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Tag No.: K0071
Based on observation and interview it was determined the facility failed to properly maintain one soiled linen chute on one of nine floors in this component.
Findings include:
A. Observation on September 13, 2012, at 1:40 PM, revealed the third floor (facility second) ambulatory surgery soiled linen chute access door was held open by an unauthorized stop.
Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the soiled linen chute access door was held open by an unauthorized stop.
Observation made during a revisit survey on February 14, 2013, at 1:25 PM, revealed the third floor (facility second) ambulatory surgery soiled linen chute access door was held open by a plastic bin.
Tag No.: K0076
Based on observation and interview it was determined the facility failed to properly maintain five medical gas storage areas on three of nine floors in this component.
Findings include:
A. Observation on September 13, 2012, between 10:59 AM and 1:28 PM, revealed the following medical gas storage deficiencies:
10:59 AM - First floor (facility basement), loading dock area, 20 E-sized oxygen cylinders stored in racks, area not properly configured as a medical gas cylinder storage area due to close proximity to combustibles and electrical outlet installed less than five feet from the floor. Completed 01/25/2013
11:22 AM - First floor (facility basement), H-tank room, used to store over 3,000 cubic feet of oxygen, was not properly configured as a medical gas cylinder storage area due to lack of 72 square inches of ventilation. Completed 01/25/2013
1:12 PM - Third floor (facility second), ICU alcove, contained 2 unsecured E-sized oxygen cylinders. Deficiency is not corrected 02/14/2013
1:27 PM - Fourth floor (facility third), respiratory care equipment room, contained 3 unsecured E-sized oxygen cylinders. Completed 01/25/2013
1:28 PM - Third floor (facility second), PACU nurses station, contained 2 unsecured E-sized oxygen cylinders. Completed 01/25/2013
Exit interview with maintenance representative #1, and maintenance representative #2 on September 14, 2012, between 8:30 AM and 8:45 AM, confirmed the medical gas cylinder storage deficiencies.
Observation made during a revisit survey on February 14, 2013, at 1:46 PM, revealed the third floor (facility second) medical gas storage room had 2 unsecured E-sized oxygen cylinders.