HospitalInspections.org

Based on document review and interview, the facility failed to have documentation of fire drills on at least a quarterly basis during the previous twelve months. This deficit practice affects all occupants of the building. The census was 61.

Findings include:

Review, conducted on the morning of 4/07/10, of the St. Louis building fire drill records showed the facility did not have documentation for a fire drill being conducted on each shift on a quarterly basis. Only three fire drills were documented with those drills occurring on September 29, 2009 at 8:09 P.M., January 21, 2010 at 7:35 P.M. and March 31, 2010 at 2:18 P.M.

Staff H Quality Manager confirmed at 3:30 P.M. on 4/07/10 there were no other documents detailing a fire drill other than the three which had been provided by the facility staff.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 19.7.1.2 states:"Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), coded announcement shall be permitted to be used instead of audible alarms."

Based on document review and interview, the facility failed to conduct inspections of all portions of the sprinkler system. This deficit practice affects all occupants of the building. The census was 61.

Findings include:

A review of the last two sprinkler system inspection reports, conducted on the morning of 4/07/10, revealed inspections of the sprinkler system occurred on 8/27/09 and 2/16/10 by an outside contractor. Both inspection reports state the piping in the system has not been checked for obstructive materials in the last five years and the check valve has not been internally inspected in the last five years.

When questioned about the sprinkler inspection reports at 9:30 A.M. on 4/09/10, Staff W Director of Plant Operation confirmed neither item noted in the reports had been inspected.

The National Fire Protection Association 101, 2000 edition section 4.6.12.1 shows:"Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter by continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

Based on observation and interview, the facility failed to maintain all patient use corridors in an unobstructed manner. This deficit practice affects all patients and staff on each patient floor. The facility census was 61.

Findings include:

Observations during a tour of the St. Louis building, conducted on the afternoon 4/07/10, revealed the following obstructions in the patient corridors:

- Observation at 1:57 P.M. revealed a vital signs monitor in the patient corridor by patient room 307.
- Observation at 1:58 P.M. revealed a clean linen cart and a vital signs monitor, plugged into a corridor electrical outlet to recharge, in the patient corridor by patient room 308.
- Observation at 2:03 P.M. revealed a vital signs monitor in the patient corridor by patient room 312.
- Observation at 2:06 P.M. revealed a vital signs monitor, plugged into a corridor electrical outlet to recharge, in the patient corridor by patient room 213.
- Observation at 2:11 P.M. revealed a clean linen cart in the patient corridor by patient room 209.
- Observation at 2:13 P.M. revealed a clean linen cart in the patient corridor by patient room 207.
- Observation at 2:14 P.M. revealed a sling scale in the patient corridor by patient room 205.

Staff W Director of Plant Operation confirmed during each observation the units were located in the corridor and were not in use by staff at the time of the observation.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 7.1.10.1states: "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency."