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Tag No.: K0050
Based on document review and interview, the facility did not ensure that all staff members participated in routine fire drills.
Findings include:
Review of the hospital fire drills for 2015 and 2016 showed that doctors, surgeons, and anesthesiologists have not participated in fire drills.
Additionally, none of the doctors, surgeons, and anesthesiologists participated in the Operating Room Site specific fire drills.
During interview with Staff L, Vice President of Facilities, and Staff K, Director of Engineering on 9/27/16 at approximately 2:00 PM, they both acknowledged the findings.
Tag No.: K0144
Based on document review and interview, the facility did not ensure the maintenance of its emergency generator. Specifically, broken gauges of an emergency generator were not repaired.
Findings include:
Review of the Emergency Generator Testing Log on 9/28/2016 identified that the gauges of generator #2 were not working since March 2016. There was no indication that the problem with the generator gauges had been corrected as at the time of the review on 9/28/2016 at approximately 3:30 PM.
The above finding was identified in the presence of Staff L, Vice President of Facilities, and Staff K, Director of Engineering on 9/27/2016, who acknowledged the findings.