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ARBUCKLE MEMORIAL HOSPITAL AUTHORITY
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview the facility failed to ensure hazardous areas were protected and without penetrations as required.
Findings:
On 9/25/20 at 11:08am the surveyor observed a penetration between the hazardous area mechanical room housing the oxygen closet and another mechanical room. The penetration was observed to be a metal vent that had been installed.
On 9/25/20 at 11:08am the surveyor asked staff D why they have a penetration in their hazardous area wall. Staff D stated he doesn't know why the vent was installed and they will repair the wall.
On 9/25/20 at 11:12am the surveyor observed combustibles stored in the hazardous area oxygen storage closet.
On 9/25/20 at 11:12am the surveyor asked staff D why there is combustibles stored in the oxygen storage closet. Staff D stated they will remove the combustible items as soon as they can and make sure they don't store any flammable items there again.
Anesthetizing Locations
Tag No.: K0323
Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.
Findings:
Record review showed the temperature and relativity logs showed the range for relative humidity to be 20-60% instead of 30-60% as required.
On 9/25/20 at 2:18pm the surveyor asked staff E why the temp and relative humidity logs showed 20-60%. Staff E stated they will correct the range to reflect 30-60% relative humidity.
Electrical Systems - Wet Procedure Locations
Tag No.: K0913
Based on observation and interview the facility failed to ensure the endoscopic wet procedure area was protected with GFCI or LIM as required.
Findings:
On 9/23/20 at 11:47am the surveyor observed the electrical receptacles in the endoscopic room were hospital grade electrical receptacles and not GFCI. The endoscopic area was not protected with line isolation monitoring or ground fault circuit interrupt devices as required for wet procedure location(s).
On 9/23/20 at 11:47am the surveyor asked staff E why there was no electrical protection built into the endoscopic procedure area. Staff E stated they did not know why but will get it corrected.
Electrical Systems - Maintenance and Testing
Tag No.: K0914
Based on record review and interview the facility failed to ensure annual impedance testing of patient care related electrical receptacles was completed as required.
Findings:
Record review showed impedance testing was not completed for the endoscopic area for 2018 and 2019.
On 9/23/20 at 12:00pm the surveyor asked staff D why the endoscopic areas were not tested for 2018 and 2019. Staff D stated the endoscopic area was closed for those periods but understands now that they will have to continue to maintain/test patient care related electrical receptacles.