HospitalInspections.org

Based on observations and document review, the facility failed to provide the required testing of emergency illumination which could prevent patients, staff and visitors from safely exiting an area of the facility if a loss of power occurred.

Findings include:

On 12/12/18 at 10:30PM, based on a interview with MD and during document review, it was determined that the operating room emergency lighting has not been tested or documented for the required 30-second monthly or the 90-minutes annually. This does not comply with Section 19.2.9.1 and 7.9.3.

Based on record review and interview, the facility failed to ensure that the kitchen hood fire extinguishing system was properly installed, inspected and cleaned semi-annually. This deficient practice could affect patients, staff and visitors if the extinguishing system failed to operate properly during a fire at the cooking surface.

Findings Include:

A. On 12/12/18 at 11:35AM, during record review and interview with MD, it was determined that the facility failed to provide the required two Kitchen Hood extinguishing system inspections. Record review identified only one system inspection in the last 12 months. This does not comply with Section 19.3.2.5. and NFPA 96, Section 11.2.1

B. On 12/12/18 at 11:40AM, during record review and interview with MD, it was determined that the facility failed to provide an inspection report of the grease buildup in the exhaust hood ductwork. Based on the amount of cooking at this facility at least semi-annual inspections will be required per NFPA 96, Section 11.4.