HospitalInspections.org

Based upon record review and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to provide fire drill records reflecting personnel participating in drills conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:

1) During document review records indicating the names of staff participating in fire drills were lacking on the majority of the drills conducted in the last 12 months.
NOTE: The drills have been conducted as required, however it is not possible to determine how many staff participated.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) Second floor west corridor, a large quilt was hung on the exterior wall of the facility. The quilt was examined to determine if it had been treated for fire resistance. No indication of fire resistance rating was found.

The quilt was removed from the wall at time of survey.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that could result in endangerment of the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) The facility emergency generator is not equipped with a remote manual stop switch required by NFPA 110 (1999) 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director.

Based upon record review and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to provide fire drill records reflecting personnel participating in drills conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:

1) During document review records indicating the names of staff participating in fire drills were lacking on the majority of the drills conducted in the last 12 months.
NOTE: The drills have been conducted as required, however it is not possible to determine how many staff participated.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to ensure that hanging fabrics are rated as flame resistant. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) Second floor west corridor, a large quilt was hung on the exterior wall of the facility. The quilt was examined to determine if it had been treated for fire resistance. No indication of fire resistance rating was found.

The quilt was removed from the wall at time of survey.

The above was discussed and acknowledged by the Maintenance Director.

Based upon observations and staff interviews on June 1, 2015 between approximately 0930 and 1330 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that could result in endangerment of the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) The facility emergency generator is not equipped with a remote manual stop switch required by NFPA 110 (1999) 3-5.5.6.

The above was discussed and acknowledged by the Maintenance Director.