HospitalInspections.org

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on staff interview, the facility has not implemented inspection of doors in means of egress for 2017. According to staff, 2018 has not been performed at the time of this survey.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on observation the facility failed to provide proper directional arrow signage for exiting to stairwell. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on observation, the facility failed to install the door to the Storage Room in Kitchen with a self-closing or automatic-closing device.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on observation the facility failed to distinguish the circuit breaker for the fire alarm with red marking at the electrical panel "Life Safety" located in the Intensive Care Unit. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) During an observation at ceiling height, above the cross corridor doors, in the path of the smoke barrier, the caulk used to seal the penetration had a gray color. Upon request for flame spread specification, the facility could not make available for review.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) The exhaust fan in the Mechanical Room (2nd floor) was operating without any cover.
2) In Operating Room No. 1, the receptacles on the essential electric system were not labeled.
3) In Operating Room No. 2, the receptacles on the essential electric system were peeling off.
4) The line isolation monitor panel servicing Operating Room No. 1 was not labeled.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on staff interview, there was no logs maintained for HEPA filter change schedule.
2) Based on staff interview, the relative humidity and temperature in operating room number 3 and C-section room were being monitored by the building automation system (BAS). However, the BAS has no capability to alert staff when relative humidity and temperature are outside the permitted range. Please address this shortcoming in your risk assessment.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on a review of the fire drill records, it was conducted without regular consistency. For example, in the first and second quarter of 2018, fire drills were conducted only on one shift. Fire drills were not held at unexpected times.

Findings:
The inspector observed, while accompanied by the CEO, Executive Director, and Assistant Director, during the hours of the inspection from 10:30 AM to 3:00 PM on 08/24/18, that there were the following issues:
1) Based on observation the facility failed to perform additional testing / maintenance of receptacles (both hospital-grade and non-hospital-grade) in patient care areas at intervals based on documented performance data for the year 2016 and 2017. According to staff, 2018 has not been performed at the time of this survey.