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SANFORD CANBY MEDICAL CENTER
Multiple Occupancies
Tag No.: K0131
Based on observation and staff interview the facility failed to maintain the proper 2 hour fire resistive ratings for occupancies as described in the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.3. This deficient practice could allow for the transfer of smoke or fire from another occupancy and affect all patients and an undetermined amount of staff and visitors.
Findings include:
On the facility tour between 8:00 am to 12:00 pm on 05/18/2017 observations and staff interview revealed above ceiling penetrations without the proper fire stopping in the following locations along the clinic separation.
1. A 1" hole in the 2 hour fire barrier in the ProTime room.
2. Inside a conduit in the 2 hour fire barrier in the waiting room.
3. Inside a conduit in the 2 hour fire barrier above the door to the clinic staff entrance.
This deficient condition was confirmed by the Director of Plant Operations
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and staff interview the facility to maintain 2 hazardous storage rooms in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for all of all patients and an undetermined amount of staff and visitors.
Findings include:
On the facility tour between 8:00 am to 12:00 pm on 05/18/2017 observations and staff interview revealed 2 doors in the following locations did not have self closing doors.
1. The storage room in the birthing room
2. The storage room in room 102
This deficient condition was confirmed by the Director of Plant Operations
Alcohol Based Hand Rub Dispenser (ABHR)
Tag No.: K0325
Based on observation and staff interview the facility failed to install one ABHR (Alcohol Based Hand Rub) dispenser in accordance with The Life Safety Code, NFPA 101 2012 edition section 19.3.2.6. This deficient practice could cause a fire or electrical short affecting all 25 patients.
Findings include:
On the facility tour between 8:00 am to 12:00 pm on 05/18/2017 observations and staff interview revealed an ABHR located directly above an electrical outlet in the staff locker room.
This deficient condition was confirmed by the Director of Plant Operations.
Health Care Facilities Code - Other
Tag No.: K0900
Based on observation and staff interview the facility failed to provide for the proper lighting where deep sedation and general anesthesia is administered according to the Health Care Facilities Code, NFPA 99, 2012 edition section 6.3.2.2.11. This deficient practice could possibly cause harm to a patient in the event of a power outage.
Findings include:
On the facility tour between 8:00 am to 12:00 pm on 05/18/2017 observations and staff interview revealed there was no battery powered light in the operating room.
This deficient condition was confirmed by the Director of Plant Operations.