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BAILEY MEDICAL CENTER, LLC
Egress Doors
Tag No.: K0222
Based on observation and interview the facility failed to ensure doors in a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress as required in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.6.
Findings:
On 08/02/17 at 11:24 am deadbolt locks were observed to be on the following doors in the facility: CT door, isolation room on second floor, sleep lab rooms #3 and #4 on second floor, patient room repurposed into doctor sleep room on second floor, patient rooms on third floor 336, 327, 331 and 332. The CEO was asked why the deadbolts were on the doors and he stated in the past they had contracted with doctors who placed them on the doors. He stated the doctors contract ended so they removed several of the deadbolts but did not remove them all. He stated they would remove each deadbolt.
Anesthetizing Locations
Tag No.: K0323
Based on record review and interview the facility failed to ensure ventilation within the surgical suite was in accordance with ASHRAE 170 as required.
Findings:
On 08/02/17 at 2:23 pm during record review the facility temperature and relative humidity logs for January, March and June of 2017 indicated the facility's range to be 25-60% and not 30-60% as required. The safety manager was asked why the facility's starting range number for relative humidity was 25%. She stated they would check on it.
Utilities - Gas and Electric
Tag No.: K0511
Based on observation and interview the facility failed to ensure eletrical wiring and equipment complied with NFPA 70, National Electric Code as required.
Findings:
On 08/02/17 at 11:24 am a multiplug was observed to be in use at the radiology assistants desk area. The faclity manager stated he would have the multiplug removed.
On 08/02/17 at 2:47 pm a countertop non-GFCI eletrical receptacle was observed within six feet of a water source in the emergency department. The facility manager stated he checked and the electrical receptacle was not on a GFCI circuit at the breaker box and would install one that is GFCI.
On 08/02/17 at 3:09 pm power strips were observed to be in use within operating room #1, and #2 and were lying on the floor were they could come into contact with water and/or body liquids as a result of the sugical procedures performed. The surgical nurse manager stated they would be removed from the floor. The surveyor asked the facility manager if they were operating under the CMS categorical waiver for power strips in the operating room and he stated no.
Fire Drills
Tag No.: K0712
Based on record review and interview the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.
Findings:
On 08/02/17 at 10:25 am record review showed fire drills dated 02/28/17 and 03/16/17 did not include a transmission of a fire alarm signal. The maintenance manager was asked how they conduct their fire drills and he stated they would include a fire alarm signal on every fire drill from now on.
Gas Equipment - Labeling Equipment and Cylind
Tag No.: K0928
Based on record review, observation and interview the facility failed to ensure gas piped system valves were labeled as required in NFPA 99, 2012, Chapter 11.5.3.1.
Findings:
On 08/02/17 at 3:53 pm record review showed the facility's most recent medical gas annual certification dated 02/28/17 indicated the bulk oxygen main valve was not labeled. The surveyor observed the bulk oxygen main valve was not labeled. The facility manager stated they would make certain the valve gets labeled.