HospitalInspections.org

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues:

A) Door inspection at all mean of egress was not available for review.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues:

A) Some of the smoke barrier cross corridor doors were not fully closed to prevent the smoke migrate to other smoke compartments.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues:

A.) The fire caulking was not provided entirely at some smoke compartment wall above ceiling.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.

(A) The receptacle's annual testing report was not available for review.
(B) The 30X36 clearance in front of some electrical panels were not provided.
(C) Please provide electrical panel and circuit number labeling for each fire alarm control panel.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.

A) The Risk Assessment by the facility to determine the categories of system is required for the facility.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities, during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.

B) The receptacles provided in some exam room in ED department -critical care areas - were not adequate. Please provide 14 receptacles = 7 duplexes in each exam room in ED department.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.


A) There were two parked cars within 10'-0" of medical gas bulk storage tank. It is not permissible and please provide no parking signage post or on the ground.
B) Some medical gas cylinders were not secure in place or individually chained.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.


A) There were two parked cars within 10'-0" of medical gas bulk storage tank. It is not permissible and please provide no parking signage post or on the ground.
B) Some medical gas cylinders were not secure in place or individually chained.

The inspector observed, while accompanied by the Director of Quality Management and the Director Facilities during the hours of the inspection from 1:00 PM to 4:00 PM on 09/13/2022 that there were the following issues. They were the following issues.


A) The following verbiages were not incorporated into fire protection of the facility. Also, the training report was not available for review. Please provide updated policy for the fire loss prevention in operating room in accordance with NFPA 99, 2012.
" Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers:
" packaging is non-flammable.
" applicators are in unit doses.
" Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify:
" application site is dry prior to draping and use of surgical equipment.
" pooling of solution has not occurred or has been corrected.
o solution-soaked materials have been removed from the OR prior to
" draping and use of surgical devices.
" policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use.
" Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually.