HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there were penetrations in the smoke barriers at the following locations. They were: 1) between the reception area and the lab, 2) the x-ray changing room, 3) the linen room in the back of the treatment room (the wall did not go to deck), 4) the maintenance hall, 5) the maintenance hall at a flex duct penetration, 6) the equipment storage corridor, 7) the 2nd floor at patient room 207 (j-boxes exposed), and 8) the 2nd floor meds room.

Based on observation the facility failed to provide adequate hazardous area enclosures.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that the doors in the following hazardous areas did not latch properly: 1) H.R. storage, 2) Waste Holding, and 3) Building Maintenance Storage. In addition, the following location did not have closers: 1) the Equipment Storage room at the Nurse Station, and 2) the General Storage room at the Nurse Station (both on 2nd floor).

Based on observation the facility failed to provide an adequate fire stair enclosure.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that the fire door on the west fire stair on the 1st floor did not latch properly.

Based on observation the facility failed to provide adequate illumination at exterior exits.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there were two exits that did not have adequate illumination. They were at the following locations: 1) the west stair exit to the outside (had only one lamp in a single fixture), and the east stair exit to the outside (had no light fixture).

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that the facility had only conducted one fire drill in each of the two shifts over the past year. These must be conducted quarterly in each shift.

Based on observation the facility failed to provide a smoking policy that reflected the actual policy of the facility.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that the smoking policy required revision to reflect the policy of the facility.

Generator Alarm:

" A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15.

Based on observation the facility failed to provide a second alarm for the generator.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there was only a generator alarm at the reception area. There was not a second alarm in a location readily observed by operating personnel at a regular work station.


Disaster Drills:

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

Based on observation the facility failed to provide adequate records of the disaster drills.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there were no records at the facility of the disaster drills.


Fuel and Water Preferred Customer Status:

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there were no letters from vendors indicating that the facility is a preferred customer in emergency conditions.

Based on observation the facility failed to provide adequate medical gas alarms.

The inspector observed, while accompanied by the Chief Clinical Officer, the Director of Quality Management, Plant Manager, and the Plant Operation Consultant during the hours of the inspection from 11:45 am to 3:45 pm on 6/4/2013 that there was only a medical gas alarm at the reception area. There must be a second alarm in a location readily observed by engineering staff.
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