HospitalInspections.org

A) (Modified 9/23/09) 4th Floor Lab Waiting Area, Lab Reception Area: The Reception Area is open to the corridor and Waiting Area and is open to the means of egress for two patient areas. The Reception Area is not staffed 24/7. The Reception Area and Waiting Area do not comply with exception # 6 of 19.3.6.1. (no smoke detection throughout and no 24 hour supervision or, alternately, sprinkler protection in place of supervision).

Surveyor 14290
Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Corrected 1/21/09

B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. Sixth Floor Respiratory Care Storage
Room. Surveyor 14290 notes that
this door was also observed to be
installed in a wood frame. 8/13/08: A
fire rated door assembly (door, frame
and hardware) is not provided in
accordance with 19.3.2.1

(Modified 9/23/09): The door installed
is not a 3/4 hour fire rated door. The
frame is not installed in accordance with
mfr requirements for a fire rated door
frame and the wall construction is
incomplete.


Surveyor 07113

A) Corrected 1/21/09
B) Corrected 1/21/09
C) Corrected 1/22/09
D) Corrected 5/20/09
E) Corrected 9/23/09

F) (New 9/23/09) 7th Floor Storage room door next to Stair # 5 lacks self closing hardware.

Surveyor 20224

G) NEW 03/08/10 7th Floor Holding room in O.R. Suite is being used for storage and lacks one hour rated wall enclosure along with a fire rated self closing door.

H) NEW 03/08/10 7th Floor Recovery room in O.R. Suite appears to be used for a dual purpose due to the following:
1. Due to the amount of material and equipment stored within the room. This room appears to be used as storage and lacks the one hour rated wall enclosure and a fire rated self closing door.





14290


Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Corrected 1/21/09

B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. Sixth Floor Respiratory Care Storage
Room. Surveyor 14290 notes that
this door was also observed to be
installed in a wood frame. 8/13/08: A
fire rated door assembly (door, frame
and hardware) is not provided in
accordance with 19.3.2.1

(Modified 9/23/09): The door installed
is not a 3/4 hour fire rated door. The
frame is not installed in accordance with
mfr requirements for a fire rated door
frame and the wall construction is
incomplete.

A) Corrected 9/23/09
B) Corrected 1/21/09
C) Corrected 1/21/09
D) Corrected 9/23/09
E) Deleted 5/20/09
F) 1) Corrected 03/08/10
2) Corrected 9/23/09
3) Corrected 03/08/10
4) Corrected 9/23/09
G) Corrected 9/23/09
H) Corrected 03/08/10


14290


Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Exit Stair 3 was observed to discharge, at the Main Floor, interior to the building as prohibited by 7.7.1.

B. 1. Corrected 03/08/10



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F. Doors in exit access corridors were observed that are equipped with thumbturn
deadbolt retractors, which require more than one releasing mechanism operation to exit
the room as prohibited by 7.2.1.5.4. Locations observed include:

1. 7th Floor:

a. Corrected 9/23/09

b. Storage Room between O.R.#1 and O.R. #2. UPDATE 03/08/2010: This storage room door lacks a strike plate in the door frame, therefore it remains as a deficient latching door. Further, this door to a storage room is not self closing to comply with 19.3.2.1.

c. Corrected 03/08/10.
d. Corrected 03/08/10

2. 4th Floor West

a. Corrected 9/23/09
b. Corrected 9/23/09
c. Corrected 9/23/09
d. Corrected 9/23/09
e. Corrected 9/23/09
f. Corrected 9/23/09
g. Corrected 03/08/10

3. Corrected 9/23/09

4. 3rd Floor (all East Wing):

a. Corrected 9/23/09
b. Corrected 9/23/09
c. Corrected 9/23/09
d. Corrected 03/08/10

G. Rooms were observed to be equipped with deadbolts that permit the doors to be locked in a manner which prevents egress, as prohibited by 7.2.1.5.1. Locations observed include (all 7th Floor):

1. West Wing::

a. Corrected 9/23/09
b. Corrected 9/23/09

c. Storage Room door next to Stair 6

d. Corrected 9/23/09
e. Corrected 9/23/09
f. Corrected 9/23/09

2. Corrected 03/08/10.

3. O.R. Women's Locker Room (Modified
1/21/09: the door from the locker room
to the semi restricted corridor lacks
positive latching corridor and the door
has a dead bolt lock.

4. NEW 03/08/2010: Soiled Utility Door does not close upon latching

A. During an interview held at the site on the morning of September 25, 2007, the provider's Associate Vice President for Support Services stated that the Fifth Floor Intensive Care Unit constitutes a suite of rooms. The following deficiencies were observed at this Unit:
1. Corrected 03/08/10

Surveyor 20224

2. Corrected 03/08/2010
3. Corrected 03/08/2010

B) NEW 03/10/2010: Surveyor observed that the ICU Suite is a large unsprinklered area with both required exits located at the same end of suite. The surveyor finds from the available life safety floor plans that the two exit paths from this unit are not remote to comply with 7.5.1.4.

A. Deleted 01/26/09
B) Corrected 9/23/09
1) Corrected 5/20/09
C) Corrected 5/20/09
D) Deleted 1/21/09
E) Corrected 5/20/09


Surveyor 20224

F) NEW 03/08/2010: The facility is considered a high rise by the Life Safety Code, it is not fully smoke detected or sprinkler protected. From Document review and staff interview it appears that the facility staff are not aware of the location of Fire Barriers on each floor for the safe evacuation of patients from one compartment to the next. During review of the Fire Drill logs, the surveyor noted that the fire drill conducted on 02/18/2010 and 02/24/2010 both contained notes written by staff who declared that they did not know where the fire barrier is located.


14290


A. During a review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical building components, key building data, or elements of these systems not shown on currently maintained floor plans include (but are not necessarily limited to):

2. Building construction type information by
building and/or by floor

6. Shaft enclosures and their fire resistance
ratings, including exit stairs, exit
discharge enclosures, elevators,
ventilation shafts, and linen and/or
refuse chute shafts.

8. Exit access corridors and designated
corridor walls.

10. Hazardous areas and their fire resistance
ratings.

A. (Modified 10/24/08): The fire pump is not tested annually, including a test on emergency power in accordance with the procedures identified under 5.3.3.4 of NFPA 25-1998.

1/21/09: The documentation for the annual testing is fragmented and does not indicate that the emergency power test (four questions)occurred at the same time as the full flow fire pump test.

A) New 03/08/10 It could not be demonstrated that an evaluation and a policy/procedure for the placement and replacement of the appropriate class of fire extinguisher (A, B, C) related to the potential class of fire hazard has been completed.
Upon observation and staff interview it appears that the facility contains a number of Class A fire extinguishers. From documentation, the specific location for a class of fire extinguisher in relation to the type of hazard it is appropriate to be used for is unknown. Therefore, the misuse of a Class A fire extinguisher on a Class C type of fire is possible which does not comply with NFPA 10 1998, 4-4.1.4. For example:

1) Review of the fire watch documentation indicates that on January 4, 2010 , a fire extinguisher is missing, this is written again January 10, 2010, February 27, 2010 and March 3, 2010 from both the 7th and 8th floors. It is unknown what Class extinguisher is missing and if it has been replaced.

2) Review of the fire watch documentation indicates that during January and February a general note "all extinguishers need to be updated" was written. During staff interview, there is no explanation for the note and no one was aware of the written statement and what it pertains to.


B) New 03/08/10 Based upon random observation, and personnel interview, the surveyor finds that fire extinguishers lack adequate documentation to support annual maintenance to comply with NFPA 10-1998, Chapter 4.

1) It is unknown if the in-house inspector is a trained technician to comply with NFPA 10 1998, 4-1.2 and 4-4 for qualifications of a yearly maintenance inspector.

2) The documentation used for the monthly inspection appears to be used as the yearly inspection and does not indicate the specific maintenance performed on each individual fire extinguisher to comply with 4-3.1 and 4-3.2 for a monthly inspection or 4-3.4.1, and 4-4.2 for yearly maintenance.

Based on random observation during the survey walk-through, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.
Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Surveyor 07113 (Modified 9/23/09): Most but not all of the deficiencies that require interim measures have been corrected. Interim measures are required for remaining deficiencies and must be enhanced as needed, until all items are corrected.
1. Corrected 9/23/09
2. Corrected 9/23/09
3. Corrected 9/23/09

C. Deleted 1/21/09

D. Corrected 9/23/09

E) (New 9/23/09) (From Complaint 092576): There is a single, common, patient shower in the 5th Floor Telemetry Unit. This shower is not maintained as a safe and sanitary environment for patients. The surveyor observed mold growing in the grout lines of the lower shower walls and in the floor just outside of the shower. The mold is evidence of lack of adequate housekeeping in this space.


Surveyor 20224

F). New 03/08/10 By staff interview and observation the surveyor finds the following conditions are not met A722: CFR (Code of Federal Regulations) 482.41(c) Except as otherwise provided in this section, the hospital must maintain adequate facilities for its services.
1. Ground floor level Physical Therapy suite, surveyor observed that the faucet in the Women's bathroom lacks hot water.


G) New 03/08/10 By direct observation the surveyor finds that the following condition is not met A723: CFR 482.41?(1) Diagnostic and therapeutic facilities must be located for the safety of patients. Diagnostic and therapeutic facilities must be in rooms or areas specifically designed for the purpose intended.
1. Physical Therapy room is located on the floor level below the level of exit discharge. Exiting from the Physical Therapy area requires the use of stairs (Stair #1 and Stair #2) up to the above floor level (elevators are unacceptable means of emergency egress). It is unsure where the area of refuge is located or how patients are provided for during an emergency (refer to K-Tag 048 item F).

2. Physical Therapy room - Women's Bathroom, From direct observation, the square footage of the room, the swing of the entry door, the location and type of toilet grab bars within this room does not comply with the Americans with Disabilities Act. The layout of this room does not appear to provide for the purpose intended, use by the physically disabled.


H) New 03/08/10 By direct observation the surveyor finds that the following condition is not met A725: CFR 482.41?(3) The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. 7th Floor O.R. Suite Recovery room lacks much of what meets minimum state requirements:
a. Entry to the room does not facilitate one way flow.
b. Minimum of one bed per O.R. with 4 ' -0 " clearance on the sides and
6 ' -0 " clearance at the foot.
c. Adequate storage and work space.
d. Each bed equipped with oxygen, suction and at least one duplex outlet.
e. When ambulatory surgery is performed using local anesthetics, a room separate from the general recovery is set aside.

A) Corrected 9/23/09

B) (New 9/23/09): Electrical Room/Old Boiler Room: Access to electrical panels and/or switchgear was blocked by storage. A minimum of 3'-0" of clear space is not maintained: Locations include but are not necessarily limited the locations shown in the photographs attached (taken on 9/23/09) and labeled as Pic # 1 through Pic # 5.

C) Corrected 03/08/2010


14290


A. Corrected 8/13/08
B. Corrected 9/23/09

A) (New 8/13/08): Elevator # 4 at the 7th Floor elevator foyer lacks smoke detection. Based upon this and based upon personnel interview, the surveyors finds that this elevator does not comply with the automatic recall provisions of ANSI A17.3.

B) (New 8/13/08): The elevator that was identified as the "freight elevator" lacks automatic recall in accordance with the provisions of ANSI A17.3.

A) (Modified 9/23/09) 4th Floor Lab Waiting Area, Lab Reception Area: The Reception Area is open to the corridor and Waiting Area and is open to the means of egress for two patient areas. The Reception Area is not staffed 24/7. The Reception Area and Waiting Area do not comply with exception # 6 of 19.3.6.1. (no smoke detection throughout and no 24 hour supervision or, alternately, sprinkler protection in place of supervision).

Surveyor 14290
Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Corrected 1/21/09

B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. Sixth Floor Respiratory Care Storage
Room. Surveyor 14290 notes that
this door was also observed to be
installed in a wood frame. 8/13/08: A
fire rated door assembly (door, frame
and hardware) is not provided in
accordance with 19.3.2.1

(Modified 9/23/09): The door installed
is not a 3/4 hour fire rated door. The
frame is not installed in accordance with
mfr requirements for a fire rated door
frame and the wall construction is
incomplete.


Surveyor 07113

A) Corrected 1/21/09
B) Corrected 1/21/09
C) Corrected 1/22/09
D) Corrected 5/20/09
E) Corrected 9/23/09

F) (New 9/23/09) 7th Floor Storage room door next to Stair # 5 lacks self closing hardware.

Surveyor 20224

G) NEW 03/08/10 7th Floor Holding room in O.R. Suite is being used for storage and lacks one hour rated wall enclosure along with a fire rated self closing door.

H) NEW 03/08/10 7th Floor Recovery room in O.R. Suite appears to be used for a dual purpose due to the following:
1. Due to the amount of material and equipment stored within the room. This room appears to be used as storage and lacks the one hour rated wall enclosure and a fire rated self closing door.





14290


Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Corrected 1/21/09

B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. Sixth Floor Respiratory Care Storage
Room. Surveyor 14290 notes that
this door was also observed to be
installed in a wood frame. 8/13/08: A
fire rated door assembly (door, frame
and hardware) is not provided in
accordance with 19.3.2.1

(Modified 9/23/09): The door installed
is not a 3/4 hour fire rated door. The
frame is not installed in accordance with
mfr requirements for a fire rated door
frame and the wall construction is
incomplete.

A) Corrected 9/23/09
B) Corrected 1/21/09
C) Corrected 1/21/09
D) Corrected 9/23/09
E) Deleted 5/20/09
F) 1) Corrected 03/08/10
2) Corrected 9/23/09
3) Corrected 03/08/10
4) Corrected 9/23/09
G) Corrected 9/23/09
H) Corrected 03/08/10


14290


Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Exit Stair 3 was observed to discharge, at the Main Floor, interior to the building as prohibited by 7.7.1.

B. 1. Corrected 03/08/10



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F. Doors in exit access corridors were observed that are equipped with thumbturn
deadbolt retractors, which require more than one releasing mechanism operation to exit
the room as prohibited by 7.2.1.5.4. Locations observed include:

1. 7th Floor:

a. Corrected 9/23/09

b. Storage Room between O.R.#1 and O.R. #2. UPDATE 03/08/2010: This storage room door lacks a strike plate in the door frame, therefore it remains as a deficient latching door. Further, this door to a storage room is not self closing to comply with 19.3.2.1.

c. Corrected 03/08/10.
d. Corrected 03/08/10

2. 4th Floor West

a. Corrected 9/23/09
b. Corrected 9/23/09
c. Corrected 9/23/09
d. Corrected 9/23/09
e. Corrected 9/23/09
f. Corrected 9/23/09
g. Corrected 03/08/10

3. Corrected 9/23/09

4. 3rd Floor (all East Wing):

a. Corrected 9/23/09
b. Corrected 9/23/09
c. Corrected 9/23/09
d. Corrected 03/08/10

G. Rooms were observed to be equipped with deadbolts that permit the doors to be locked in a manner which prevents egress, as prohibited by 7.2.1.5.1. Locations observed include (all 7th Floor):

1. West Wing::

a. Corrected 9/23/09
b. Corrected 9/23/09

c. Storage Room door next to Stair 6

d. Corrected 9/23/09
e. Corrected 9/23/09
f. Corrected 9/23/09

2. Corrected 03/08/10.

3. O.R. Women's Locker Room (Modified
1/21/09: the door from the locker room
to the semi restricted corridor lacks
positive latching corridor and the door
has a dead bolt lock.

4. NEW 03/08/2010: Soiled Utility Door does not close upon latching

A. During an interview held at the site on the morning of September 25, 2007, the provider's Associate Vice President for Support Services stated that the Fifth Floor Intensive Care Unit constitutes a suite of rooms. The following deficiencies were observed at this Unit:
1. Corrected 03/08/10

Surveyor 20224

2. Corrected 03/08/2010
3. Corrected 03/08/2010

B) NEW 03/10/2010: Surveyor observed that the ICU Suite is a large unsprinklered area with both required exits located at the same end of suite. The surveyor finds from the available life safety floor plans that the two exit paths from this unit are not remote to comply with 7.5.1.4.

A. Deleted 01/26/09
B) Corrected 9/23/09
1) Corrected 5/20/09
C) Corrected 5/20/09
D) Deleted 1/21/09
E) Corrected 5/20/09


Surveyor 20224

F) NEW 03/08/2010: The facility is considered a high rise by the Life Safety Code, it is not fully smoke detected or sprinkler protected. From Document review and staff interview it appears that the facility staff are not aware of the location of Fire Barriers on each floor for the safe evacuation of patients from one compartment to the next. During review of the Fire Drill logs, the surveyor noted that the fire drill conducted on 02/18/2010 and 02/24/2010 both contained notes written by staff who declared that they did not know where the fire barrier is located.


14290


A. During a review of the facility's fire protection plan documents, it was determined that the facility has not prepared and maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical building components, key building data, or elements of these systems not shown on currently maintained floor plans include (but are not necessarily limited to):

2. Building construction type information by
building and/or by floor

6. Shaft enclosures and their fire resistance
ratings, including exit stairs, exit
discharge enclosures, elevators,
ventilation shafts, and linen and/or
refuse chute shafts.

8. Exit access corridors and designated
corridor walls.

10. Hazardous areas and their fire resistance
ratings.

A. (Modified 10/24/08): The fire pump is not tested annually, including a test on emergency power in accordance with the procedures identified under 5.3.3.4 of NFPA 25-1998.

1/21/09: The documentation for the annual testing is fragmented and does not indicate that the emergency power test (four questions)occurred at the same time as the full flow fire pump test.

A) New 03/08/10 It could not be demonstrated that an evaluation and a policy/procedure for the placement and replacement of the appropriate class of fire extinguisher (A, B, C) related to the potential class of fire hazard has been completed.
Upon observation and staff interview it appears that the facility contains a number of Class A fire extinguishers. From documentation, the specific location for a class of fire extinguisher in relation to the type of hazard it is appropriate to be used for is unknown. Therefore, the misuse of a Class A fire extinguisher on a Class C type of fire is possible which does not comply with NFPA 10 1998, 4-4.1.4. For example:

1) Review of the fire watch documentation indicates that on January 4, 2010 , a fire extinguisher is missing, this is written again January 10, 2010, February 27, 2010 and March 3, 2010 from both the 7th and 8th floors. It is unknown what Class extinguisher is missing and if it has been replaced.

2) Review of the fire watch documentation indicates that during January and February a general note "all extinguishers need to be updated" was written. During staff interview, there is no explanation for the note and no one was aware of the written statement and what it pertains to.


B) New 03/08/10 Based upon random observation, and personnel interview, the surveyor finds that fire extinguishers lack adequate documentation to support annual maintenance to comply with NFPA 10-1998, Chapter 4.

1) It is unknown if the in-house inspector is a trained technician to comply with NFPA 10 1998, 4-1.2 and 4-4 for qualifications of a yearly maintenance inspector.

2) The documentation used for the monthly inspection appears to be used as the yearly inspection and does not indicate the specific maintenance performed on each individual fire extinguisher to comply with 4-3.1 and 4-3.2 for a monthly inspection or 4-3.4.1, and 4-4.2 for yearly maintenance.

Based on random observation during the survey walk-through, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.
Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Surveyor 07113 (Modified 9/23/09): Most but not all of the deficiencies that require interim measures have been corrected. Interim measures are required for remaining deficiencies and must be enhanced as needed, until all items are corrected.
1. Corrected 9/23/09
2. Corrected 9/23/09
3. Corrected 9/23/09

C. Deleted 1/21/09

D. Corrected 9/23/09

E) (New 9/23/09) (From Complaint 092576): There is a single, common, patient shower in the 5th Floor Telemetry Unit. This shower is not maintained as a safe and sanitary environment for patients. The surveyor observed mold growing in the grout lines of the lower shower walls and in the floor just outside of the shower. The mold is evidence of lack of adequate housekeeping in this space.


Surveyor 20224

F). New 03/08/10 By staff interview and observation the surveyor finds the following conditions are not met A722: CFR (Code of Federal Regulations) 482.41(c) Except as otherwise provided in this section, the hospital must maintain adequate facilities for its services.
1. Ground floor level Physical Therapy suite, surveyor observed that the faucet in the Women's bathroom lacks hot water.


G) New 03/08/10 By direct observation the surveyor finds that the following condition is not met A723: CFR 482.41?(1) Diagnostic and therapeutic facilities must be located for the safety of patients. Diagnostic and therapeutic facilities must be in rooms or areas specifically designed for the purpose intended.
1. Physical Therapy room is located on the floor level below the level of exit discharge. Exiting from the Physical Therapy area requires the use of stairs (Stair #1 and Stair #2) up to the above floor level (elevators are unacceptable means of emergency egress). It is unsure where the area of refuge is located or how patients are provided for during an emergency (refer to K-Tag 048 item F).

2. Physical Therapy room - Women's Bathroom, From direct observation, the square footage of the room, the swing of the entry door, the location and type of toilet grab bars within this room does not comply with the Americans with Disabilities Act. The layout of this room does not appear to provide for the purpose intended, use by the physically disabled.


H) New 03/08/10 By direct observation the surveyor finds that the following condition is not met A725: CFR 482.41?(3) The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. 7th Floor O.R. Suite Recovery room lacks much of what meets minimum state requirements:
a. Entry to the room does not facilitate one way flow.
b. Minimum of one bed per O.R. with 4 ' -0 " clearance on the sides and
6 ' -0 " clearance at the foot.
c. Adequate storage and work space.
d. Each bed equipped with oxygen, suction and at least one duplex outlet.
e. When ambulatory surgery is performed using local anesthetics, a room separate from the general recovery is set aside.

A) Corrected 9/23/09

B) (New 9/23/09): Electrical Room/Old Boiler Room: Access to electrical panels and/or switchgear was blocked by storage. A minimum of 3'-0" of clear space is not maintained: Locations include but are not necessarily limited the locations shown in the photographs attached (taken on 9/23/09) and labeled as Pic # 1 through Pic # 5.

C) Corrected 03/08/2010


14290


A. Corrected 8/13/08
B. Corrected 9/23/09

A) (New 8/13/08): Elevator # 4 at the 7th Floor elevator foyer lacks smoke detection. Based upon this and based upon personnel interview, the surveyors finds that this elevator does not comply with the automatic recall provisions of ANSI A17.3.

B) (New 8/13/08): The elevator that was identified as the "freight elevator" lacks automatic recall in accordance with the provisions of ANSI A17.3.