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Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to conduct testing/maintenance of fire rated doors as required by NFPA 80. This could result in the failure of the fire rated door to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility has not conducted annual testing of fire rated doors. The report must include, the person conducting the test, date of the test, inventory of all the fire rated doors, findings and corrections completed.


The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

Servicing records of the kitchen suppression system could not verify servicing was being conducted every 6 months as required. Last report in the records book was in 2015. Tag on the system indicated was serviced on 10/2016 by ABC Fire Control. No current reports available for review.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to maintain electrical equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, visitors, and staff to a risk of an electrical fire.

The findings include, but are not limited to:
During the facility tour, I observed the following electrical hazards.
1. EW crash cart is stationed in the corridor, but plugged into an outlet in the staff break room.
The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to conduct testing/maintenance of the fire/smoke dampers. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility has not conducted an inventory and testing of all the fire/smoke dampers. Interview with staff revealed that they are in the process of finding contractor to conduct this inventory and testing. Records could not be produced that indicated this had been done within the last 6 years.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on January 09, 2018 between approximately 1300 and 1530 hours the facility has failed to ensure suspended heaters have the proper features as required. This could cause overheating and potential fire that could endanger, patients, visitors, and staff.
The findings include, but are not limited to:
During the facility tour I observed 2 suspended heaters in the maintenance shop and 2 heaters in the basement. Documentation could was not produced from the manufacturer that these suspended heaters have a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure.
The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to provide a documented maintenance program for the piped in medical gas and vacuum systems. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

Document review revealed the following deficiencies:

1. No documentation to support inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets.
2. No documentation to support inspection and maintenance schedules established through risk assessment considering manufacturer recommendations.
3. No documentation of inspection procedures and testing methods established through risk assessment.
4. No documentation that person maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between 0900 and 1300 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

Record review of the generator servicing records revealed the following deficiencies:

1. The generator has not had a 4 continuous hour load test within the last 3 years.
2. Documentation was not provided that the diesel has been tested annually.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on January 09, 2018 between 1300 and 1530 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, visitors, and staff in the facility due to the increased fire risk.

The findings include, but are not limited to:

During the facility tour I observed unapproved use of power strips in the following locations:

1. The power strip used in Patient Exam room 1 was not UL1363A.
2. Financial Counseling office was observed to have a power strip plugged into another power strip.
3. Portable heater in Utilization Review office as observed to be plugged into a power strip.
4. Radiology doctor's office was observed to have an extension cord being used as a permanent source of power.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to provide a documented maintenance program and policy for Patient Care Related Electrical Equipment (PCREE). This could result in the failure of the electrical units and expose patients, staff and/or visitors to electrical shocks or fire.

The findings include, but are not limited to:

Document review revealed the following deficiencies:

1. No documentation to support inventory of all PCREE and testing findings.
2. No documentation of testing intervals established by policies and protocols.
3. No documentation that personnel responsible for the testing, maintenance and use of electrical appliances receive continuing education.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on January 09, 2018 between approximately 1300 and 1530 hours, the facility has failed to maintain oxygen storage as required. This could allow for confusion and staff obtaining the wrong cylinder when needed which could endanger patients, staff and/or visitors.

The findings include, but are not limited to:

During the facility tour, I observed that the oxygen storage room did not have the full and empty tanks appropriately segregated. Both empty and full were in the same crate. Also, there was no sign "EMPTY" above or on the empty tanks as required.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on January 09, 2018 between approximately 0900 and 1300 hours the facility has failed to provide a complete written policy for Fire Los Prevention in Operating Rooms as required. This could result in staff not informed of what steps to take or process to complete in a fire emergency in an operating room which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:
Record review of the Fire policy for Operating Rooms, did not include all of the required elements. Missing from the policy were the following:

1. Equipment shutdown and control operations.
2. Control of chemical spills.
3. Extinguishment of drapery, clothing and equipment fires.
4. Documentation of training provided to new OR personal (including surgeons), continuing education.
5. Incidents are reviewed monthly, and procedures are reviewed annually.

The above was discussed and acknowledged by the facility staff.