HospitalInspections.org

Based on document review and interview it was determined that the facility failed to provide facility specific emergency preparedness annual training to all staff, within the previous twelve months.

Findings include:

Document review on July 8, 2019, at 10:30 a.m., revealed at the time of survey, the facility lacked documentation verifying that all staff had facility specific emergency preparedness training within the previous twelve months.

Interview with the clinical director on July 8, 2019, at 10:30 a.m., confirmed the facility lacked documentation verifying that all staff had facility specific emergency preparedness training within the previous twelve months.

Based on document review and interview it was determined that the facility failed to conduct a full scale emergency preparedness exercise within the previous twelve months.

Findings include:

Document review on July 8, 2019, at 11:00 a.m., revealed the facility lacked documentation verifying the facility had conducted a full scale emergency preparedness exercise within the previous twelve months.

Interview with the clinical director on July 8, 2019, at 11:00 a.m., confirmed the facility lacked documentation verifying the facility had conducted a full scale emergency preparedness exercise within the previous twelve months.

Based on observation and interview it was determined that the facility failed to maintain the attic space, that has only one means of egress, free of stored materials.

Findings include:

Observation on July 9, 2019, at 8:55 a.m., revealed the attic had multiple cardboard boxes and other materials stored in the space.

Interview with the facility manager on July 9, 2019, at 8:55 a.m., confirmed the attic space had multiple cardboard boxes and other materials stored in it.

Based on observation and interview it was determined that the facility failed to inspect and maintain hazardous storage areas, in one of one hazardous storage rooms.

Findings include:

Observation on July 9, 2019, at 10:36 a.m., revealed the hazardous storage room had combustible materials stored next to a gas fired hot water heater.

Interview with the facility manager on July 9, 2019, at 10:36 a.m., confirmed the hazardous storage room had combustible materials stored next to a gas fired hot water heater.

Based on observation and interview it was determined that the facility failed to maintain areas used as hazardous storage, to have construction with a fire barrier having a one hour fire resistance rating, and three quarter hour fire rated door with an automatic door closure, on one of three levels.

Findings include:

Observation on July 9, 2019, at 9:50 a.m., revealed the first floor, room # 122, had multiple combustible materials stored in the room, that lacked the required fire barrier rating.

Interview with the facility manager on July 9, 2019, at 9:50 a.m., confirmed the first floor, room # 122, had multiple combustible materials stored in the room, that lacked the required fire barrier rating.

Based on document review and interview it was determined that the facility failed to test and maintain the battery operated smoke detectors, in one of one buildings.

Findings include:

1. Document review on July 9, 2019, at 10:25 a.m., revealed the facility lacked documentation verifying that the battery operated smoke detectors were:
A. Tested weekly for the previous twelve months.
B. Batteries were replaced semi-annually for the previous twelve months.

Interview with the facility manger on July 9, 2019,at 10:25 a.m.,confirmed the battery operated smoke detector deficiencies listed above existed.

Based on document review and interview it was determined that the facility failed to maintain the automatic sprinkler system on one of one systems.

Findings include:

Document review on July 8, 2019, at 9:30 a.m., revealed the quarterly sprinkler report, dated February 26, 2019, indicated 18" clearance is required between sprinklers and storage.

Interview with the facility manager on July 8, 2019, at 9:30 a.m., confirmed the quarterly sprinkler report, dated February 26, 2019, indicated 18" clearance is required between sprinklers and storage.

Based on observation and interview it was determined that the facility failed to maintain corridor doors free of impediments, that would keep the door from closing, on seven of more than one hundred corridor doors.

Findings include:

1. Observation on July 9, 2019, between 9:30 a.m. and 9:45 a.m., revealed the following first floor, Emergency department doors, had manual door hold open devices installed at the bottom of the doors:
A. (9:30 a.m.) Room #1.
B. (9:33 a.m.) Room #2.
C. (9:35 a.m.) Room #3.
D. (9:37 a.m.) Room #4.
E. (9:40 a.m.) Room #5.
F. (9:43 a.m.) Room # 6.
G. (9:45 a.m.) Triage Room.

Interview with the facility manager on July 9, 2019, at 9:45 a.m., confirmed the Emergency department doors listed above, had manual hold open devices installed at the bottom of the doors.

Based on document review and interview it was determined that the facility failed to test and inspect the fire, ceiling, and smoke dampers throughout the building, within the previous six years, per NFPA 101-8.5.5.4.2 and NFPA 105-6.5.2.

Findings include:

Document review on July 8, 2019, at 9:10 a.m., revealed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Interview with the facility manager on July 8, 2019, at 9:10 a.m., confirmed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Based on document review and interview it was determined that the facility failed to maintain the medical gas system alarms and displays, for one of one systems.

Findings include:

1. Document review on July 8, 2019, at 10:15 a.m., revealed the Medical Gas Testing Report dated April 22, 2019, indicated the following deficiencies:
A. Normal (Green) indicators malfunctioned in the following locations:
1. ED treatment room #5.
2. OR Rooms.
B. Abnormal (Red and Yellow) indication malfunction.
C. Vacuum - reduced flow/no flow in the following locations:
1. OR #1.
2. OR #2.
D. Outlets/Inlets - Oxygen identified the following deficiencies:
1. Leak with connection in - OR #1.
2. Leak with connection out - Room 105 and Cardio Pulmonary waiting.

Interview with the facility manager on July 8, 2019, at 10:15 a.m. confirmed the medical gas system deficiencies listed above existed.