Every finding on record at Hospice of Southwest Ohio, Inc

Based on observation and interview the facility failed to ensure electronic door locking systems were installed in accordance with NFPA 101-2012 Edition, Section 19.2.2.2.4. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Observation on 12/15/21 at 12:32 P.M, with Staff A identified the electronic controlled egress door locks located at the end of the first floor in-patient unit at the north and south stairwell exits. Further examination revealed the doors were not equipped with 15 second door release function. In addition, the doors were not equipped with proper signs to notify an occupant for egress. Interview with Staff A at that time revealed the doors could only be released by staff key card or activation of the fire alarm system. Staff A agreed the in-patient hospice patient unit would not meet the definition of a dementia or behavioral type unit. Staff A verified the doors were not equipped with a 15 second delay at the time of discovery.

Based on record review and interview, the facility failed to inspect and test the fire alarm interface equipment in accordance with NFPA 101-2012 Edition, Section 9.6.1.5*; NFPA 72-2010 Edition, Sections 21.7.2*; 21.2.8; 14.6.2.4*. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Record review on 12/15/21 at 9:48 A.M. of the fire alarm inspection reports dated 01/28/21 lacked documentation to validate the fire alarm interface equipment was tested for monitor integrity, annually. Further review noted two electromagnetic exit door locks on the first floor and eight door hold open devices, which were interconnected to the fire alarm system, was not tested. Interview with Staff A verified the findings at the time of discovery.

Based on observations and staff interview, the facility failed to ensure sprinkler protection was provided at the bottom of the hydraulic elevator shaft in accordance with NFPA 101-2012 Edition, Section 9.7.1.1*; NFPA 13-2011 Edition, Section 8.15.5.1*. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Observations on 12/16/21 at 10:45 A.M. during tour of the facility with Staff A, identified a hydraulic elevator shaft, across from the first floor nurses' station. This elevator shaft vertically connected all three floors and observation revealed it lacked sprinkler coverage at the bottom of the shaft. Interview with Staff A verified the findings at the time of discovery.

Based on record review, observation and interview, the facility failed to ensure the wet stand pipe system and sprinkler heads were inspected and tested in accordance with NFPA 101-2012 Edition, Section 9.7.5; NFPA 25-2011 Edition, Sections 6.3.1.1*; 6.3.2.1; 5.2.1.1*. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Record review of the facility sprinkler inspection and test records from the previous 12 months was completed with Staff A on 12/15/21 at 09:45 A.M. Further review revealed the documentation lacked a five year hydrostatic test and flow test of the discovered wet pipe stand pipe system, located at the north and south stairwells and all three floors. No additional documentation was provided to validate the test was completed. Observation on 12/15/21 at 11:47 A.M. during tour of the facility with Staff A, noted the application of concealed type sprinkler heads inside the first floor family lounge and the storage room, near Patient Room #6. Further examination revealed the sprinkler head deflectors were displaced inside the ceiling which would obstruct the water discharge pattern as designed. Interview with Staff A verified the findings at the time of discovery.

Based on observation and interview, the facility failed to ensure corridor doors closed and latched in accordance with NFPA 101-2012 Edition, Section 19.3.6.3.5*. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Observation on 12/15/21 between 10:50 A.M. and 12:45 P.M., during tour of the facilitywith Staff A identified the following deficient practices: 1. Patient Room #9 corridor door failed to latch into the frame after three attempts. 2. Spa corridor door failed to latch into the frame after three attempts. Interview with Staff A verified the findings at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101-2012 Edition, Sections 19.7.1.4 and 19.7.1.6. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Record review on 12/15/21 at 3:10 P.M. with Staff B noted the performed fire and evacuation drills within the previous 12 months. Further review revealed the documentation lacked any fire and evacuation drills for second shift for fourth quarter of 2020; first and second shift for first quarter 2021; second shift for second quarter of 2021; and first and second shifts for third quarter 2021. In addition, drills were not performed under varied conditions to capture the beginning, middle and end of the shifts. Furthermore, the record lacked any documentation to validate the fire alarm signal was transmitted to the off site monitoring station. Interview with Staff B verified the findings at the time of discovery.

Based on observation, record review and interview, the facility failed to ensure rated fire door assemblies were inspected annually in accordance with NFPA 101-2012 Edition, Section 8.3.3.1; NFPA 80-2010 Edition, Sections 5.2.1*; 5.2.3.3. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Observation on 12/15/21 at 10:50 A.M. identified the following deficient practices with the 90 minute rated doors throughout the facility: 1. South stairwell third floor contained painted door label. 2. South stairwell first floor contained painted door label. 3. Center hall second floor dual fire doors: no label discovered on right hand door, however left hand leaf did contain a label. 4. First floor soiled linen room was discovered within a one hour fire rated assembly with no door label. In addition, an open air was discovered at the bottom of the door between the door frame. Record review on 12/15/21 at 9:45 A.M. of the facility inspection and test records from the previous 12 months and the provided life safety schematics noted the documentation lacked an annual inspection of the 90 minute rated double leaf swinging fire doors within the center halls of floors one, two and three. In addition, no record of annual inspection was provided for both the north and south 90 minute rated stairwell doors. Additional review of the life safety schematics noted the first floor soiled linen room contained a one hour rated separation; however, the corridor door was not labeled. Interview with Staff A verified the findings at the time of discovery.

Based on record review and staff interview, the facility failed to initially test each electrical outlet inside patient care areas in accordance with NFPA 99-2012 Edition, Sections 6.3.4.1.2. This deficient practice had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: Record review of the facility inspection and test records from the previous 12 months was completed on 12/15/21 at 2:30 P.M. with Staff A. Further review revealed the in-patient hospice patient care rooms were equipped with hospital grade electrical outlets; however, no record was provided to validate the outlets were initially tested after installation. Interview with Staff A verified the findings at the time of discovery.

Based on observation, interview and documentation review, the facility failed to maintain electronic locking systems (K222). The facility failed to inspect and test the fire alarm interface equipment (K345). The facility failed to ensure sprinkler protection was provided at the bottom of the hydraulic elevator shaft (K351). The facility to ensure the wet stand pipe system and sprinkler heads were inspected and tested (K353). The facility failed to ensure corridor doors closed and latched (K363). The failed to perform quarterly fire drills and evacuations each shift (K712). The facility failed to ensure rated fire door assemblies were inspected annually (K761). The facility failed to initially test each electrical outlet inside patient care areas (K914).

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically Chapter 19 of the applicable provisions of the 2012 existing edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This had the potential to affect all patients receiving services from the inpatient unit. The facility census was four. Findings include: 1. K222 - the facility failed to maintain electronic locking systems. 2. K345 - the facility failed to inspect and test the fire alarm interface equipment . 3. K351 - the facility failed to ensure sprinkler protection was provided at the bottom of the hydraulic elevator shaft. 4. K353 - the facility to ensure the wet stand pipe system and sprinkler heads were inspected and tested. 5. K363 - the facility failed to ensure corridor doors closed and latched. 6. K712 - the failed to perform quarterly fire drills and evacuations each shift. 7. K761 - the facility failed to ensure rated fire door assemblies were inspected annually. 8. K912 - the facility failed to initially test each electrical outlet inside patient care areas.