HospitalInspections.org

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues:

A) Door inspection at all mean of egress was not available for review.

B) There are doors located at the egress corridor were not able to be latch. Please provide latch hardware to all egress corridor door.

C) The magnetic locked device located at the ED department was not wiring to the fire alarm system and released upon the fire alarm activation.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues:


D) Some of the smoke barrier cross corridor doors were not fully closed to prevent the smoke migrate to other smoke compartments.

E) Two sets of the smoke compartment door or double egress doo were hold open without wiring to fire alarm and close upon activation of the fire alarm.

F) The astragal was missing at some of the smoke compartment double egress corridor doors.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues:

A.) The fire caulking was not provided entirely at some smoke compartment wall above ceiling.

B.) The door closer and UL fire rated door label were not provided at the dietary dry storage room. Please verify all fire rated door is equipped with door closer.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues:

A.) Tow fire alarm pull stations were missing at the two exit stairs on the second level.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues.

(A) Please provide electrical panel and circuit number labeling for each fire alarm control panel.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues.

A) The type I electrical system was not provided because of the items provided to each life safety, critical, and equipment branches were not provided according to the NFPA 99 Type I system. Such as the generator battery was not powered from the life safety branch (currently equipment branch). The nurse calling system was not powered from the critical branch (currently life safety branch). The FACP panel was not powered from the life safety branch (currently normal power or equipment branch).

B) There was not a receptacle powered from the life safety branch at the ATS room.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant, during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues.

A) The receptacles provided in some exam room in ED department -critical care areas - were not adequate. Please provide 14 receptacles = 7 duplexes in each exam room in ED department.

The inspector observed, while accompanied by the CEO, Director of Quality Management, the Maintenance Staff, and Assistant during the hours of the inspection from 2:00 PM to 6:30 PM on 09/14/2022 that there were the following issues. They were the following issues.


A) The following verbiages were not incorporated into fire protection of the facility. Also, the training report was not available for review. Please provide updated policy for the fire loss prevention in operating room in accordance with NFPA 99, 2012.
" Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers:
" packaging is non-flammable.
" applicators are in unit doses.
" Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify:
" application site is dry prior to draping and use of surgical equipment.
" pooling of solution has not occurred or has been corrected.
o solution-soaked materials have been removed from the OR prior to
" draping and use of surgical devices.
" policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use.
" Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually.