HospitalInspections.org

Based on review of records, policies and staff interviews on September 11 & 12, 2017 between the hours of 0830 and 1600 and 2000 and 2330 it was determined that the facility failed to insure staff were following the established policies and procedures for the safe use and handling of flammable liquids, and failed to insure that staff were trained to activate the fire alarm system in the event of a fire.

following are the findings and code references identified in the 2012 life safety code.

1. LSC 2012 section 8.7.3.1 The storage or handling of flammable liquids or gases shall be in accordance with NFPA 30.

Upon review of the facility policy # 04.06 section #III sub section F indicated that staff must not bring any type chemical product, liquid, granular or aerosol, to be used for any reason on/at/or in any of the WSH buildings, wards, or properties.

The finding was that one of the maintenance personnel brought lin seed oil into the ward E-5 and was using it to treat the plywood cabinets for water repellence, after leaving for the day the rags that were used found there way into a plastic 32 gallon garbage can and after a number of hours spontaneously combusted starting a fire in the can.

2. LSC 19.7.2.2 Section (1)

Upon review of the facility policy 12.03 section H paragraph 1 subsection A. If smoke or fire is found, Activate the fire alarm by pulling the pull station located in the smoke zone involved.

Based on staff interviews on 9/12/2017 the staff involved in finding the source of the smoke failed to activate the fire alarm system causing a delay in the response of the fire department to the facility, no staff pulled the pull station in the fire area.