HospitalInspections.org

K321 Hazardous Areas - Enclosure 2012 EXISTING


Findings:


The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:


1) Main Building, 4th floor. The door to the pharmacy storage room did not latch.

2) Main Building, 4th floor. In the Echo Testing patient care areas, the med surg rooms were used as either equipment storage or general storage. Hazardous areas are protected in accordance with NFPA 99, 2012, 19.3.2.1.

K355 Portable Fire Extinguishers


Findings:


The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:

1) The fire extinguishers log showed there were water extinguishers in use but field verification did not find any. Please update the inventory to match actual items in use.

K902 Gas and Vacuum Piped Systems - Other

Findings:

The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:

1) St. John's Campus. In the basement mechanical room, copper piping was not separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action.

K909 Gas and Vacuum Piped Systems - Information and Warning Signs

Findings:

The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:

1) Main Building, 4th floor. At the cross corridor door near the stairs, above the ceiling, there were medical gas piped system piping without any label.

K911 Electrical Systems - Critical Branch


Findings:

The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:

1) There were circuits that were not items listed as allowed per NFPA 70 517.33 placed on the critical branch. This was exemplified by but not limited to: Main Building, 1st floor, critical panels "CHA", "CL1", and "SA".

2) There were circuits essential to the Life Safety Branch that were placed on the Critical Branch. This was exemplified by but not limited to: Main Building, 4th floor, critical panel "CL6"; Main Building, 5th floor, critical panel "CL8".

K911 Electrical Systems - Other
Findings:
The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:
1) St. John's Campus. In the basement and first floor level where the automatic transfer switches were located, the panels did not have permanent hard label.
2) At the Central Plant of Main Building, there was a junction box without cover.

K918 Electrical Systems - Essential Electric System Maintenance and Testing

Findings:

The inspector observed, while accompanied by the Director Engineering and Quality Manager Quality Resources, during the hours of the inspection from 3:30 PM to 6:30 PM on 08/16/17 and the following day on 8/17/17 from 8:30 AM - 5:00 PM, accompanied by Director Engineering, Quality Manager Quality Resources, Facility Safety Manager, Maintenance Supervisor, and Mechanics, that there were the following issues:

1) There were no written records of maintenance and testing of the generators(s), performed by a third party company available for the year 2016.