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SARAH D CULBERTSON MEMORIAL HOSPITAL
Emergency Lighting
Tag No.: K0291
Based on document review testing of the battery powered emergency lighting systems was not conducted as required. Failure to properly perform maintenance activities can result in failure of the required lighting systems during an emergency event.
Findings include:
On July 18, 2023, at 12:30 pm while in the company of the FMD and DQIRM it was determined that the documentation for monthly 30-second and annual 90-minute tests for the Battery-Operated Emergency Lights in accordance with Sections 19.2.9.1 & 7.9.3 is not available for review.
Hazardous Areas - Enclosure
Tag No.: K0321
Based upon observation hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.
Findings include:
On July 18, 2023, at 12:15pm while in the company of the FMD and DQIRM it was observed that the Soiled Holding between Radiology and E.D. is being used for storage of combustible materials. It was also observed that the room was not sprinklered and that the enclosure does not meet the 1-hour fire rated construction requirements to comply with Section 19.3.2.1 due to the door serving the room not self-latching.
Gas and Vacuum Piped Systems - Other
Tag No.: K0902
Based on observation the facility lacks complete electrical bonding of the piped medical gas system. Failure to install and maintain the required bonding could result in the system becoming electrically energized. This deficient practice could affect the safety of all patients, staff, and visitors.
Findings include:
On July 18, 2023, at 1:15 pm while in the company of the FMD and DQIRM it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping has been completed. Therefore, the installation is not in compliance with 2011 NFPA 70, Section 250.104(B).
Electrical Systems - Receptacles
Tag No.: K0912
Based on observation ground fault circuit interruption (GFCI) is not provided in accordance with code requirements. If GFCI protection is not provided as required, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.
Findings include:
On July 18, 2023, while in the company of the FMD and DQIRM it was observed that several electrical receptacles are not provided with GFCI protection in accordance with 2011 NFPA 70, Section 210.8(B).
Locations observed:
1. at 12:15pm in Soiled Holding between Radiology and E.D.
2. The condition was noted as typical in Toilet Rooms within Patient Rooms throughout the facility.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on document review the required weekly essential electrical equipment visual inspection is not being conducted. Failure to properly perform the required maintenance activities can result in failure of the generator during a utility outage.
Findings include:
On July 18, 2023, at 12:15pm while in the company of the FMD and DQIRM it was determined that the documentation for weekly visual inspections of the generator in accordance with 2010 NFPA 110, Section 8.4.1 is not available for review.