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OPTIM MEDICAL CENTER - TATTNALL
No Description Available
Tag No.: K0012
Based on observation and staff tour, the facility failed to maintain their building construction type of II-000.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal wood studs above ceiling in emergency room area.
No Description Available
Tag No.: K0014
Based on observation and staff tour, the facility failed to maintain their interior wall finish in the sleep lab building in accordance with 19.3.3.1 and 19.3.3.2
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the interior wall finish in the sleep lab building exceeded class A flame spread rating of 0-25 and smoke development of 0-450.
No Description Available
Tag No.: K0017
Based on observation and staff tour, the facility failed to maintain their interior corridor door separation in the sleep building in accordance with 19.3.6.1 and 19.3.6.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal there was no door provide in the case door open in the interior corridor.
No Description Available
Tag No.: K0018
Based on observation and staff tour, the facility failed to maintain it fire rated interior corridor doors through out.
Finding are:
On facility tour between 10:00 am and 3:00 PM on 05/16/12, observation revealed multi fire rated doors through out facility were being chocked open by a door chock attached to the bottom of door.
No Description Available
Tag No.: K0025
Based on observation and staff tour, the facility failed to maintain their 1/2 hour fire rated smoke barrier.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal unprotected holes and penetration through the 1/2 hour fire rated smoke barrier.
On facility tour between 10:00 am and 08:30 PM on 05-16-12, and further review of construction plans, the existing smoke barrier was not maintain and a door open has been cut into the smoke barrier wall.
No Description Available
Tag No.: K0029
Based on observation and staff tour, the facility failed to maintain their hazardous areas in accordance with 19.3.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM, on 05-16-12, observation revealed unprotected holes and penetration through medical gas storage room, & several storage rooms.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal flammable and combustible material in laundry room area and not hazardous placard signage and emergency information posted on exterior side of doors.
No Description Available
Tag No.: K0038
Based on observation and staff tour, the facility failed to maintain their exits and egress in accordance with 19.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed combustible storage and medical equipment being kept in the interior exit corridor.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed key operated locks on egress side of exit doors in the emergency room area.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed key operated locks on egress side of exit doors in the sleep lab building.
No Description Available
Tag No.: K0042
Based on observation and staff tour, the facility failed to maintain 2 remote exit doors out of the physical therapy area.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the physical therapy area is over 1,000 square footage and there is not 2 remote exit doors provided.
No Description Available
Tag No.: K0046
Based on observation and staff tour, the facility failed to maintain their records and documentation on emergency lighting.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation and record review reveal that the facility is keeping records where each emergency light is being tested on a monthly for 30 min and a yearly basic for 1 1/2 hour.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal no emergency lighting in the sleep lab building.
No Description Available
Tag No.: K0047
Based on obseravtion and staff tour, the facility failed to maintain their exit lighting records and documention.
Finding are:
On facility tour between 10:00 am and 03:00 pm on 05-16-12, observation and record review reveal that the facility is not keeping records where they test each exit signage through out hospital and sleep lab building on a monthly basic.
On facility tour between 10:00 am and 03:00 pm on 05-16-12, observation reveal inadequated exit siganage in recovery area and x-ray area.
No Description Available
Tag No.: K0048
Based on observation and staff tour, the facility failed to provide training so employees know where their written plan for protection of all patients and for their evacuation in the event of an emergency.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation and staff interview employee in recovery area, and lab area did know where their written plan for evacuation and protection in the event of an emergency.
No Description Available
Tag No.: K0055
Based on observation and staff tour, the facility failed to provide a outside window or outside door for the sleeping rooms in the sleep lab building.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal no outside window nor outside door in the two sleep lab rooms in the sleep lab building.
No Description Available
Tag No.: K0056
Based on observation and staff tour, the facility failed to maintain a complete automatic sprinkler system through out building.
Finding are;
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the loading dock, the newly installed electrical room & the bathroom in the activity room area with out complete automatic sprinkler protection.
No Description Available
Tag No.: K0062
Based on observation and staff tour, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the automatic sprinkler piping above the suspend ceiling was being supported with plastic ties in several areas.
No Description Available
Tag No.: K0069
Based on observation and staff tour, the facility failed to maintain their cooking area in the physical therapy area in accordance with 19.5.2.2
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the kitchen stove in the physical therapy is not provide with automatic extinguisher system in which they cook on top of stove.
No Description Available
Tag No.: K0077
Based on observation and staff tour, the facility failed to maintain their medical gas piping in accordance with NFPA 99.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the medical gas piping above the suspend ceiling in several areas are not provide with any form of identification on piping.
No Description Available
Tag No.: K0106
Based on observation and staff tour, the facility failed to provide records and documentation where they are testing their Line isolation panel in accordance with NFPA 99.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation, staff interview and record review reveal that the facility is not testing, and keeping records on where they are testing their line isolation monitors in the operation rooms.
No Description Available
Tag No.: K0147
Based on observation and staff tour, the facility failed to maintain their electrical wiring and equipment in accordance with NFPA 70.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal electrical junction box covers off above the suspended ceiling through out.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal electrical conduit above suspended ceiling was not being supported in accordance with NFPA 70.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal open (knock out plug) in several electrical junction boxes above suspended ceiling.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal low voltage wring laying on top of suspended ceiling, draping over sprinkler piping and not being supported in accordance with NPPA 70 article 800.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal combustible storage inside the electrical rooms.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal no directory for electrical breaker in the newly building electrical room.
LIFE SAFETY CODE STANDARD
Tag No.: K0012
Based on observation and staff tour, the facility failed to maintain their building construction type of II-000.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal wood studs above ceiling in emergency room area.
LIFE SAFETY CODE STANDARD
Tag No.: K0014
Based on observation and staff tour, the facility failed to maintain their interior wall finish in the sleep lab building in accordance with 19.3.3.1 and 19.3.3.2
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the interior wall finish in the sleep lab building exceeded class A flame spread rating of 0-25 and smoke development of 0-450.
LIFE SAFETY CODE STANDARD
Tag No.: K0017
Based on observation and staff tour, the facility failed to maintain their interior corridor door separation in the sleep building in accordance with 19.3.6.1 and 19.3.6.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal there was no door provide in the case door open in the interior corridor.
LIFE SAFETY CODE STANDARD
Tag No.: K0018
Based on observation and staff tour, the facility failed to maintain it fire rated interior corridor doors through out.
Finding are:
On facility tour between 10:00 am and 3:00 PM on 05/16/12, observation revealed multi fire rated doors through out facility were being chocked open by a door chock attached to the bottom of door.
LIFE SAFETY CODE STANDARD
Tag No.: K0025
Based on observation and staff tour, the facility failed to maintain their 1/2 hour fire rated smoke barrier.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal unprotected holes and penetration through the 1/2 hour fire rated smoke barrier.
On facility tour between 10:00 am and 08:30 PM on 05-16-12, and further review of construction plans, the existing smoke barrier was not maintain and a door open has been cut into the smoke barrier wall.
LIFE SAFETY CODE STANDARD
Tag No.: K0029
Based on observation and staff tour, the facility failed to maintain their hazardous areas in accordance with 19.3.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM, on 05-16-12, observation revealed unprotected holes and penetration through medical gas storage room, & several storage rooms.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal flammable and combustible material in laundry room area and not hazardous placard signage and emergency information posted on exterior side of doors.
LIFE SAFETY CODE STANDARD
Tag No.: K0038
Based on observation and staff tour, the facility failed to maintain their exits and egress in accordance with 19.2.1
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed combustible storage and medical equipment being kept in the interior exit corridor.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed key operated locks on egress side of exit doors in the emergency room area.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation revealed key operated locks on egress side of exit doors in the sleep lab building.
LIFE SAFETY CODE STANDARD
Tag No.: K0042
Based on observation and staff tour, the facility failed to maintain 2 remote exit doors out of the physical therapy area.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the physical therapy area is over 1,000 square footage and there is not 2 remote exit doors provided.
LIFE SAFETY CODE STANDARD
Tag No.: K0046
Based on observation and staff tour, the facility failed to maintain their records and documentation on emergency lighting.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation and record review reveal that the facility is keeping records where each emergency light is being tested on a monthly for 30 min and a yearly basic for 1 1/2 hour.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal no emergency lighting in the sleep lab building.
LIFE SAFETY CODE STANDARD
Tag No.: K0047
Based on obseravtion and staff tour, the facility failed to maintain their exit lighting records and documention.
Finding are:
On facility tour between 10:00 am and 03:00 pm on 05-16-12, observation and record review reveal that the facility is not keeping records where they test each exit signage through out hospital and sleep lab building on a monthly basic.
On facility tour between 10:00 am and 03:00 pm on 05-16-12, observation reveal inadequated exit siganage in recovery area and x-ray area.
LIFE SAFETY CODE STANDARD
Tag No.: K0048
Based on observation and staff tour, the facility failed to provide training so employees know where their written plan for protection of all patients and for their evacuation in the event of an emergency.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation and staff interview employee in recovery area, and lab area did know where their written plan for evacuation and protection in the event of an emergency.
LIFE SAFETY CODE STANDARD
Tag No.: K0055
Based on observation and staff tour, the facility failed to provide a outside window or outside door for the sleeping rooms in the sleep lab building.
Finding are:
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal no outside window nor outside door in the two sleep lab rooms in the sleep lab building.
LIFE SAFETY CODE STANDARD
Tag No.: K0056
Based on observation and staff tour, the facility failed to maintain a complete automatic sprinkler system through out building.
Finding are;
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal the loading dock, the newly installed electrical room & the bathroom in the activity room area with out complete automatic sprinkler protection.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observation and staff tour, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the automatic sprinkler piping above the suspend ceiling was being supported with plastic ties in several areas.
LIFE SAFETY CODE STANDARD
Tag No.: K0069
Based on observation and staff tour, the facility failed to maintain their cooking area in the physical therapy area in accordance with 19.5.2.2
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the kitchen stove in the physical therapy is not provide with automatic extinguisher system in which they cook on top of stove.
LIFE SAFETY CODE STANDARD
Tag No.: K0077
Based on observation and staff tour, the facility failed to maintain their medical gas piping in accordance with NFPA 99.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal the medical gas piping above the suspend ceiling in several areas are not provide with any form of identification on piping.
LIFE SAFETY CODE STANDARD
Tag No.: K0106
Based on observation and staff tour, the facility failed to provide records and documentation where they are testing their Line isolation panel in accordance with NFPA 99.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation, staff interview and record review reveal that the facility is not testing, and keeping records on where they are testing their line isolation monitors in the operation rooms.
LIFE SAFETY CODE STANDARD
Tag No.: K0147
Based on observation and staff tour, the facility failed to maintain their electrical wiring and equipment in accordance with NFPA 70.
Finding are:
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal electrical junction box covers off above the suspended ceiling through out.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal electrical conduit above suspended ceiling was not being supported in accordance with NFPA 70.
On facility tour, between 10:00 am and 03:00 PM on 05-16-12, observation reveal open (knock out plug) in several electrical junction boxes above suspended ceiling.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal low voltage wring laying on top of suspended ceiling, draping over sprinkler piping and not being supported in accordance with NPPA 70 article 800.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal combustible storage inside the electrical rooms.
On facility tour between 10:00 am and 03:00 PM on 05-16-12, observation reveal no directory for electrical breaker in the newly building electrical room.