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CHASE COUNTY COMMUNITY HOSPITAL
Emergency Lighting
Tag No.: K0291
Based on observation and interview, the facility failed to maintain emergency lighting units. This deficient practice has the potential to inhibit the ability of staff to move safely through the area in the case of a loss of power, which could affect all occupants in one of two smoke zones.
Findings are:
Observation on 7/27/2021 at 12:50 P.M. revealed the facility failed to maintain the emergency lighting unit located in the transfer switch room. Interview of Maintenance Personnel on 7/27/2021 at 12:50 P.M., they stated that they were unaware that the emergency lighting unit was not working.
2. Observation on 7/27/2021 at 1:30 P.M. revealed the facility failed to maintain the emergency lighting unit located in CT room. Interview of Maintenance Personnel on 7/27/2021 at 1:30 P.M., they stated that they were unaware that the emergency lighting unit was not working.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, the facility failed to maintain the required one-hour fire resistive construction for hazard areas. This deficient practice has the potential of affecting all occupants in one of two smoke zones, by allowing fire and smoke to spread from a hazard area.
Findings are:
On 7/27/2021 at 12:45 P.M., observations revealed that the facility failed to provide the required one-hour fire resistive construction for the boiler room.
During interview conducted on 7/27/2021 at 12:45 P.M., Maintenance personnel stated that they were unaware of the requirement for the fire resistive construction.
Fire Drills
Tag No.: K0712
Based on observation and record review, the facility failed to conduct fire drills or staff orientation training. This has the potential of affecting all occupants in two of two smoke zones. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency.
Finding are:
On 7/27/2021 at 1:45 P.M., record review, the facility failed to conduct a fire drills or staff orientation training for the first and second shifts in the fourth quarter of 2020, and the first and second shifts in the first quarter of 2021.
During interview conducted on 7/27/2021 at 1:45 P.M., Maintenance personnel stated that they were unaware of the missing drills and that the previous maintenance director was in charge of conducting drills.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
Based on observation and interview, the facility failed to provide the proper storage for oxygen cylinders. This has the potential of affecting approximately 5 occupants in one of two smoke zones. This deficient practice has the potential to allow the damage to pressurized gas cylinders.
Findings are:
On 7/27/2021 at 1:00 P.M., observation reveled a single non-secured oxygen cylinder in the OR ante storage room.
During interview conducted on 7/27/2021 at 1:00 P.M., Maintenance personnel stated that they were unaware of the oxygen cylinders stored in an unsecured manor.