HospitalInspections.org

Based on document review and interview the facility failed to maintain the emergency generator. This deficient practice increases the likelihood of generation equipment malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25.

Findings are:
Document review on 4/7/2025 at 9:21 am found the facility could not provide documentation for monthly generator testing during the use of a temporary generator, nor an annual inspection or load bank test for the permanent generator.

During interview on 4/7/2025 at 9:21 am staff confirmed the lack of documentation.

Based on document review and interview the facility failed to provide periodic smoke detector sensitivity testing. This deficient practice increases the likelihood of system malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25.

Findings are:
Document review on 4/7/2025 at 9:34 am found the facility could not provide documentation of a sensitivity test of the fire alarm smoke detectors.

During interview on 4/7/2025 at 9:34 am staff confirmed the lack of documentation.

Based on observation and interview the facility failed to maintain a ceiling membrane to collect heat and activate the fire sprinkler system. This deficient practice increases the likelihood of sprinkler system malfunction or failure affecting all occupants of the facility. Facility census was 14 and licensed for 25.

Findings are:
Observation between 10:11 am and 10:53 am on 4/7/2025 found missing ceiling tiles in:
1. Both lower level training rooms.
2. RT Blood & Gas office
3. Main Floor EVS Room
4. Clean Utility room by Specialty Nurses Desk

During interview on 4/7/2025 between 10:00 and 10:53 am staff confirmed missing or out of place ceiling tiles.

Based on document review and interview the facility failed to conduct quarterly fire drills for each shift. This deficient practice increases likelihood of confusion and delayed response from staff affecting all occupants. Facility census was 14 and licensed for 25.

Findings are:
Document review on 4/7/2025 at 09:15 am found the facility failed to:
1. Conduct a drill in first quarter 2024 for the overnight shift.
2. Conducted 4 of 9 fire drills within an hour of another drill.

During interview on 4/7/2025 at 9:15 am staff confirmed the lack of drill and timing of drills.

Based on observation and interview the facility failed to prohibit the use of portable space heaters in the facility. This deficient practice increases the likelihood of fire cause by a heating device affecting all occupants. Facility census was 14 and licensed for 25.

Observation on 4/7/2025 between 9:50 am and 10:49 am found portable space heaters in the following locations:
1. Billing Office
2. Imaging Office
3. Schedulers Office
4. Patient Access Office
5. Both Occupational Health Offices

During interview on 4/7/2025 between 9:50 and 10:49 am staff confirmed the presence of the portable space heaters.

Based on document review and interview the facility failed to maintain the emergency generator. This deficient practice increases the likelihood of generation equipment malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25.

Findings are:
Document review on 4/7/2025 at 9:21 am found the facility could not provide documentation for monthly generator testing during the use of a temporary generator, nor an annual inspection or load bank test for the permanent generator.

During interview on 4/7/2025 at 9:21 am staff confirmed the lack of documentation.

Based on observation and interview the facility failed to prohibit the improper use of power strips and extension cords. This deficient practice increases the likelihood of electrical fire or injury and affects all occupants. Facility census was 14 and licensed for 25.

Findings are:
Observation on 4/7/2025 between 9:52 and 10:42 am found:
1. 3 way power tap in use in H.I.M. office
2. Daisy chained power strips and high draw appliances (refrigerator) in to power strips in the IT office.
3. Extension cord powering a lamp in the Quality Office
4. High Draw appliances (Toaster and Coffee Pot) into power strip in the Surgery Break Room

During interview on 4/7/2025 between 9:52 and 10:42 am staff confirmed the inappropriate uses of power strips and extension cords.