HospitalInspections.org

Based on observation and interview, the facility failed to prevent an exit stairwell to be free of the storage or combustibles. This deficient practice has the potential to interfere and delay egress in the stair. The facility census was 38 on the day of survey.

Findings are:
Observations on 8-4-20 at 1:38 pm and 2:22 pm revealed:
1. The east stair enclosure contained a chair stored within the exit enclosure.
2. The west stair enclosure contained a chair stored within the exit enclosure.

During an interview on 8-4-20 at 1:38 pm and 2:22 pm, Administration Staff A confirmed the items within the exit stair enclosure.

Based on observation and interview, the facility failed to assure doors to hazard areas equipped with self-closing devices would close and latch within the doorframe. This deficient practice would allow smoke, fire and gasses to spread into the exit corridor. The facility census was 38 on the day of survey.

Findings are:
Observations on 8-4-20 at 2:07 pm revealed, the supply room door behind the center nurses station, which was equipped with a self-closing device failed to latch within the doorframe.

During an interview on 8-4-20 at 2:07 pm, Administration Staff A confirmed the door failed to latch within the doorframe.

Based on observation and interview, the facility failed to assure that all fire alarm devices were labeled. This deficient practice increased the potential that the fire alarm would fail due to incomplete testing.. The facility census was 38 on the day of survey.

Findings are:
Observations on 8-4-20 at 1:00 pm revealed, the smoke detector in the 2nd floor north electrical room failed to be labeled or identified.

During an interview on 8-4-20 at 1:00 pm, Administration Staff A confirmed the smoke detector failed to be identified.

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions for two of six quarters. When fire drills are held within the same time frame, they are not conducted under varied times and conditions. If facility staff is not challenged by different times and conditions, they might not respond appropriately when faced with a real fire which has the potential to affect all occupants. The facility census was 38 on the day of survey.

Findings are:
Fire drill documentation review on 8-4-20 at 11:50 am revealed:
1. The facility failed to conduct a 3rd shift drill during the second quarter of 2020.
2. The facility failed to conduct a 3rd shift drill during the second quarter of 2019.
3. The facility failed to conduct a 1st and 3rd shift drill during the first quarter of 2019.

During an interview on 8-4-20 at 11:50 am, Maintenance Staff A confirmed the findings.