HospitalInspections.org

Based on observation and staff interview the facility failed to continously maintain the means of egress free of all obstructions and impediments so that exits are readily accessible at all times in the case of fire or other emergency.

Findings include:

During the tour of the endoscopy suite on 09/11/12 at approximately 10:30 AM, it was noted that the secondary egress from the endoscopy suite on the 4 th floor of the building was blocked with four (4) large treatment chairs. Interview of the Director of Nursing for Surgery revealed that the space was used as a waiting area for patients and that patients begin receiving their Intravenous Anesthesia drug sitting in these chairs.

Furthermore, the door (N40494) that served as the exit access door behind these treatment chairs was found to be locked with a lock and key. Therefore, this door was not arranged to be opened readily to serve as the exit passage to the secondary means of egress.

Based on staff interview, the facility failed to train all of its employees with respects to the fire alarm system and their duties in the event of a fire emergency.

Findings include:

During interview regarding fire safety, two of two dietary employees ( one (1) dietician and one (1) dietary aide) interviewed did not have knowledge about the fire alarm suysytem. They were not aware of the location of the pull boxes and did not know how to activate them.

Upon interview of these two employees, it was also revealed that the dietician had not attended any fire drills for over a year and the dietary aide was a new employee and had not attended a fire drill at all. The dietary aide also stated that she was inserviced about building fire safety in July, but was not able to recollect the facts that were stated during the inservice.

Based on review of documents and staff interview, the facility failed to maintain all the components of the fire alarm system in good repair.

Findings include:

During review of the testing of the fire and smoke dampers conducted in April of 2012, it was noted that approximately 50 percent of the dampers had failed due to being jammed, had an inoperable actuator, or not being accessible.
Documented evidence was not available to indicate that the repairs were either conducted or were in the process. The facility also did not institute an Interim Life Safety Plan to ensure patient safety in the event of fire while the smoke dampers are under repair.

Based on review of documents and staff interview, the facility to maintain the piped in gases in compliance with NFPA 99C 2005 Edition.

Findings include:

Review of the medical gas inspection reports of testing conducted 11/28/2011-12/01/12 revealed that the master alarms were found to be non-compliant with NFPA 99C 2005 Edition and visual signals were lacking on area panels in many areas of the hospital.

Review of the repair document revealed that the repairs were still in progress. Interview of the Director Of Engineering revealed that there was no set completion dates for the repairs.