HospitalInspections.org

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, the door closer (means for suitable for keeping the door closed) at the Physical Therapy entry door needed to be adjusted to ensure the door completely closes/latches of its own accord.

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, the door closers (self-closing devices) at the following locations needed adjusting/reattachment so that the doors are self-closing: (1) Soiled Work Room on 2nd floor; (2) Break Room/Central Supply on 1st floor; and, (3) ICU Soiled Work Room. Also, the existing main entrance door at Main Central Supply had a door catch that holds the door open, so that the door did not self-close; and the door at Materials Management Storage did not have a self-closing device installed as required.

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, required manual alarm boxes (pull boxes) were not present at: (1) the Materials Management exit door; (2) the Emergency Room exit door; and, (3) the Emergency Department exit door.

Continuity of Essential Building Systems. When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (1) Electricity, (2) Water, (3) Ventiliation, (4) Fire protection systems, (5) Fuel Sources, (6) Medical gas and vacuum systems (if applicable), (7) Communication systems. NFPA 99 (2002), 12.3.3.2

This STANDARD is not met as evidenced by: Based on observations of facility logs/records, on the afternoon of 06/06/2014, a letter indicating priority of delivery service for diesel fuel was not provided.

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, the door closer (means for suitable for keeping the door closed) at the Physical Therapy entry door needed to be adjusted to ensure the door completely closes/latches of its own accord.

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, the door closers (self-closing devices) at the following locations needed adjusting/reattachment so that the doors are self-closing: (1) Soiled Work Room on 2nd floor; (2) Break Room/Central Supply on 1st floor; and, (3) ICU Soiled Work Room. Also, the existing main entrance door at Main Central Supply had a door catch that holds the door open, so that the door did not self-close; and the door at Materials Management Storage did not have a self-closing device installed as required.

This STANDARD is not met as evidenced by: Based on observations during the survey of the facility, on the afternoon of 06/06/2014, required manual alarm boxes (pull boxes) were not present at: (1) the Materials Management exit door; (2) the Emergency Room exit door; and, (3) the Emergency Department exit door.

Continuity of Essential Building Systems. When designated by the emergency management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (1) Electricity, (2) Water, (3) Ventiliation, (4) Fire protection systems, (5) Fuel Sources, (6) Medical gas and vacuum systems (if applicable), (7) Communication systems. NFPA 99 (2002), 12.3.3.2

This STANDARD is not met as evidenced by: Based on observations of facility logs/records, on the afternoon of 06/06/2014, a letter indicating priority of delivery service for diesel fuel was not provided.