HospitalInspections.org

Based on observation, interview, and record review the facility failed to ensure the extinguishment system for the kitchen hood was inspected routinely and could be operated as designed when needed. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six.

Findings included:

1. Observation on 11/07/23 at 9:13 AM, the manual pull which activated the kitchen extinguishment system was blocked by a refrigerator. Interview upon observation with Staff G, Maintenance Team Lead Assistant, confirmed the pull could not be activated as it was blocked by the refrigerator.

2. During an interview on 11/08/23 at 10:15 AM, Staff H, Maintenance Team Lead, stated it was not clear if the most recent fire system inspection included the kitchen extinguishment system and the previous inspection before that was dated 06/01/21.

3. Review of the facility's policy titled, "Kitchen Hood Automatic Fire Extinguisher System," dated 05/23/17, showed the system was to be inspected every six months.

Based on interview and National Standards the facility failed to ensure a check of the fire alarm system was performed annually. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six.

Findings included:

1. During an interview on 11/07/23 at 9:30 AM, Staff G, Maintenance Team Lead Assistant, stated after a phone call with the fire alarm isnpection company the most recent inspection believed to have happened only checked the fire extinguishers and the fire alarm system was not checked. At 10:40 AM Staff G confirmed the most recent inspection would have been due on 08/04/23 and the last full inspection was done in 06/01/21.

2. Review of the National Fire Protection Association (NFPA) code 72, 2010 edition, showed fire alarm systems should be inspected in accordance with table 14.4.5. The table showed an annual inspection should be performed for the entire system annually.

Based on interview, record review, and observation the facility failed to ensure all fire doors were repaired and maintained in a fully functional manner. The facility census was one Acute Care patient, four Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of six.

Findings included:

1. During an interview on 11/07/23 at 8:30 AM, Staff G, Maintenance Team Lead Assistant, stated the fire doors had received an inspection earlier in the year and confirmed five doors were indicated on the report as being in need of repair and any needed repairs had not yet been done.

2. Review of the facility's report of the most recent fire door inspection dated 04/17/23 showed five of 11 doors had repairs needed and listed these as three being critical and two being immediate.

3. Observation on 11/08/23 showed a set of double doors between the kitchen and the dining area to have a broken closer on one of the doors and a wedge of cardboard holding the door open. The set of double doors near the rehabilitation and administration area did not completely close when released from the magnetic hold opens and had an approximately one inch gap.