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Tag No.: K0020
Based on observation and interview with staff, the facility failed to enclose vertical openings between floors for pipe chases serving the patient toilet rooms with construction having a fire resistance rating of at least one hour. Findings,
The vertical openings between floors for patient toilet room pipe chases are not enclosed with construction having a fire resistance rating of at least one hour. The vertical openings between floors for the pipe chases are not sealed with construction capable of maintaining the fire resistance rating required for the floor to floor separation. The vertical openings from floor to floor condition is from the original construction.
Tag No.: K0052
Based upon observation, review of records and interview with staff, the facility failed to provide a fire alarm system required for life safety that is tested and maintained in accordance with NFPA 70 and 72.
Findings,
The smoke evacuation system for the Operating Room was not included on the report for the annual fire alarm test.
Tag No.: K0056
Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13, to provide complete coverage for all portions of the building. 19.3.5 Findings,
The Loading Dock, OB Room 1, 2nd floor EDS, and Respiratory does not have sprinkler coverage.
Tag No.: K0077
Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that complies with NFPA 99, Chapter 4. Findings,
Original Patient room Oxygen and Medical Air Gas Piping at the head wall above the ceiling was removed and replaced with 3/8 inch soft copper. The facility could not provide a re-certification of the modified piping.
Tag No.: K0130
1) Based upon observation and interview with staff, the facility failed to provide verification of tested medical equipment throughout the facility in accordance with NFPA 99, 1999 Edition, Chapter 7. Findings,
Per Chapter 7-6.2.1.1, the facility failed to ensure that all Medical Equipment, Surgical Instruments and Monitoring Equipment; as well as, electrical appliances used for the care and entertainment of the patient; purchased or otherwise acquired by the facility, is tested and maintained to meet standards. The facility failed to provide records of the testing of such instruments, equipment and appliances at the time of the Life Safety Code Survey. 7-6.3.1.2
Tag No.: K0133
Based on observation and interview with staff, the facility failed to ensure that Fume hoods are tested in accordance with NFPA 99. 5.4.3, 5.6.2 Findings,
The Micro- Biology room used in-conjunction with the fume hood was not tested to ensure that the room is negative in relationship with the adjacent hospital rooms or space.