HospitalInspections.org

Based on observations during the facility walk-through survey on 05/29/2014, with the plant operations director, senior tech, and maintenance tech., it could not be verified that the fire alarm system was powered from the Life Safety Branch of the emergency electrical system (EES). There was no identifying markings on the fire alarm panel to indicate the electrical panel or circuit providing electrical power to the fire alarm system. An inspection of the various emergency electrical panel directories, onsite during the walk-through, identified no circuits labeled "fire alarm" or similar.

Based on observations during the facility walk-through inspection on 05/29/2014, with the plant operations director, the senior tech, and the maintenance tech, it was noted that three air handling units (one serving the mechanical areas and dietary, one serving the second floor nursing units, and one serving the surgery department) lacked working pressure monitor gauges (manometers or magnahelics) on the final filters.

Based on a review of the records during the facility survey on 05/29/2014, it was noted that A medical gas service company (Stacy Systems) documented in August 2013 that there was a leak in an oxygen outlet at Recovery #1 bed, and a leak in an oxygen outlet in Surgery #2. According to conversations with the plant operations director during this same review of the records on 05/29/2014, these two leaks had not been correctoed to date, due to budget constraints.

Based on observations and conversation with the plant operations director during the facility walk-through survey on 05/29/2014, it was determined that there was no remote annunciator panel for the emergency generator, located within the hospital, at a 24 hour staffed location. There was an annunciator panel located in an abandoned office within the mechanical room, which had once been the engineering.maintenance office, but is no longer occupied.

Based on observations during the facility walk-through inspection/survey on 05/29/2014, with the plant operations director, the senior tech, and the maintenance tech, it was noted that two medical gas alarm area alarm panels, located in surgery and recovery, were not in working order. They did not function at all.

Based on a review of the records and discussions with the plant operations director during the facility survey on 05/29/2014, it was noted that documentation for the testing of the emergency generator failed to indicate that the generator load testing at 30 day intervals, included a 30% of capacity loading of the generator for 30 minutes minimum.

Based on observations during the facility walk-through survey on 05/29/2014, with the plant operations director, senior tech, and maintenance tech., it could not be verified that the fire alarm system was powered from the Life Safety Branch of the emergency electrical system (EES). There was no identifying markings on the fire alarm panel to indicate the electrical panel or circuit providing electrical power to the fire alarm system. An inspection of the various emergency electrical panel directories, onsite during the walk-through, identified no circuits labeled "fire alarm" or similar.

Based on observations during the facility walk-through inspection on 05/29/2014, with the plant operations director, the senior tech, and the maintenance tech, it was noted that three air handling units (one serving the mechanical areas and dietary, one serving the second floor nursing units, and one serving the surgery department) lacked working pressure monitor gauges (manometers or magnahelics) on the final filters.

Based on a review of the records during the facility survey on 05/29/2014, it was noted that A medical gas service company (Stacy Systems) documented in August 2013 that there was a leak in an oxygen outlet at Recovery #1 bed, and a leak in an oxygen outlet in Surgery #2. According to conversations with the plant operations director during this same review of the records on 05/29/2014, these two leaks had not been correctoed to date, due to budget constraints.

Based on observations and conversation with the plant operations director during the facility walk-through survey on 05/29/2014, it was determined that there was no remote annunciator panel for the emergency generator, located within the hospital, at a 24 hour staffed location. There was an annunciator panel located in an abandoned office within the mechanical room, which had once been the engineering.maintenance office, but is no longer occupied.

Based on observations during the facility walk-through inspection/survey on 05/29/2014, with the plant operations director, the senior tech, and the maintenance tech, it was noted that two medical gas alarm area alarm panels, located in surgery and recovery, were not in working order. They did not function at all.

Based on a review of the records and discussions with the plant operations director during the facility survey on 05/29/2014, it was noted that documentation for the testing of the emergency generator failed to indicate that the generator load testing at 30 day intervals, included a 30% of capacity loading of the generator for 30 minutes minimum.