and chief compliance officer, on 03/12/2019 at 11:30 AM confirmed the facility failed to provide policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies.

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.

Based on record review and interview, the facility failed to develop a communication plan with a method for sharing information and medical documentation for residents under the facility's care, with other health providers to maintain the continuity of care and means in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).

The findings include;

Based on record review and interview with the maintenance director and chief compliance officer, on 03/12/2019 at 11:30 AM confirmed the facility failed to ensure the communication plan included a means for sharing information and medical documentation for residents.

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.

Based on observations, the facility failed to maintain the hazardous areas.

This observation affected 1 of 7 smoke compartments with the potential to affect the lab employees.

The finding included:

Observation on 03/12/2019 at 10:02 AM, revealed the lab storage room door was not capable of self closing (hardware was mounted for self closing device, but the closer had been removed.)
NFPA 101, 19.3.2.1.3 (2012 Edition)

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.

Based on document review, the facility failed to maintain the cooking facility.

This observation affected 1 of 7 smoke compartments with the potential to affect the kitchen employees.

The finding included:

Document review on 03/12/2019 at 10:50 AM, revealed the facility failed to provide documentation for 1 of 2 hood suppression system inspections for 2018.
NFPA 101, 19.3.2.5.1 (2012 Edition), NFPA 101, 9.2.3 (2012 Edition), NFPA 96, 11.2.1 (2011 Edition)

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.

Based on observations, the facility failed to maintain the gas and vacuum systems.

This observation affected 1 of 7 smoke compartments with the potential to affect all patients.

The findings included:

Observation on 03/12/2019 at 10:31 AM, revealed medical gas lines touching dissimilar metals in the radiology corridor outside of the labratory.
NFPA 99, 5.1.10.11.4.2 (2012 Edition)

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.

Based on observations, the facility failed to maintain the electrical equipment.

This observation affected 1 of 7 smoke compartments with the potential to affect patients, visitors, and staff within the dining area.

The finding included:

Observation on 03/12/2019 at 9:50 AM, revealed an extension cord under the steam table (powering the cash register) in the dining room.
NFPA 99, 10.2.4 (2012 Edition)

The maintenance director was present when this deficiency was identified, and was later acknowledged by the CEO during the exit conference on 03/12/2019.