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Tag No.: K0020
The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.
On 08/24/10 at 11:50 AM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the copper, medical gas piping that has just been installed up through closet WP367 in the West Pavilion-3rd floor had voids and penetrations around them that were not sealed using a UL approved system for fire stopping.
Tag No.: K0025
The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 as required by the LSC
On 08/24/09 thru 08/31/10 at 10:30 AM and at times throughout the survey, the surveyor along with the Facilities Systems Coordinator observed that the smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls in the west pavillion, the east pavillion, North Pavillion and the YNPH had voids around penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.
Tag No.: K0033
The facility did not ensure that exit components such as stairways were arranged to provide both a continuous path of escape and protection against fire or smoke from other parts of the building as required by the referenced LSC.
On 08/24/10 at 11:15 AM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the sprinkler piping that passes through the exit stair enclosure, stair #3 at the 3rd floor, had voids and penetrations that were not sealed using a UL approved system for fire stopping two (2) hour enclosures.
Tag No.: K0050
The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.
On 08/31/10 at 10:30 AM, the surveyor was not provided with documentation by the Facilities Systems Coordinator that fire drills were all conducted in the YNPH building for the 2nd quarter 2010 3rd shift and the 1st quarter 2010 1st shift.
Tag No.: K0075
The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.
On 08/24/10 at 1:10 & 2:15 PM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the Rubbermaid, Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were not located in a room protected as a hazardous area when not attended as required by the referenced LSC; i.e. North Pavilion container observed at 1:10 PM & East Pavilion container observed at 2:15 PM.
Tag No.: K0130
1. The facility did not ensure that electrical receptacle outlets in patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..
On 08/31/10 at 10:30 AM, the surveyor was not provided with documentation by the Facilities Systems Coordinator that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99.
27293
2. The facility did not ensure that electrical devices in patient areas were being inspected as required in NFPA 99 " Health Care Facilities "
On 08/24/10 at 11:21 AM and at other times throughout the day, the surveyor while accompanied by the Facilities Safety Coordinator, observed that all of the electric, Neptune (Stryker) Fluid Management units located throughout the 3rd floor, operating suites lacked preventive maintenance stickers as required in NFPA 99, Section 7-5.1.3,7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. Units labeled as EXEMPT from electrical safety inspections/leakage testing yet are issued Bio Medical Engineering control ID numbers.
3. The facility did not ensure that patient care electrical devices in patient areas were being inspected as required in NFPA 99 " Health Care Facilities "
a. On 08/24/10 at 11:03 AM and at other times throughout the day, the surveyor while accompanied by the Facilities Safety Coordinator, observed that all of the portable X-Ray/C-Arm devices located throughout the 3rd floor operating suites lacked preventive maintenance stickers and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. 5 units in South Pavilion OR ' s & 2 Units on East Pavilion had no stickers; staff had to call GE service company to obtain PM dates during survey. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.
b. On 08/24/10 at 11:35 AM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the CRYO CATH unit that was staged for use in the South Pavilion OR corridor lacked a preventive maintenance sticker and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3,7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. Unit Director believes unit is not facility-owned yet is issued a Bio Medical Engineering control ID number. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.
c. On 08/24/10 at 11:40 AM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the COBRA Cardiac Ambulation unit that was staged for use in the South Pavilion OR corridor lacked a valid, preventive maintenance sticker and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3,7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. Label indicated due for PM in 6/10, staff placed note over PM sticker. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.
d. On 08/24/10 at 1:15 PM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the BLANKETTROLL III, blanket/bed warming units that were located throughout the North Pavilion Operating Room Suites lacked a valid, preventive maintenance sticker and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3,7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. Units located in OR ' s 5,6 & 7 PM stickers indicated due in 07/10. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.
e. On 08/30/10 at 10:00 AM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the portable X-Ray device located in the Radiology corridor at Shoreline Medical Center in Guilford, lacked a preventive maintenance sticker as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. no sticker, staff had to call GE service company to obtain PM date during survey. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.
f. On 08/30/10 at 1:30 PM the surveyor while accompanied by the Facilities Safety Coordinator, observed that the portable X-Ray/C Arm device located in the Women ' s Surgical Center at Temple Medical Center, lacked a preventive maintenance sticker as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. no sticker, staff had to call GE service company on 5th floor to obtain PM date during survey. An interview with the Facilities Safety Coordinator, prior to survey revealed that facility policy is to assign inventory control identification stickers as well as PM done & due dates on all of bio-med equipment.