HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a means suitable for keeping the door closed. Findings:

Several doors in the OB Wing, Rooms B,C, B-10, Clean Utility, and the Locker Room did not have latching hardware.

Based on observation, interview with staff and review of records, the facility failed to provide documentation that the fire alarm system is tested and maintained in accordance with NFPA 70 and 72. 9.6.1.4. Finding:

The most recent fire alarm inspection report provided was the quarterly report for 3/11/201l. .

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that provides complete coverage for all portions of the building requiring a sprinkler system. Findings:

There was not complete sprinkler system coverage provided in the OB Wing and the Nurse's Dressing Room of the sprinklered floor.

Based on observation, interview with staff and review of records, the facility failed to provide anesthetizing locations where relative humidity is maintained equal to or greater than 35%. Findings:

Logs of humidity levels for 2-9-2011 and 2-13-2011 recorded the humidity levels were not maintained equal to or greater than 35%. There is no documentation what, if any, actions were taken.

Based on observation and interview with staff, the facility failed to provide area alarms with audible and visible signals in all critical care locations. NFPA 99, 4.3.1.2.2(c)1 Findings:

There is not an area alarm in the nursery.

Based on observation and interview with staff, the facility failed to properly document the inspection and exercising under load for 30 minutes per month of the generators in accordance with NFPA 99, 3.4.4.1 Findings,

The generator log reports provided for the Detroit and Oman generators failed to document the amount of load tested to show that it was 30% or greater and with a simulated cold start and appropriate automatic and manual transfer of all essential electrical loads.

Based on observation and interview with staff, the facility failed to properly install and identify certain emergency outlets by color coding or other consistent identification in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings,

Room 204 did not have outlets marked or color coded as emergency power. Other rooms on the wing also did not have outlets marked or color coded as emergency power to be consistent with rooms on the west wing of the hospital.

Based on observation and interview with staff, the facility failed to provide a means suitable for keeping the door closed. Findings:

Several doors in the OB Wing, Rooms B,C, B-10, Clean Utility, and the Locker Room did not have latching hardware.

Based on observation, interview with staff and review of records, the facility failed to provide documentation that the fire alarm system is tested and maintained in accordance with NFPA 70 and 72. 9.6.1.4. Finding:

The most recent fire alarm inspection report provided was the quarterly report for 3/11/201l. .

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that provides complete coverage for all portions of the building requiring a sprinkler system. Findings:

There was not complete sprinkler system coverage provided in the OB Wing and the Nurse's Dressing Room of the sprinklered floor.

Based on observation, interview with staff and review of records, the facility failed to provide anesthetizing locations where relative humidity is maintained equal to or greater than 35%. Findings:

Logs of humidity levels for 2-9-2011 and 2-13-2011 recorded the humidity levels were not maintained equal to or greater than 35%. There is no documentation what, if any, actions were taken.

Based on observation and interview with staff, the facility failed to provide area alarms with audible and visible signals in all critical care locations. NFPA 99, 4.3.1.2.2(c)1 Findings:

There is not an area alarm in the nursery.

Based on observation and interview with staff, the facility failed to properly document the inspection and exercising under load for 30 minutes per month of the generators in accordance with NFPA 99, 3.4.4.1 Findings,

The generator log reports provided for the Detroit and Oman generators failed to document the amount of load tested to show that it was 30% or greater and with a simulated cold start and appropriate automatic and manual transfer of all essential electrical loads.

Based on observation and interview with staff, the facility failed to properly install and identify certain emergency outlets by color coding or other consistent identification in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings,

Room 204 did not have outlets marked or color coded as emergency power. Other rooms on the wing also did not have outlets marked or color coded as emergency power to be consistent with rooms on the west wing of the hospital.