HospitalInspections.org

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that the smoke barrier had penetrations all along the extent of the barrier. These must be sealed from both sides of the barrier.

Based on observation the facility failed to provide adequate hazardous area enclosures.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were the following issues.

A. The following spaces did not have adequate latching of the doors: 1) ED Equipment Storage, 2) Med/Surge Equipment Storage, 3) PBX Storage, 4) Maintenance, and 5) Housekeeping #4.
B. The following spaces did not have closers: 1) Med/Surge Supply, and 2) Clean Linen.
C. The following spaces had a penetrations in the ceiling: 1) Housekeeping/Clean Supply Room, and 2) PBX Storage.

Based on observation the facility failed to maintain an adequate fire sprinkler system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were missing escutcheon plates in the following areas: 1) Rad X-Ray room, and 2) Doctor ' s Lounge.

Also, there was storage in the following space that was above the plane 18 inches below the sprinkler head deflectors: 1) Social Work Office, and 2) Medical Records.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that the medical gas yard had a vehicle parked closer than 10 feet from the enclosure.

Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were no letters from vendors stating that the hospital was a preferred customer for water and fuel in the event of an emergency.

Based on observation the facility failed to provide an adequate essential electrical system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were the following issues. They were: 1) The ATS panels were not labeled according to the branch that they serve, 2) the critical receptacles were not labeled according to the panel and breaker supplying them power in the E.D.

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that the smoke barrier had penetrations all along the extent of the barrier. These must be sealed from both sides of the barrier.

Based on observation the facility failed to provide adequate hazardous area enclosures.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were the following issues.

A. The following spaces did not have adequate latching of the doors: 1) ED Equipment Storage, 2) Med/Surge Equipment Storage, 3) PBX Storage, 4) Maintenance, and 5) Housekeeping #4.
B. The following spaces did not have closers: 1) Med/Surge Supply, and 2) Clean Linen.
C. The following spaces had a penetrations in the ceiling: 1) Housekeeping/Clean Supply Room, and 2) PBX Storage.

Based on observation the facility failed to maintain an adequate fire sprinkler system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were missing escutcheon plates in the following areas: 1) Rad X-Ray room, and 2) Doctor ' s Lounge.

Also, there was storage in the following space that was above the plane 18 inches below the sprinkler head deflectors: 1) Social Work Office, and 2) Medical Records.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that the medical gas yard had a vehicle parked closer than 10 feet from the enclosure.

Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were no letters from vendors stating that the hospital was a preferred customer for water and fuel in the event of an emergency.

Based on observation the facility failed to provide an adequate essential electrical system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 3:00 pm to 5:45 pm on 3/25/2014 that there were the following issues. They were: 1) The ATS panels were not labeled according to the branch that they serve, 2) the critical receptacles were not labeled according to the panel and breaker supplying them power in the E.D.