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Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning equipment installed in accordance with the manufacturer's specifications. 9.2, 18.5.2.1, 18.5.2.2, NFPA 90A. Findings include:

a) A counter top air conditioning unit installed on the counter top in the lab was providing additional method of cooling. This unit was installed because the HVAC unit is to small and is over come by all the heat producing equipment of the lab. The unit is also not provided with a 80% efficient air filter.

1) Based on observation and interview staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, 1999 Edition Chapter 12. Findings include:

a) Rules and Regulations required to be posted in accordance with NFPA 99 chapter 12-4.1.1.4 for control of personal in the Operating Rooms was not posted in the operating rooms. Rules and Regulations were found posted in the semi restricted corridor. This was verified by the Director of Surgery and Director of Engineering.

1) Based on observation and interview with staff, the facility failed to provide the Hospitals with Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) The emergency Transfer Switch is not provided with 90 minute battery back up lighting over the switch in the room housing the switch, adjacent to the boiler room. This was verified by the Director of Engineering.

Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The Two Anesthesia Machines located in the Operating Rooms were tested yearly. This was verified by the Medical Device stickers located on the unit and interview with the Director of Surgery. NFPA 99 1999 edition chapter 7-6.2.1.2 establishes and requires all patient care equipment in critical care areas to be re-tested every 6 months. During the entrance conference with the CEO and the Director of Engineering, the two individuals was asked if the facility was engaged with any waivers, or any alternative methods of compliance. Interpretive Guidelines Appendix A , 485.623(b) Standard: Maintenance allows for Alternate Equipment Management (AEM) Program, this allows for equipment to tested yearly instead of every 6 months, if the facility has documented data, however documented data was not presented or recommended to the governing body for approval and implementation.

Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning equipment installed in accordance with the manufacturer's specifications. 9.2, 18.5.2.1, 18.5.2.2, NFPA 90A. Findings include:

a) A counter top air conditioning unit installed on the counter top in the lab was providing additional method of cooling. This unit was installed because the HVAC unit is to small and is over come by all the heat producing equipment of the lab. The unit is also not provided with a 80% efficient air filter.

1) Based on observation and interview staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, 1999 Edition Chapter 12. Findings include:

a) Rules and Regulations required to be posted in accordance with NFPA 99 chapter 12-4.1.1.4 for control of personal in the Operating Rooms was not posted in the operating rooms. Rules and Regulations were found posted in the semi restricted corridor. This was verified by the Director of Surgery and Director of Engineering.

1) Based on observation and interview with staff, the facility failed to provide the Hospitals with Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) The emergency Transfer Switch is not provided with 90 minute battery back up lighting over the switch in the room housing the switch, adjacent to the boiler room. This was verified by the Director of Engineering.

Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The Two Anesthesia Machines located in the Operating Rooms were tested yearly. This was verified by the Medical Device stickers located on the unit and interview with the Director of Surgery. NFPA 99 1999 edition chapter 7-6.2.1.2 establishes and requires all patient care equipment in critical care areas to be re-tested every 6 months. During the entrance conference with the CEO and the Director of Engineering, the two individuals was asked if the facility was engaged with any waivers, or any alternative methods of compliance. Interpretive Guidelines Appendix A , 485.623(b) Standard: Maintenance allows for Alternate Equipment Management (AEM) Program, this allows for equipment to tested yearly instead of every 6 months, if the facility has documented data, however documented data was not presented or recommended to the governing body for approval and implementation.