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HARNEY DISTRICT HOSPITAL
Sprinkler System - Installation
Tag No.: K0351
Based on observations during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the lower hallway of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (NFPA 13, Standard for Installation of Sprinkler Systems. Findings include, but are not limited to:
On 04/25/2017, at 1500 hours, there were fire sprinkler heads in the lower hallway that were too close together (less than 6" apart) which had the potential for Cold Fusion in the event of an activation during a fire.
Health Care Facilities Code - Other
Tag No.: K0900
Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure that Relative Humidity Levels were in accordance to NFPA 99 and S&C Letter 15-27 regarding acceptable RH Levels in accordance with Manufacturer's IFU's (Instructions For Use) in anesthetizing locations. This reulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
On 04/26/2017, during record review, the facility's anesthetizing Operating Rooms #1 and #2 had 25 instances of RH levels below 30% within the past 3 months without supporting documentation stating that the electrical equipment within the OR's can withstand the lower RH levels.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to provide safe storage for compressed gas in one birthing suite within the facility. This resulted in the potential for injury to staff, guests and patients from a damaged compressed gas cylinder releasing unexpectedly. Findings include, but were not limited to:
On 04/25/2017, at 1028 hours, there was an "H" sized medical air cylinder within the OB Birthing Suite #2.