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MEMORIAL HOSPITAL
Discharge from Exits
Tag No.: K0271
Based on observation during facility tour conducted on 12/07/16, and staff interview it was determined that the facility failed to provide the required pathway from the exit to the public way. This has a potential to affect all patients at this facility.
Findings include:
During the tour of the building on 12/07/16 it was observed that the Exit access out of the rear of the imagining facility, exited to a conceit pad that ended and had soft mulched landscape between the pad and the public way, thus, did not provide a firm surface to the public way. The mulched area provided a 4 foot gap between the pad and the public way. This was confirmed by Staff AA at the time of discovery.
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on document review and staff interview it was determined the facility failed to perform smoke detector sensitivity testing within the first year of installation, as found in NFPA 72 1999 edition, 7-3.2.1.
Findings include:
During the review of the fire alarm testing documents it was found that smoke detectors had not had sensitivity testing performed within the first year. On 12/08/16 at 12:30 PM during an interview with Staff AA it was confirmed the facility did not perform the required testing.
Portable Fire Extinguishers
Tag No.: K0355
Based on observations and staff interview the facility failed to ensure portable fire extinguishers were checked. This deficient practice had the potential to affect any patient in the facility, with a census of 16, and a capacity of 97.
Findings include:
On tour of the facility on 12/05/16 at 3:29 PM observations were made in the IT (information technology) data center room of three portabel fire extinguishers labeled with tags dated 10/16. Interview with Staff AA at that time confirmed the three extinguishers had not been checked in the month of November 2016.
Gas Equipment - Precautions for Handling Oxyg
Tag No.: K0929
Based on observations and staff interview the facility failed to ensure portable gas tanks were secured in a medical gas storage room.
Findings include:
Observations were made on an afternoon tour 12/06/16 in a medical gas storage room, where two cylinders were not secured in medical gas room. The observation was confirmed with Staff AA at the time of the observation.