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Tag No.: K0029
Based on observation in th presence of Staff #3, it was determined that the facility failed to separate hazardous areas with smoke resistant walls and self closing doors.
Findings include:
1. On 4/20/10 at 11:00 AM there were 4 penetrations in the fire rated corridor wall, in the 1st floor housekeeping storage room.
2. On 4/20/10 at 11:30 AM, the corridor door to the main store room could not latch.
3. On 4/20/10 at 12:15 PM, the corridor door to the 1st floor surgical storage room could not close.
Tag No.: K0039
Based on observation it was determined that the facility failed to provide a clear and unobstructed minimum width of 4 feet.
Findings include:
1. On 4/20/10 at 11:00 AM, in the presence of Staff #3, the exit corridor at room #3327 was reduced to 2'-4" by 2 plugged in computers on wheels and a patient table.
Tag No.: K0106
Based on observation in the presence os Staff#3, it was determined that the facility failed to provide an emergency generator with fuel on site.
Findings include:
1. On 4/20/10 at 11:00 AM, generator #1 operated with the use of piped natural gas fuel which was not on site.
Tag No.: K0211
Based on observation, it was determined that the facility failed to ensure Alcohol Based Handrub (ABHR) dispensers were not located above ignition sources.
Findings include:
1. On 4/20/10 at 11:00 AM, in the presence of Staff #3, in x-ray room #2 an ABHR dispenser was located directly above an electrical box.
2. On 4/20/10 at 2:45 PM, in the presence of Staff #3, an ABHR dispenser was located directly above and electrical switch in the Hematology lab.