HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide the required 18 inch clear (storage free) zone for multiple sprinkler heads located within the 1927 Support Services Building. The following rooms contained the storage violations:

1. RESPIRATORY THERAPY
2. STORAGE (near Lab Manager's office)
3. STORAGE CLOSET (across from Heritage Program Manager's Office)
4. MED RECORDS

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to properly secure the various medical gas cylinders in accordance with NFPA 99, 1999: 4-3.5.2.2(a).:
1. The reserve Oxygen cylinders located in the bulk oxygen area.
2. The smaller "E" cylinders located in the exterior medical gas storage area under roof.

1. Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide a log documenting the required semi-annual Electrical Equipment Inspections for Biomedical in the Critical Areas.

2. Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide a log documenting the required annual and semi-annual Electrical Power Distribution and Grounding Systems regarding Effectiveness in the General and Critical Areas respectively.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide an emergency generator log documenting the required weekly inspections, and the load test every 30 days.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide the required 18 inch clear (storage free) zone for multiple sprinkler heads located within the 1927 Support Services Building. The following rooms contained the storage violations:

1. RESPIRATORY THERAPY
2. STORAGE (near Lab Manager's office)
3. STORAGE CLOSET (across from Heritage Program Manager's Office)
4. MED RECORDS

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to properly secure the various medical gas cylinders in accordance with NFPA 99, 1999: 4-3.5.2.2(a).:
1. The reserve Oxygen cylinders located in the bulk oxygen area.
2. The smaller "E" cylinders located in the exterior medical gas storage area under roof.

1. Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide a log documenting the required semi-annual Electrical Equipment Inspections for Biomedical in the Critical Areas.

2. Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide a log documenting the required annual and semi-annual Electrical Power Distribution and Grounding Systems regarding Effectiveness in the General and Critical Areas respectively.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 5:30 pm, while accompanied by the CEO, CNO, Facilities Manager, and IT Manager the facility failed to provide an emergency generator log documenting the required weekly inspections, and the load test every 30 days.