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Based on record review and interview, the facility failed to include staff response to alarms, the evacuation of the immediate area, and the evacuation of the smoke compartment in the written plan for the protection of 12 of 12 patients and for their evacuation from the building in the event of an emergency. LSC 19.2.2.2 requires a written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects all patients in the facility.

Based on a review of the facility's written Fire Safety Plan on 03/14/12 at 10:30 a.m. with the environmental coordinator, the fire safety plan dated 10/20/11 did not address the evacuation of the immediate area, the evacuation of the smoke compartment, or the preparation of the floor and building for evacuation. This was verified by the environmental coordinator at the time of record review and confirmed by the administrator at the exit conference on 03/14/12 at 5:00 p.m.

Based on observation and interview, the facility failed to ensure 6 of 6 wet location patient care areas were provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas that are subject to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have ground-fault circuit interrupter (GFCI) protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations with the environmental coordinator during a tour of the facility from 10:50 a.m. to 4:40 p.m. on 03/14/12, room G123, room G217, room G133, room G137, room G117, and room G107 each had an electric receptacle within one foot of the handwashing sinks in each room which was not provided with a ground fault circuit interrupter. Furthermore, all electrical panels were checked during the time of observations and there were no ground fault circuit interrupter breakers in the electrical panels. This was verified by the environmental coordinator at the time of observations and confirmed by the administrator at the 5:00 p.m. exit conference on 03/14/12.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 12 of 12 patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice affects all occupants in the facility including patients, staff, and visitors.
Findings include:
Based on a review of the facility's Fire Safety Plan on 03/14/12 at 10:30 a.m. with the environmental coordinator, there was no written fire watch policy in the event the fire alarm system is out of service for 4 hours or more in a 24 hour period. This was verified by the environmental coordinator at the time of record review and confirmed by the administrator at the exit conference on 03/14/12 at 5:00 p.m.

Based on record review and interview, the facility failed to include staff response to alarms, the evacuation of the immediate area, and the evacuation of the smoke compartment in the written plan for the protection of 12 of 12 patients and for their evacuation from the building in the event of an emergency. LSC 19.2.2.2 requires a written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects all patients in the facility.

Based on a review of the facility's written Fire Safety Plan on 03/14/12 at 10:30 a.m. with the environmental coordinator, the fire safety plan dated 10/20/11 did not address the evacuation of the immediate area, the evacuation of the smoke compartment, or the preparation of the floor and building for evacuation. This was verified by the environmental coordinator at the time of record review and confirmed by the administrator at the exit conference on 03/14/12 at 5:00 p.m.

Based on observation and interview, the facility failed to ensure 6 of 6 wet location patient care areas were provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas that are subject to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have ground-fault circuit interrupter (GFCI) protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations with the environmental coordinator during a tour of the facility from 10:50 a.m. to 4:40 p.m. on 03/14/12, room G123, room G217, room G133, room G137, room G117, and room G107 each had an electric receptacle within one foot of the handwashing sinks in each room which was not provided with a ground fault circuit interrupter. Furthermore, all electrical panels were checked during the time of observations and there were no ground fault circuit interrupter breakers in the electrical panels. This was verified by the environmental coordinator at the time of observations and confirmed by the administrator at the 5:00 p.m. exit conference on 03/14/12.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 12 of 12 patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice affects all occupants in the facility including patients, staff, and visitors.
Findings include:
Based on a review of the facility's Fire Safety Plan on 03/14/12 at 10:30 a.m. with the environmental coordinator, there was no written fire watch policy in the event the fire alarm system is out of service for 4 hours or more in a 24 hour period. This was verified by the environmental coordinator at the time of record review and confirmed by the administrator at the exit conference on 03/14/12 at 5:00 p.m.