HospitalInspections.org

This tag not met as observed by surveyor #20980 and the facility Biomedical and Maintenance Manager. It was observed that three patient room doors had none rated glove box storage units hanging on the doors.

This tag not met as observed by surveyor #20980 and the facility Biomedical and Maintenance Manager. It was observed that the patient room doors of rooms 237 and 255 were not closing properly to maintain a smoke tight enviroment during a fire.

This tag not met as observed by surveyor #20980 and the facility Biomedical and Maintenance Manager. The following observations were made:

1) It was observed that several signs hanging from the ceiling in the hallway leading to Medical Surgery were hanging below 80 inches from the floor. NFPA 101 requires that nothing will be below the 6' 8" (80") from the floor.

2) It was observed that the north exit door leading out of the OR area was very difficult to open. The door should open freely with no more that 30 foot pounds required to open it.

This tag not met as observed by surveyor #20980 and the facility Biomedical and Maintenance Manager. The following observations were made:
1) It was observed that in the pharmacy storage was stacked to close to the sprinkler head. Storage can not be closer than 18" from the sprinkler head.

2) It was also observed that the sprinkler system records were not being maintained at the facility for review. At time of survey communication was established with the sprinkler company and records were sent to the facility. It is the responsibility of the facility to maintain and review the records to ensure that any issues found during inspection/testing of the system can be addressed and corrected in a timely manner.

This tag not met as observed by surveyor #20980 and the facility Biomedical and Maintenance Manager. It was observed that the outside oxygen storage area was not properly protected to prevent damage from vehicles.

This tag not met as observed by surveyor 20980. It was observed that the during a records review of the Medical Gas inspection report dated 23 July, 2015 the following deficiencies were noted and as of time of survey no action had been taken to correct the items:

1) ER/Radiology area alarm located left of ER Room 3-4 is defective.

2) ER/Radiology, the zone valve located across from X-Ray 2 has a leak at the stem on the oxygen valve when in the OFF position.

3) PACU Bay 2-2nd vacuum has a low flow of 2.25 scfm and needs a new faceplate.

4) Surgical Services operating room 1-2nd vacuum inlet on the ceiling closest to the door leaks at the end of the hose.

5) Surgical Services operating room 2-pt vacuum inlet on the ceiling closest to the anesthesia machine leaks at the end of the hose.

6) Room 217 in SCU the medical air outlet has a defective faceplate and needs to be replaced.

7) Room 247 in Medical Surgical the oxygen outlet leaks 50 psig.

8) Master Alarms and Sources - Medical air manifold high/low pressure switch is defective and does not sound when the medical air low pressure is in alarm.

9) Master Alarms and Sources - The vacuum pump low pressure switch is defective and does not sound when the vacuum low is in alarm.

10) The ER/Radiology zone valves located across form X-ray 2 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves.

11) The ER/Radiology area alarm located left of rooms 3 & 4 has no constant pressure displays.

12) In the procedure room soiled utility located in Surgical Services the medical air outlet is being used for the blowing down of scopes and is to be used only for air intheapplication of human respiration and calibration of medical devices for respiratory applications.

13) There is no area alarm monitoring the medical gasses to the Labor and Delivery Rooms 1 & 2.

14) Zone valves located left of the SCU entrance are behind the door.

15) The zone valves located left of the SCU entrance are behind the door.

16) The is no vacuum zone valve that shuts off the supply to the inlets in room 205.

17) In the Nitrogen/Nitrous Oxide Manifold Room both pressure relief vent lines for the nitrogen and nitrous oxide manifolds are soft soldered.

18) In the Nitrogen/Nitrous Oxide Manifold room the bottom vent that is one foot from the finished floor is obstructed by multiple medical air cylinders.

19) In the Nitrogen/Nitrous Oxide Manifold room the vacuum pump pressure switch is not located immediately downstream of the main vacuum pump source valve.

20) In the Nitrogen/Nitrous Oxide Manifold room the vacuum pump source valve located at the backup pump in the old boiler room is not a three piece valve permitting inline serviceability.

21) In the Nitrogen/Nitrous Oxide Manifold room the EOSC box needs to be secured with a padlock.

22) The Oxygen Supply System located outside of the building has the following deficiencies:
-There is only one entry gate at the bulk pad
-Oxygen source valve is not a three piece valve permitting in line serviceability and also has threaded connections
-There is not three foot of work space clearance around the components on the oxygen bulk pad.
-Downstream piping after the source valve is bent.
-Part of the oxygen pipeline is outside of the bulk pad fencing and unprotected.
-There is no high/low pressure switch monitoring the supply of oxygen to the building.