HospitalInspections.org

Based on observation, the governing body was not responsible for services furnished in the hospital.

Findings were:

Facility policy titled " Fire Safety Policy " states, in part, " In the event of a fire, preparation to respond appropriately is essential to the safety of patients, visitors and staff. To assist with this preparedness, the District shall conduct at least 12 fire drills per year ... "

A review of documents on 2-22-11 revealed that the facility had conducted only 5 of the 12 required fire drills during the review period of 2-1-10 through 1-31-11 (performed on 2-16-10, 3-15-10, 8-5-10, 10-7-10 and 1-20-11).

The above was confirmed in an interview with the Administrator on the afternoon of 2-23-11 in the second floor conference room.

Based on observation, the infection control officer did not develop and implement policies governing control of infections and communicable diseases.

Findings were:

During a tour of the facility on 2-23-11, 1 of 1 visitor bathroom on the first floor (located at the base of the staircase) had missing ceramic tiles that prevented the floor from being properly cleaned.

During a tour of the facility on 2-23-11, 1 of 1 patient bathroom adjoining patient rooms #201 and #202 had gapping, cracked flooring that prevented the floor from being properly cleaned.

During a tour of the facility on 2-23-11, a 3 " -4 " triangular gouge was noted in the wall of patient room #106.

During a tour of the facility on 2-23-11, split and torn flooring was noted in the second floor bathroom, preventing the floor from being properly cleaned. The same bathroom was noted to have a stained and discolored toilet seat.

The above was confirmed in an interview with the Administrator on the afternoon of 2-23-11 in the second floor conference room.