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PANA COMMUNITY HOSPITAL
No Description Available
Tag No.: K0012
Based on observation the facility failed to provide components of a building's designated construction type. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit stair and to a discharge on another floor.
Finding include:
On 02/22/2016 at 10:00 am, 3rd floor Center stair, the surveyor observed while accompanied by the facility F.D. and C.E.O., portions of the hospital which contain unprotected structural steel beams. This does not comply with the minimum construction type requirements of 19.1.6.2 and NFPA 220, 1999 Edition.
No Description Available
Tag No.: K0046
Based on document review the facility does not maintain proper records of required testing. This could effect anybody having surgery if the battery lights did not work upon loss of power.
Findings include:
On 2/22/16 at 2:45 pm, the surveyor observed during document review, while accompanied by the CEO and the FD, that records were not available showing that battery lights were tested for 30 seconds each month and for 90 minutes annually in accordance with the 2000 Edition of NFPA-101, Section 7.9.3.
No Description Available
Tag No.: K0067
Based on observation, the facility failed to provide a completely enclosed ventilation system. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
Finding includes:
On 02/22/2016 at 10:30am, 2nd floor, while accompanied by the facility F.D. and C.E.O., the surveyor observed a duct penetration through the fire rated smoke barrier which was not installed as required by the duct/damper manufacturer. Location observed above the ceiling at the pair of cross corridor doors leading into surgery. This installation does not comply with 19.3.7.3 exception no. 2 and NFPA 90A .
No Description Available
Tag No.: K0130
A. Due to the number, variety, and severity of the life safety code deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.
B. On 02/22/2016 at 12:45 pm, 1st floor negative pressure patient room ante room, the surveyor observed while accompanied by the F.D. and C.E.O., a faucet mounted temperature pressure regulator installed over a sink which does not comply with ANSI Z358.1-1998.
No Description Available
Tag No.: K0160
Based on observation, the facility failed to provide an elevator recall system. This could effect anybody using the elevator during a fire.
Findings include:
On 2/22/16 at 2:30 pm, while accompanied by the CEO and the FD, the surveyor observed that the elevators were not equipped with a recall system to meet the requirements of ANSI/ASME A 17.1.