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PURCELL MUNICIPAL HOSPITAL
Anesthetizing Locations
Tag No.: K0323
Based on record review, and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were followed as required.
Findings:
Record review showed the facility did not complete test and balance testing/inspection for 2015, 2016, 2017, 2018 and 2019 as required for the following areas to ensure ventilatory guidelines per ASHRAE 170-2008 were maintained: A-Wing soiled utility, isolation room #213, nurse station housekeeping, C-wing soiled utility, H.I.M. Corr West housekeeping, H.I.M. Corr West to hall housekeeping, Operating room #1, Operating room #2, anesthesia supply, surgical instruments room, autoclave room, decontam, operating room supply storage, instrument storage, recovery housekeeping, operating room housekeeping, operating room soiled utility, emergency room soiled utility, ER bay 6, ER bay 5, ER bay 4, ER clean utility, endo holding, endo scope cleaning, endo treatment, endo recovery.
On 06/17/19 at 10:53 am the suveyor asked staff Z why there was only a test and balance report for 2014. Staff Z stated that he had requested one be done but another staff person stated that it did not need to be done. Staff Z stated he will get the test and balance done on an annual basis.
Fire Drills
Tag No.: K0712
Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.
Findings:
Record review showed the facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.
On 06/27/19 at 2:18 pm the surveyor stated to Staff Z the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff Z stated they would add that to the fire drill documentation.
Fundamentals - Building System Categories
Tag No.: K0901
Based on record review and interview the facility failed to ensure the building system risk assessments were completed.
Findings:
Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.
On 06/27/18 at 10:23 am during record review the surveyor asked Staff Z for the EES and Medical Gas building system risk assessments, and Staff Z stated they did not have them done.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
Based on observation and interview the facility failed to ensure electrical equipment was protected as required.
Findings:
On 06/27/19 at 10:55 am the surveyor observed a refrigerator and a microwave plugged into a power tap in the radiology department break area.
On 06/27/19 at 10:55 am the surveyor asked staff Z why the refrigerator and microwave was plugged into a power tap. Staff Z stated that the staff are trained to know not to do that and he will remove the power tap immediately.