HospitalInspections.org

Based on document review and interview, it was determined the facility failed to develop and update the emergency preparedness plan.

Findings include;

1. Interview and document review on Novemeber 8, 2022, between 9:15 am and 10:30 am, revealed the facility emergency preparedness plan was developed for an acute care hospital.

Interview at the time of the exit confrence on November 8, 2022, at 2:30 pm, with the Director of Operations, Facilities Director, and Maintenance Supervisor confirmed the EP plan had not been updated to reflect the facility is currently a free-standing psychiatric hospital.

Based on observation and interview, it was determined the facility failed to provide an all weather hard packed surface at two exit discharges.

Findings include;

1. Observation on November 8, 2022, between 2:20 pm and 2:25 pm, revealed there was no hard packed, all weather surface at the following exit discharges.

a. At 2:20 pm, the East exit has no hard packed surface to the public way.
b. At 2:25 pm, the West exit has no hard packed surface to the public way.

Interview at the time of the exit confrence on November 8, 2022, at 2:30 pm, with the Director of Operations, Facilities Director, and Maintenance Supervisor confirmed the both exits discharged on to a grassy area.

Based on observation and interview, it was determined illumination of exit access corridors was not maintained on one of one floors.

Findings include;

1. Observation on November 8, 2022, at 1:05 pm, revealed the exit access corridor at the M wing nurse station was very dark and all illumination could be powered off by a switch in the corridor.

Interview at the time of the exit confrence on November 8, 2022, at 2:30 pm, with the Director of Operations, Facilities Director, and Maintenance Supervisor confirmed all corridor illumination in this area could be powered off, leaving the area dark.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one location.

Findings include:

1. Observation on November 8, 2022, at 1:25 pm, revealed an approximatley 12 inch by 20 inch section of sheetrock missing from the ceiling in the boiler room near Chiller #1.

Interview at the time of the exit confrence on November 8, 2022, at 2:30 pm, with the Director of Operations, Facilities Director, and Maintenance Supervisor confirmed the missing section of ceiling.

Based on observation and interview, it was determined the facility failed to provide remote annunciation of the emergency generator that provides alternate power to the complete building.

Findings include:

1. Observation on November 8, 2022, at 1:40 pm, revealed there was no remote annunciator for the emergency generator located in an area that would be observed by staff at all hours.

Interview at the time of the exit confrence on November 8, 2022, at 2:30 pm, with the Director of Operations, Facilities Director, and Maintenance Supervisor confirmed the current remote annunciator was not in a location currently staffed at all hours.