HospitalInspections.org

Based on observation, document review, and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings include:
During tours of the hospital at various times during the survey from 7/31/2012 to 8/3/2012, the following were identified in the presence of the hospital staff who were accompanying the state surveyor.

1. Interview with the Fire Safety Director and the Senior Associate Executive Director of the hospital revealed that the fire alarm system was tested and found to be defective on 6/27/2012. The three buildings of the hospital (C, D and E) were under fire watch.
2. Although, the documentation of the fire alarm testing that detailed the problem was requested repeatedly, they were not provided for review. Therefore the exact problem of the fire alarm system in each building was not determined.
3. The hospital staff said that the fire alarm company was still working to fix the problem and that fire alarm panels need to be changed. Also, the staff said that they had a purchase order for the defective panel and other parts and that the fix of the fire alarm system is awaiting the required parts.
4. Per interview with the Associate Director of Safety and Administrator, the coding system of the fire alarm was not functioning, the smoke doors did not hold (open and close properly as per function and design), and that the audible alarm is not working. The staff member stated that the hospital performs a fire watch using the hospital Police Officers and Fire Watch Personnel.