HospitalInspections.org

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the areas listed because electrical power may not be available for their treatment.

Findings include:

A. At 12:08 PM, general care patient beds were observed at which 1 circuit is not from the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held at that time and in a Patient Sleeping Room, the provider's Director of Plant Operations confirmed that this condition exists at each Patient Sleeping Room bed location.

B. Corrected 9/5/12