HospitalInspections.org

Based on observation and interview the facility failed to maintain the exit lights in the east and west corridors. This deficient practice has the potential for persons not being able to locate exit doors that leads to the outside of the building. Facility census was 5 patients at the time of the inspection, facility is licensed for 25 patients.

Findings are:
Observation on 05-04-18 at 9:50 am revealed that the exit lights were not operating during the Life Safety Code (LSC) survey.

Interview with Maintenance Personnel 1 on 05-04-18 at 12:00 pm verified the observation

Based on observation and interview the facility failed to maintain proper operation on a fire rated door in the west corridor between the hospital and the clinic areas. This deficient practice has the potential to allow fire and smoke to to extend from the hospital into the clinic area. Facility census was 5 patients with a licensed capacity of 25 patients total.

Findings are:
Observation on 05-04-18 at 11:35 am revealed that the fire rated door separating the hospital and the clinic area failed to close and latch properly when released from the open position.

Interview with Maintenance Personnel 1 on 05-04-18 at 12:00 pm verified the observation.

Based on interview and record review the facility failed to provide conduct fire evacuation drills. This deficient practice has the potential for staff not being familiar with procedures during a fire emergency within the facility and would effect all patients and staff in the facility at that time. Census was 5 patients with licensing for 25 patients.

Findings are:

Record reviews on 05-04-18 at 11:50 am revealed that documentation did not indicate that a fire drill was conducted during the second quarter of 2017.

Interview with Maintenance Personnel 1 at 12:00 pm verified the findings.

Based on record review and interview the facility failed to have a written policy or documentation for staff response for a fire or emergency that could be encountered during surgical procedures. The deficient practice did not provide staff education and training for a fire or other emergency that could occur in the Operating Room during surgical procedures

Findings are:

Record review on 5-04-18 at 12:15 PM. revealed the facility did not have a policy or procedures detailing emergency response to a fire emergency that could be encountered during surgical procedures, including fire alarm activation, evacuation of patients, equipment shutdown, and control operations, control of chemical spills, extinguishment of drapery, clothing, and equipment fires.

During the exit interview on 05-04-18 at 12:30 PM Maintenance Supervisor A verified the findings.