HospitalInspections.org
Bringing transparency to federal inspections
TRIHEALTH EVENDALE HOSPITAL
PHYSICAL ENVIRONMENT
Tag No.: A0700
Based on interview, record review, and observation, the facility failed to maintain an environment safe from fire in regard to the failure to maintain rated barriers, exit signs on path of egress, smoke detectors at a proper distance from air handlers, maintainance of the sprinkler system, portable fire extinguishers free of obstruction and to failure to ensure medical gas shut off valve locations were familiar to staff (A710). The cumulative effect of these systemic practices resulted in the facility's inability to ensure a safe environment.
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on observation and staff interview, the facility failed to ensure all medical records were protected from water damage in case of a fire. This had the potential to affect all medical records filed and stored at the facility. The patient census was 11.
Findings include:
A tour of the business department where medical records were filed was conducted on 02/12/14 starting at 1:55pm. During the tour it was revealed the medical records were filed in an area protected by a sprinkler system. The records were kept in a rolling cabinet that locked and closure of the cabinet did not include a part of the cabinet fixed to the wall containing medical records, leaving the unprotected medical records exposed to potential water damage in case of a fire. Staff E confirmed there were medical records potentially exposed to water damage in case of a fire, and that no information contained in the medical records had been scanned.
A second tour of the business department where medical records were filed was conducted on 02/13/14 at 11:15am, as well as a tour of the sprinklered designated medical records storage room containing medical records in cardboard boxes dating back to 2006, and during that tour, interviews were conducted with Staff A, B, and D which confirmed medical records were filed and stored in areas exposed to potential water damage in case of a fire.
On 02/13/14 at 2:15pm, Staff A confirmed medical records were exposed to potential water damage in the business department, and medical records were exposed to potential water damage in the medical records storage room.
LIFE SAFETY FROM FIRE
Tag No.: A0710
Based on observation and interview, the hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.
Findings include:
The facility failed to maintain rated barriers. Please refer to K25 for specific detail.
The facility Failed to maintain a rated barrier around a storage room. Please refer to K29 for specific detail.
The facility failed to have exit signs on the paths of egress. Please refer to K47 for specific detail.
The facility failed to have smoke detectors at a proper distance from air handlers. Please refer to K51 for specific detail.
The facility failed to maintain a sprinkler system. Please refer to K62 for specific detail.
The facility failed to have portable fire extinguishers free of clutter. Please refer to K64 for specific detail.
The facility failed to ensure the medical gas system complied with NFPA 99. Please refer to K76 for specific detail.
The facility failed to ensure staff were aware of the location of the medical gas shut off valves. Please refer to K78 for specific detail.