HospitalInspections.org

Based on observation and interview, the facility failed to assure that corridors and use areas are separated by 1/2 hour fire resistive rated barriers. Failing to maintain LSC required separations will allow smoke and heat to migrate from one area to another during an incident of fire emergency. This would effect employees, patients and visitors in the area of the emergency. The facility is licensed for 25 beds and the census on the day of inspection was 3. LSC 19.3.6

Findings are:
During facility inspection on 2-10-2010, observation revealed void spaces located above the ceiling tiles in the East corridor adjacent to the Janitor's Closet.

Interview with Administrator A, at the time of observation, verified these findings.

Based on observation, record review and interview, the facility failed to completely record information resulting from fire drills as required by LSC 19.7.1.1. Not completing all information would not reveal whether repairs or adjustments to the system were needed and might allow for the failure of the system, or poor response of employees to evacuate patients and visitors, in the event of an actual fire emergency. The facility is licensed for 25 and had a census of 3 on the day of the survey.

Findings are:
During observation and review of the fire drill records, on 2-9-2010, it was revealed the facility is not completing the information that is detailed out in the fire drill records.

Interview with Administrator A verified these findings.

Based on observation and interview, the facility failed to assure that corridors and use areas are separated by 1/2 hour fire resistive rated barriers. Failing to maintain LSC required separations will allow smoke and heat to migrate from one area to another during an incident of fire emergency. This would effect employees, patients and visitors in the area of the emergency. The facility is licensed for 25 beds and the census on the day of inspection was 3. LSC 19.3.6

Findings are:
During facility inspection on 2-10-2010, observation revealed void spaces located above the ceiling tiles in the East corridor adjacent to the Janitor's Closet.

Interview with Administrator A, at the time of observation, verified these findings.

Based on observation, record review and interview, the facility failed to completely record information resulting from fire drills as required by LSC 19.7.1.1. Not completing all information would not reveal whether repairs or adjustments to the system were needed and might allow for the failure of the system, or poor response of employees to evacuate patients and visitors, in the event of an actual fire emergency. The facility is licensed for 25 and had a census of 3 on the day of the survey.

Findings are:
During observation and review of the fire drill records, on 2-9-2010, it was revealed the facility is not completing the information that is detailed out in the fire drill records.

Interview with Administrator A verified these findings.