HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 7/16/2014, accompanied by the Director of Plant Operations, the facility failed to provide an exit sign marking the exit path at two locations: 1) in the adult male wing and 2) in the administration suite. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on review of records during the survey of facility on the afternoon of 7/16/2014, attended by the Director of Plant Operations, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually. Currently there are no critical care areas. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the afternoon of 7/16/2014, accompanied by the Director of Plant Operations, the facility failed to assure that the essential electrical system was in full compliance. CCTV and motion curtain (circuits 4, 5 & 9) were powered by the life safety branch of the essential electrical system. This panel was located at first floor's electrical room, near wings 100 & 300. This equipment should be powered from another branch panel.

The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment:

1. Illumination of means of egress as required in NFPA 101, Life Safety Code;

2. Exit signs and exit direction signs required in NFPA 101, Life safety Code;

3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;"

4. communication systems, where used for issuing instruction during emergency conditions;

5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location;

6. Elevator ...

7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations during the survey walk of the facility on the afternoon of 7/16/2014, accompanied by the Director of Plant Operations, the facility failed to provide an exit sign marking the exit path at two locations: 1) in the adult male wing and 2) in the administration suite. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on review of records during the survey of facility on the afternoon of 7/16/2014, attended by the Director of Plant Operations, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually. Currently there are no critical care areas. Facility must initiate a log to retain these records.

Based on observations during the survey walk of the facility on the afternoon of 7/16/2014, accompanied by the Director of Plant Operations, the facility failed to assure that the essential electrical system was in full compliance. CCTV and motion curtain (circuits 4, 5 & 9) were powered by the life safety branch of the essential electrical system. This panel was located at first floor's electrical room, near wings 100 & 300. This equipment should be powered from another branch panel.

The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment:

1. Illumination of means of egress as required in NFPA 101, Life Safety Code;

2. Exit signs and exit direction signs required in NFPA 101, Life safety Code;

3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;"

4. communication systems, where used for issuing instruction during emergency conditions;

5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location;

6. Elevator ...

7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.