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Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Finding:

The west wing doors have roller latches.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating. Finding:,

The smoke barrier adjacent to the ER had penetrations around new wiring that were not sealed.

Based on observation, interview with staff and review of records, the facility failed to conduct fire drills that are held at least quarterly on each shift. Finding:

The facility failed to conduct a fire drill on the evening shift for the first quarter of 2012.

Based on observation, interview of staff and review of records, the facility failed to provide fire alarm test records that are properly documented and failed to maintain the fire alarm system in accordance with NFPA 72 and provide records of maintenance performed. Findings:

The report for the fire alarm test conducted on November 11, 2011 was not signed by an owner representative and the items noted on the report as deficiencies were not corrected. Records of maintenance and correction of deficiencies were not available.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system to provide complete coverage for all portions of the building. Finding:,

There is no sprinkler coverage for the former smoking area adjacent to the boiler room.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings,

The Bulk Oxygen site is not provided with dual line regulators. There is not an Oxygen supply emergency fill station located on the building.

Based on observation, interview with staff and review of records, the facility failed to provide documentation of anesthetizing locations that indicates the relative humidity is maintained equal to or greater than 35%. Finding,

The facility did not maintain logs of the humidity levels for the OR Suites.

Based on observation and interview with staff, the facility failed to test and tag electrical equipment in patient care areas in accordance with established protocols and with NFPA 99, 1999 edition, Chapter 7. Finding:

The Gentry CSI Blood Pressure/EKG Monitor located in the Recovery Room was in service for use but had not been tested and tagged as safe for use.

Based on observation, interview with staff and review of records, the facility failed to properly inspect, test and document generator checks in accordance with NFPA 99. 3.4.4.1
Findings,

The check water and check battery items were not documented as inspected on the run logs. The Generator was not shown to be exercised under load and run for 30 minutes on February 10, 2012. The records did not indicate the Generator was being exercised under load for 30 minutes with a load greater than 30% monthly.

Based on observation and interview with staff, the facility failed to provide proper identification of the Type I, EES division into a critical branch, life safety branch and the emergency system in accordance with NFPA 99. Findings:

The branches located in the boiler room were not labeled to identify the critical branch, life safety branch and equipment branch. The branch that has life safety items labeled, also had items not allowed on the life safety branch; such as, receptacles for the roof and a office.

There was no 90 minute battery back-up lighting located above the transfer switches.

Based on observation and interview with staff, the facility failed to provide required emergency power receptacles to all required areas in accordance with NFPA 70, 9.1.2 Findings,

The recovery room was not provided with emergency power receptacles that were marked or identified as emergency power.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Finding:

The west wing doors have roller latches.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating. Finding:,

The smoke barrier adjacent to the ER had penetrations around new wiring that were not sealed.

Based on observation, interview with staff and review of records, the facility failed to conduct fire drills that are held at least quarterly on each shift. Finding:

The facility failed to conduct a fire drill on the evening shift for the first quarter of 2012.

Based on observation, interview of staff and review of records, the facility failed to provide fire alarm test records that are properly documented and failed to maintain the fire alarm system in accordance with NFPA 72 and provide records of maintenance performed. Findings:

The report for the fire alarm test conducted on November 11, 2011 was not signed by an owner representative and the items noted on the report as deficiencies were not corrected. Records of maintenance and correction of deficiencies were not available.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system to provide complete coverage for all portions of the building. Finding:,

There is no sprinkler coverage for the former smoking area adjacent to the boiler room.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings,

The Bulk Oxygen site is not provided with dual line regulators. There is not an Oxygen supply emergency fill station located on the building.

Based on observation, interview with staff and review of records, the facility failed to provide documentation of anesthetizing locations that indicates the relative humidity is maintained equal to or greater than 35%. Finding,

The facility did not maintain logs of the humidity levels for the OR Suites.

Based on observation and interview with staff, the facility failed to test and tag electrical equipment in patient care areas in accordance with established protocols and with NFPA 99, 1999 edition, Chapter 7. Finding:

The Gentry CSI Blood Pressure/EKG Monitor located in the Recovery Room was in service for use but had not been tested and tagged as safe for use.

Based on observation, interview with staff and review of records, the facility failed to properly inspect, test and document generator checks in accordance with NFPA 99. 3.4.4.1
Findings,

The check water and check battery items were not documented as inspected on the run logs. The Generator was not shown to be exercised under load and run for 30 minutes on February 10, 2012. The records did not indicate the Generator was being exercised under load for 30 minutes with a load greater than 30% monthly.

Based on observation and interview with staff, the facility failed to provide proper identification of the Type I, EES division into a critical branch, life safety branch and the emergency system in accordance with NFPA 99. Findings:

The branches located in the boiler room were not labeled to identify the critical branch, life safety branch and equipment branch. The branch that has life safety items labeled, also had items not allowed on the life safety branch; such as, receptacles for the roof and a office.

There was no 90 minute battery back-up lighting located above the transfer switches.

Based on observation and interview with staff, the facility failed to provide required emergency power receptacles to all required areas in accordance with NFPA 70, 9.1.2 Findings,

The recovery room was not provided with emergency power receptacles that were marked or identified as emergency power.