HospitalInspections.org

Based on observations and discussions with the plant operations director during the facility walk through inspection on 10/02/2014, it was determined that the facility did not have a complete fire sprinkler system per NFPA 13(2002). The two story, 1962 structure was fully sprinklered. However the three story, 1973 structure had only the third floor sprinklered and only hazardous areas on the first and second floors sprinklered. A type II non-combustible building of 3 stories shall be completely sprinklered.

Based on observations during the facility walk through inspection on 10/02/2014 with the administrator and director plant operations, it was noted that the medical gas manifold room was located within the main electrical switchgear room. NFPA 99(2002)5.1.3.3.1.6 does not permit indoor locations of medical gases to be combined with rooms containing electrical contacts or transformers.

a) Based on a review of the records/documentation during the facility walk through inspection on 10/02/2014, it was noted that critical care patient area electrical outlets (duplex) were not being tested semi-annually as required by NFPA 99 (2002)3-3.3.3. for the following criteria; Physical integrity of each receptacle, Continunity of grounding of each receptacle, Correct polarity of hot and neutral connections in each receptacle, and Retention force on the grounding blade not less than 4 oz.

b) Based on observations during the facility walk through inspection on 10/02/2014, it was noted that the dishwash machine and soiled dish area is located within the main kitchen food prep. area. Soiled dish wash functions shall be separated from the work areas of the kitchen, and the dish was machine shall be a pass through type allowing clean dishes to exit the machine outside of the soiled dish area.

Based on observations and discussions with the plant operations director during the facility walk through inspection on 10/02/2014, it was determined that the facility did not have a complete fire sprinkler system per NFPA 13(2002). The two story, 1962 structure was fully sprinklered. However the three story, 1973 structure had only the third floor sprinklered and only hazardous areas on the first and second floors sprinklered. A type II non-combustible building of 3 stories shall be completely sprinklered.

Based on observations during the facility walk through inspection on 10/02/2014 with the administrator and director plant operations, it was noted that the medical gas manifold room was located within the main electrical switchgear room. NFPA 99(2002)5.1.3.3.1.6 does not permit indoor locations of medical gases to be combined with rooms containing electrical contacts or transformers.

a) Based on a review of the records/documentation during the facility walk through inspection on 10/02/2014, it was noted that critical care patient area electrical outlets (duplex) were not being tested semi-annually as required by NFPA 99 (2002)3-3.3.3. for the following criteria; Physical integrity of each receptacle, Continunity of grounding of each receptacle, Correct polarity of hot and neutral connections in each receptacle, and Retention force on the grounding blade not less than 4 oz.

b) Based on observations during the facility walk through inspection on 10/02/2014, it was noted that the dishwash machine and soiled dish area is located within the main kitchen food prep. area. Soiled dish wash functions shall be separated from the work areas of the kitchen, and the dish was machine shall be a pass through type allowing clean dishes to exit the machine outside of the soiled dish area.