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ST FRANCIS MEDICAL CENTER
Vertical Openings - Enclosure
Tag No.: K0311
Based on observation, it was determined that the facility failed to ensure vertical openings between floors are enclosed with construction having a fire resistive rating of at least 1-hour.
Findings include:
On 12/12/17 at 12:15 PM, in the presence of Staff #40 and Staff #41 in Room #C205, a gap existed between the floor and piping material providing an unprotected path for smoke and fire to travel between floors.
Alcohol Based Hand Rub Dispenser (ABHR)
Tag No.: K0325
Based on observation, it was determined that the facility failed to ensure alcohol based hand rub dispensers are installed in appropriate locations.
Findings include:
1. On 12/12/17 at 12:00 PM, in the presence of Staff #40 and Staff #41, an alcohol based hand rub dispenser was located over a light fixture in Room #263.
2. On 12/12/17 at 12:30 PM, in the presence of Staff #40 and Staff #41, an alcohol based hand rub dispenser was mounted in the Intensive Care Unit Waiting Room. This room has carpet installed on the floor and is located in an unsprinklered smoke compartment.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0374
Based on observation, it was determined that the facility failed to ensure smoke barrier doors are self-closing.
Findings include:
On 12/13/17 at 10:05 AM, in the presence of Staff #40 and Staff #41, a 30-minute labeled fire door, located between the Recovery Room and the ACC Area was held open with a wooden wedge.
Gas and Vacuum Piped Systems - Central Supply
Tag No.: K0905
Based on observations, it was determined that the facility failed to ensure rooms containing compressed gasses are properly labeled.
Findings include:
On 12/13/17 at 9:40 AM, in the presence of Staff #40 and Staff #41, the Medical Gas Room located outside the Emergency Department was not labeled with the following, "Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening."
Electrical Systems - Receptacles
Tag No.: K0912
Based on observation and staff interview, it was determined that the facility failed to ensure power receptacles in areas used to care for and treat pediatric patients are listed tamper-resistant or employ a listed cover.
Findings include:
1. On 12/12/17, during a tour of the Cares Units, power receptacles throughout Floor 3 and Floor 7 were not listed tamper-resistant or utilizing listed covers.
a. Staff #40 and Staff #41 confirmed this finding