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PUSHMATAHA COUNTY TOWN OF ANTLERS HOSPITAL
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 facility had one annual test and balance dated 07/28/16. The facility has two isolation rooms which are negatively ventilated and could not be verified if they currently meet ASHRAE 170-2008 ventilatory standards as required.
On 05/19/21 at 10:27am the surveyor asked staff J why they only have the one test and balance from 2016. Staff J stated they thought the test and balance was primarily for their surgical area which is not in operation but will get the two isolation rooms arranged to be inspected.
Cooking Facilities
Tag No.: K0324
Based on observation and interview the facility failed to ensure fire extinguisher(s) located in the kitchen had placard(s) displayed next to each one as required.
Findings:
On 05/20/21 at 11:22am the surveyor observed one ABC class fire extinguisher in the kitchen with no placard posted next to it as required.
On 05/20/21 at 11:22am the surveyor asked asked staff J why there was no placard on the ABC fire extinguisher when it was installed. Staff J stated they had inhouse staff install it and they probably were not aware of the requirement. Staff J stated they would get the appropriate placard installed for the fire extinguisher.
NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
Gas and Vacuum Piped Systems - Inspection and
Tag No.: K0908
Based on record review and interview the facility failed to ensure the medical gas system was inspected and maintained as required.
Findings:
Record review showed the facility did not complete an annual medial gas inspection for 2018 and 2019.
On 05/19/21 at 11:45am the survyeor asked staff J why there was no annual medical gas inspection for 2018 and 2019. Staff J stated they did not get to it but will get it corrected to be in compliance.