HospitalInspections.org

Based on observation it was determined the facility failed to ensure emergency lighting of at least 1.5 hr duration is provided automatically in accordance with 7.9, and 19.2.1.

Findings:

On 1/17/17 on tour of the facility it was observed that at each exit discharge emergency powered exit lighting could not be identified or observed. The director of physical operations was asked what lights were on generator power and he said he could not confirm what lights are on emergency generator power.

Based on observation and staff interview it was determined the facility failed to ensure exit singage was displayed in accordance with NFPA 101, 2012 Edition, Chapter 7.10 and 19.2.10.1.

Findings:

On 1/17/2017 on tour of the facility the north and south stairwells were observed to not have any displayed directional signage.

The director of physical operations acknowledged the missing signage in the north and south stairwells of the facility.

Based on observation it was determined the facility failed to maintain their fire alarm system in proper working order.

Findings:

On 1/17/17 on tour of the facility it was observed the fire alarm system was yellow tagged. The following impairments were identified on the Mac Systems report quarterly dated 1/4/17 and semiannual report dated 7/8/16 respectively: two check valves failed to hold backflow, and a 3rd floor pull station did not signal to panel, a 3rd floor pull station at northeast stairs was defective.

Based on record review and staff interview it was determined the facility failed to ensure documentation of fire drills was available on request.

Findings:

On 1/25/17 the director of physical operations was asked for fire drill documentation for the last three years, 2016, 2015, and 2014. The director of physical operations advised they only had documentation for 2016 fire drill documentation. The fire drill documentation for 2016 was reviewed and no other documentation was provided.

Based on staff interview it was determined the facility failed to ensure completing building systems risk assessments as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 01/17/2017 at the entrance conference the administrator was asked for their building systems risk assessments. She said the surveyor would have to talk with the Director of Physical Operations. The Director of Physical Operations was asked for the building systems risk assessments. He said he was not aware of that requirement.

Based on staff interview it was determined the facility failed to ensure completing building systems risk assessments specifically medical gas systems as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 01/17/2017 at the entrance conference the administrator was asked for their building systems risk assessments to include medical gas systems. She said the surveyor would have to talk with the Director of Physical Operations. The Director of Physical Operations was asked for the building systems risk assessments. He said he was not aware of that requirement.

Based on observation and staff interview it was determined the facility failed to ensure counter top electrical receptacles within 6 feet of a water source were on a GFCI.

Findings:

On 1/17/2017 on tour of the facility on the second floor medicine room a counter top electrical receptacle was within 6 feet of a countertop operational sink and was not GFCI.

The director of physical operations acknowledged the non-GFCI receptacle.

Based on staff interview it was determined the facility failed to ensure completing building systems risk assessments specifically the facility essential electric system categories as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 01/17/2017 at the entrance conference the administrator was asked for their building systems risk assessments to include their essential electric system categories. She said the surveyor would have to talk with the Director of Physical Operations. The Director of Physical Operations was asked for the building systems risk assessments. He said he was not aware of that requirement.