HospitalInspections.org

Based on documentation review and interview, the facility failed to conduct annual testing of the diesel fuel for the emergency generator. This deficient practice could cause the emergency generator to fail to start and run when needed and not supply emergency power to the facility. The facility has a capacity of 21, with a census of 6 on the day of survey.

Findings are:
Record review on 09-15-20 at 10:48 am revealed the lack of documentation of the annual testing of the diesel fuel for the emergency generator.

During an interview on 09-15-20 at 10:48 am, Maintenance Staff A confirmed the lack of documentation of the testing.

Based on observation and staff interview, the facility failed to maintain construction that would limit the transfer of smoke to separate a hazardous area from the rest of the building. This condition would allow smoke and fire gases to migrate into the exit corridors. The facility has a capacity of 21, with a census of 6 on the date of survey.

Findings are:
Observations on 09-15-20 at 2:12 pm revealed multiple openings in the wall of the medical record storage room in the C-wing basement. The openings included one measuring 8 inches by 16 inches, one measuring 5 inches by 12 inches, and one measuring 3 inches in diameter.

During an interview on 09-15-20 at 2:12 pm, Maintenance A acknowledged the unsealed penetrations in the wall of the storage room.

Based on observation, document review, and staff interview, the facility failed to have the required inspection and cleaning performed on the exhaust ductwork for the kitchen hood system. This deficient practice would allow excessive build-up of cooking greases and increase the chances of a fire occurring. The facility has a capacity of 21, with a census of 6 on the day of survey.

Findings are:
Document review and observation on 09-15-20 at 11:30 am revealed no documentation or required label on the kitchen exhaust hood verifying proper cleaning of the ductwork.

During an interview on 09-15-20 at 11:30 am, Maintenance Staff A confirmed the lack of documentation or cleaning of the ductwork.

Based on documentation review and interview, the facility failed to perform required fire drills. This deficient practice can lead to confusion and possible panic in the event of a real fire situation. The facility had a capacity of 21 with a census of 6 on the day of the survey.

Findings are:
Record review on 09-15-20 at 11:10 am revealed the facility failed to perform a fire drill for the first shift during the second quarter of 2020 at the hospital in Wayne.

During an interview on 09-15-20 at 11:10 am, Maintenance Staff A confirmed the findings.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke. The facility capacity was 21, with a census of 6 on the day of survey.

Findings are:

Documentation review on 09-15-20 at 11:24 am revealed that the facility failed to provide written documentation of annual inspections and testing of the all fire rated doors throughout the facility.

During an interview on 09-15-2020 at 11:24 am, Maintenance Staff A confirmed the lack of complete fire rated door inspections and documentation.

Based on documentation review and interview, the facility failed to conduct annual testing of the diesel fuel for the emergency generator. This deficient practice could cause the emergency generator to fail to start and run when needed and not supply emergency power to the facility. The facility has a capacity of 21, with a census of 6 on the day of survey.

Findings are:
Record review on 09-15-20 at 10:48 am revealed the lack of documentation of the annual testing of the diesel fuel for the emergency generator.

During an interview on 09-15-20 at 10:48 am, Maintenance Staff A confirmed the lack of documentation of the testing.