HospitalInspections.org

Based upon observations, the facility failed to maintain exit access in accordance with NFPA 101 (National Fire Protection Association). Findings include:

Surveyor observed between 11:00and 11:30 am that doors in means of egress from record storage had deadbolt locks requiring two actions to release the doors. This is not in accordance with NFPA 101, 2000: 7.2.1.5.4. Doors shall be operable with not more than one releasing operation.

Based upon observations, the facility failed to ensure sprinkler coverage in areas in accordance with NFPA 13, Standard for Installation of Sprinklers Systems. Findings include:

Surveyor observed between 11:30 and 11:45 am on 7/14/10, that central supply storage material were stored within 12 inches of sprinkler deflectors. The clearance between the deflector and the top of storage shall be 18 in. or greater, NFPA 13, 1999: 5-6.6.

Based upon observations, facility failed to maintain medical gas systems in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

Surveyor observed between 11:30 and 11:45 am on 7/14/10 that medical gas alarms were not functional in accordance with NFPA 99, 1999: 4-3.1.2.2. (b) Master alarms. A master alarm sysem shall be provided to monitor the operation and condition of the source of supply, the reserve (if any) and the pressure of main lines of all medical gas piping systems.

Based upon observations, facility failed to maintain electrical systems in accordance with NFPA 70, National Electrical Code. Findings include:

1. Surveyor observed between 11:00 and 11:30 am on 7/14/10, that emergency electrical panels in corridor and in Emergency Department were not identified properly. The emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1996: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

2. Surveyor observed between 11:00 and 11:30 am that receptacles in patient care areas were not hospital grade. It was not clear that biomedical equipment logs included the following requirements of NFPA 99, 1999: 3-3.4.2.3(a)2. Additional testing shall be performed at intervals defined by documented performance date.
Exception: Receptacles not listed as hospital grade shall be tested at intervals not exceeding 12 months.
and 3-3.3.3 Receptacle testing in Patient Care Areas.
(a) The phyiscal integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connection in each electrical receptacle shall be confirmed.
(d) The retention forcee of the grounding blade of each receptacle shall be not less than 4 oz.