HospitalInspections.org

Based on observation, the critical access hospital failed to ensure that fire resistance-rated walls were maintained properly to resist the passage of smoke.

Failure to maintain barriers to resist the passage of smoke risks spread of smoke, heat and products of combustion throughout the facility.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that penetrations or other openings in the following areas would permit smoke or heat to pass across the rated fire-resistance walls:

a) Unsealed penetrations in the wall inside the double smoke barrier doors between the hospital and the Annex on the side of the nurses' station in the Annex

b) Unsealed penetration in the corridor wall of the communications room within the CT room

c) A fire damper in the open position in the corridor wall inside the CT suite, and the attached fusible link, had not been inspected according to hospital records.

Based on observation, the critical access hospital failed to maintain doors protecting corridor openings in such as way that there is no impediment to the closing and latching of the doors.

Failure to maintain doors protecting corridor openings in closable and latchable condition risks spread of smoke and heat between the corridor and the rooms protected by the doors.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that doors in the following locations could not close or remain closed:

a) Patient room 110, where the latching hardware was missing from the door

b) The emergency department, where a privacy curtain obstructed the full closing of the room door

c) The kitchen, where a portable fan obstructed the full closing of the room door.

Based on observation, the critical access hospital failed to maintain the integrity of smoke barrier walls.

Failure to maintain the integrity of smoke barrier walls risks spread of smoke and heat between smoke compartments in the facility.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that a smoke barrier at the Annex entrance had penetrations that were sealed during the survey.

Based on observation, he critical access hospital failed to maintain the required separation of hazardous areas from other spaces.

Failure to maintain required separation of hazardous areas from other spaces risks toxic products of combustion from a fire in the hazardous area spreading throughout the area.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that:

Two doors leading from the facility linen laundering department into the hospital corridors on the east and west sides of the laundry department did not automatically fully close and latch.

Based on observation, the critical access hospital failed to ensure that exit access was readily accessible at all times.

Failure to ensure that exit access is readily available at all times risks inability of patients, staff and visitors to quickly exit the facility in the event of an emergency.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that exterior exit doors in the following locations were not readily accessible:

a) Inside the CT suite, where an exterior exit door required two separate actions to open

b) The exterior exit door adjacent to room 219, which required excessive force to open.

Based upon a record review and interviews with care givers at the nursing station in the acute care area and also with the Director of Maintenance the Dayton General Hospital has
failed to have a written procedure for fire and evacuation.

Failure to establish and train to an appropriate written fire and evacuation plan risks failure of hospital personnel to respond quickly to an emergency.

Findings include:

During interviews on 11/08/2011, nursing personnel indicated that they were all trained in the R.A.C.E. method of responding to a fire emergency. However, the written emergency plan entitled "Procedure in Case of Fire" is not reflective of the R.A.C.E. method. The plan as written states that the Fire Alarm is to be pulled as the first step, and the second step is the transmission of the alarm to the fire department. In statements regarding their training, personnel stated that their actual first step would be to rescue patients, and review of engineering documentation found that that transmission of the fire alarm to the fire department is made by a central station and not by the hospital.

Based on review of fire drill documentation, the critical access hospital failed to ensure that fire drills were conducted at unexpected times.

Failure to conduct fire drills at unexpected times risks unrealistic drill circumstances and ineffectual preparation and testing of hospital personnel fire response.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that the fire drill documentation showed that drills were conducted on each of three hospital shifts each quarter. The drills for each shift were conducted within 4 days of each other in the first week of each quarter during two of the three quarters reviewed for 2011.

Based on observation, the critical access hospital failed to maintain portable fire extinguishers in accordance with the requirements of NFPA 10.

Failure to maintain portable fire extinguishers risks failure of this critical fire-fighting device.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that portable fire extinguishers in all areas of the facility did not show evidence of monthly maintenance checks in October, 2011.

Based on observation and interview, the critical access hospital failed to address an alarm on the generator annunciator panel.

Failure to address generator annunciator alarms risks incorrect response of the generator to a power outage, and incorrect response of hospital personnel to utility alarms.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that the generator remote annunciator panel at the acute care nurses' station was in a state of alarm. The indicator light next to the line "Common Alarm" was illuminated and red. Personnel at the nurses' station stated that the light had been on for about two years, since "the new generator was installed." Hospital engineering management stated that there was no known explanation for the alarm.

Based on record review and interview, the critical access hospital failed to provide an appropriate written plan for actions to implement a fire watch in the event the automatic sprinkler system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an appropriate action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the automatic sprinkler system was not available to extinguish the fire.

Findings include:

During review of critical access hospital policies and procedures on 11/02/2011, it was found that the critical access hospital policy "Service Interruption in the Fire Sprinkler System" (Review date: 04/25/2011) stated, in part, "The Facility Manager or maintenance Technician will go to the Nurses Station of the Hospital and Nursing Home and announce that there is a failure in the fire alarm system and the facility will go on fire watch. He will explain to the Nursing staff on duty that they are responsible to check all of the rooms in their area once every hour and to log the time and initial for confirmation of their walkthrough."

This policy was not consistent with acceptable procedures for fire watch responsibilities, which include that the designated fire watch person has no other responsibilities other than fire watch duties, and that he/she will conduct a complete patrol of the inside of the facility every 15 minutes.

Based on record review and interview, the critical access hospital failed to provide an appropriate written plan for actions to implement a fire watch in the event the fire alarm system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an appropriate action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the fire alarm system was not available to notify occupants of the fire.

Findings include:

During review of critical access hospital policies and procedures on 11/02/2011, it was found that the critical access hospital policy "Service Interruption of the Fire Alarm System" (Review date: 04/25/2011) stated, in part, "The Facility Manager or maintenance Technician will go to the Nurses Station of the Hospital and Nursing Home and announce that there is a failure in the fire alarm system and the facility will go on fire watch. He will explain to the Nursing staff on duty that they are responsible to check all of the rooms in their area once every hour and to log the time and initial for confirmation of their walkthrough."

This policy was not consistent with acceptable procedures for fire watch responsibilities, which include that the designated fire watch person has no other responsibilities other than fire watch duties, and that he/she will conduct a complete patrol of the inside of the facility every 15 minutes.

Based on observation, the critical access hospital failed to ensure that fire resistance-rated walls were maintained properly to resist the passage of smoke.

Failure to maintain barriers to resist the passage of smoke risks spread of smoke, heat and products of combustion throughout the facility.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that penetrations or other openings in the following areas would permit smoke or heat to pass across the rated fire-resistance walls:

a) Unsealed penetrations in the wall inside the double smoke barrier doors between the hospital and the Annex on the side of the nurses' station in the Annex

b) Unsealed penetration in the corridor wall of the communications room within the CT room

c) A fire damper in the open position in the corridor wall inside the CT suite, and the attached fusible link, had not been inspected according to hospital records.

Based on observation, the critical access hospital failed to maintain doors protecting corridor openings in such as way that there is no impediment to the closing and latching of the doors.

Failure to maintain doors protecting corridor openings in closable and latchable condition risks spread of smoke and heat between the corridor and the rooms protected by the doors.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that doors in the following locations could not close or remain closed:

a) Patient room 110, where the latching hardware was missing from the door

b) The emergency department, where a privacy curtain obstructed the full closing of the room door

c) The kitchen, where a portable fan obstructed the full closing of the room door.

Based on observation, the critical access hospital failed to maintain the integrity of smoke barrier walls.

Failure to maintain the integrity of smoke barrier walls risks spread of smoke and heat between smoke compartments in the facility.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that a smoke barrier at the Annex entrance had penetrations that were sealed during the survey.

Based on observation, he critical access hospital failed to maintain the required separation of hazardous areas from other spaces.

Failure to maintain required separation of hazardous areas from other spaces risks toxic products of combustion from a fire in the hazardous area spreading throughout the area.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that:

Two doors leading from the facility linen laundering department into the hospital corridors on the east and west sides of the laundry department did not automatically fully close and latch.

Based on observation, the critical access hospital failed to ensure that exit access was readily accessible at all times.

Failure to ensure that exit access is readily available at all times risks inability of patients, staff and visitors to quickly exit the facility in the event of an emergency.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that exterior exit doors in the following locations were not readily accessible:

a) Inside the CT suite, where an exterior exit door required two separate actions to open

b) The exterior exit door adjacent to room 219, which required excessive force to open.

Based upon a record review and interviews with care givers at the nursing station in the acute care area and also with the Director of Maintenance the Dayton General Hospital has
failed to have a written procedure for fire and evacuation.

Failure to establish and train to an appropriate written fire and evacuation plan risks failure of hospital personnel to respond quickly to an emergency.

Findings include:

During interviews on 11/08/2011, nursing personnel indicated that they were all trained in the R.A.C.E. method of responding to a fire emergency. However, the written emergency plan entitled "Procedure in Case of Fire" is not reflective of the R.A.C.E. method. The plan as written states that the Fire Alarm is to be pulled as the first step, and the second step is the transmission of the alarm to the fire department. In statements regarding their training, personnel stated that their actual first step would be to rescue patients, and review of engineering documentation found that that transmission of the fire alarm to the fire department is made by a central station and not by the hospital.

Based on review of fire drill documentation, the critical access hospital failed to ensure that fire drills were conducted at unexpected times.

Failure to conduct fire drills at unexpected times risks unrealistic drill circumstances and ineffectual preparation and testing of hospital personnel fire response.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that the fire drill documentation showed that drills were conducted on each of three hospital shifts each quarter. The drills for each shift were conducted within 4 days of each other in the first week of each quarter during two of the three quarters reviewed for 2011.

Based on observation, the critical access hospital failed to maintain portable fire extinguishers in accordance with the requirements of NFPA 10.

Failure to maintain portable fire extinguishers risks failure of this critical fire-fighting device.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that portable fire extinguishers in all areas of the facility did not show evidence of monthly maintenance checks in October, 2011.

Based on observation and interview, the critical access hospital failed to address an alarm on the generator annunciator panel.

Failure to address generator annunciator alarms risks incorrect response of the generator to a power outage, and incorrect response of hospital personnel to utility alarms.

Findings include:

During a tour of the critical access hospital on 11/02/2011, it was observed that the generator remote annunciator panel at the acute care nurses' station was in a state of alarm. The indicator light next to the line "Common Alarm" was illuminated and red. Personnel at the nurses' station stated that the light had been on for about two years, since "the new generator was installed." Hospital engineering management stated that there was no known explanation for the alarm.

Based on record review and interview, the critical access hospital failed to provide an appropriate written plan for actions to implement a fire watch in the event the automatic sprinkler system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an appropriate action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the automatic sprinkler system was not available to extinguish the fire.

Findings include:

During review of critical access hospital policies and procedures on 11/02/2011, it was found that the critical access hospital policy "Service Interruption in the Fire Sprinkler System" (Review date: 04/25/2011) stated, in part, "The Facility Manager or maintenance Technician will go to the Nurses Station of the Hospital and Nursing Home and announce that there is a failure in the fire alarm system and the facility will go on fire watch. He will explain to the Nursing staff on duty that they are responsible to check all of the rooms in their area once every hour and to log the time and initial for confirmation of their walkthrough."

This policy was not consistent with acceptable procedures for fire watch responsibilities, which include that the designated fire watch person has no other responsibilities other than fire watch duties, and that he/she will conduct a complete patrol of the inside of the facility every 15 minutes.

Based on record review and interview, the critical access hospital failed to provide an appropriate written plan for actions to implement a fire watch in the event the fire alarm system were to be out of service for more than 4 hours in a 24 hour period.

Failure to provide an appropriate action plan to implement a fire watch risks injury to patients, staff and visitors in the event that a fire occurs but the fire alarm system was not available to notify occupants of the fire.

Findings include:

During review of critical access hospital policies and procedures on 11/02/2011, it was found that the critical access hospital policy "Service Interruption of the Fire Alarm System" (Review date: 04/25/2011) stated, in part, "The Facility Manager or maintenance Technician will go to the Nurses Station of the Hospital and Nursing Home and announce that there is a failure in the fire alarm system and the facility will go on fire watch. He will explain to the Nursing staff on duty that they are responsible to check all of the rooms in their area once every hour and to log the time and initial for confirmation of their walkthrough."

This policy was not consistent with acceptable procedures for fire watch responsibilities, which include that the designated fire watch person has no other responsibilities other than fire watch duties, and that he/she will conduct a complete patrol of the inside of the facility every 15 minutes.