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Tag No.: K0223
Based on observation and interview, it was determined that the facility failed to inspect doors with closures on one of over fifty doors.
Findings include:
Observation on July 13, 2021, at 10:16 a.m., revealed the second floor, door 229, had the closure arm disconnected and zip tied preventing it from working properly.
Interview with the maintenance tech, on July 13, 2021, at 10:16 a.m., confirmed the door with the closure was disconnected.
Tag No.: K0363
Based on observation and interview, it was determined that the facility failed to inspect one of over one hundred corridor doors.
Findings include:
Observation on July 13, 2021, at 11:00 a.m., revealed the first floor, door 1516, near PACU and ASU failed to latch in the frame.
Interview with the maintenance tech, on July 13, 2021, at 10:16 a.m., confirmed the door failed to latch.
Tag No.: K0908
Based on document review and interview, it was determined that the facility failed to comply with requirements of one of one gas and vacuum piped systems.
Findings include:
Document review on July 13, 2021, at 9:05 a.m., revealed the following medical gas deficiences on their April 27-28 2021 report:
A. (9:05 a.m.) med gas due point monitor is inaccurate;
B. (9:05 a.m.) normal change over lights are burnout/not present;
C. (9:05 a.m.) rm 302 cover frame damaged;
D. (9:05 a.m.) outlets/inlets leaks.
Interview with the maintenance tech on July 13, 2021, at 9:05 a.m., confirmed the deficiences listed above on the report were not corrected at the time of the survey.
Tag No.: K0913
Based on observation and interview, it was determined that the facility failed to maintain electrical systems within wet procedure locations on two of three building levels.
Findings include:
Observation on July 13, 2021, between 9:44 a.m. and 12: 28 p.m., revealed the following wet procedure deficiencies:
A. (9:44 a.m.) second floor nursery sink, lacked a non-ground fault circuit interrupter (GFCI) outlet near the sink area;
B. (9:58 a.m.) second floor, room 254, lacked a non-ground fault circuit interrupter (GFCI) outlet near the sink area;
C. (10:00 a.m.) second floor, room 256, lacked a non-ground fault circuit interrupter (GFCI) outlet near the sink area;
D. (12:28 p.m.) first floor, therapy, had a hydro thermal hydrocollator that was not plugged into a GFCI outlet.
Interview with the maintenance tech on July 13, 2021, at 12:28 p.m., wet procedure deficiencies listed above.
Tag No.: K0920
Based on observation and interview, it was determined that the facility failed to inspect electrical equipment on two of three floors.
Findings include:
Observation on July 13, 2021, between 10:10 a.m. and 12:20 p.m. revealed the following electrical equipment deficiencies:
A. (10:10 a.m.) second floor, room 212, had a microwave, toaster oven, and water cooler plugged into a surge protector;
B. (10:42) first floor, data room 1070, had a surge protector plugged into a surge protector;
C. (12:20) first floor, near corridor 14111, behind vending, had a surge protector secured tightly to the wall.
Interview with the maintenance tech, on July 13, 2021 at 12:20 p.m., confirmed the electrical deficiencies listed above.