HospitalInspections.org

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Based on observation and interview, the building failed to maintain an alcohol based hand rub dispenser per the requirements of:

2012 NFPA 101, 19.3.2.6* (8)
2012 NFPA 101, 8.7.3.1

Findings include:

On 09/19/2017, during a tour of the building from 7:45 am to 3:00 pm, the alcohol based hand rub dispenser was observed installed above an ignition source (receptacle) in the Major Surgery Room (234).

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12
2012 NFPA 101, 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 09/19/2017, during a tour of the building from 7:45 a.m. to 3:00 p.m., the portable fire extinguisher located in the kitchen near the cooler was observed installed more than 5 ft. from the floor to the top of the fire extinguisher (approximately 70").

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 483.90 (a) (1) (ii)

Findings include:

On 09/19/2017, during a tour of the building from 7:45 am to 3:00 pm, the following corridor doors were observed not to positive latch:

1. Room 105
2. Room 110

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the building failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4* (5),(6)

Findings include:

On 09/19/2017, during a tour of the building from 7:45 am to 3:00 pm, the visitors smoking area was observed without the following items:

1. An ashtray of noncombustible material
2. A metal container with self-closing cover device

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the building failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8

Findings include:

On 09/19/2017, during a tour of the building from 7:45 a.m. to 3:00 p.m., based on review of documentation and interview the building failed to have a fuel quality test performed at least annually using tests approved by ASTM standards.


A member of the maintenance staff was present when this deficiency was identified.