HospitalInspections.org
Bringing transparency to federal inspections
GUNDERSEN ST ELIZABETH'S HOSPITAL AND CLINICS
Discharge from Exits
Tag No.: K0271
The facility failed to comply with Life Safety Code ( 18.2.7, 19.2.7 )
This deficient practice could affect the safety of all ( 7 ) the residents, staff and visitors within the smoke compartment/ Facility.
Findings Include:
On facility tour between 12:30 PM and 05:30 PM on 07/30/2018, observations and staff interview revealed the following:
Observations during the inspection revealed: ( 1 ) Egress Door in the 1998 Wing of the facility had the following deficiencies: required more than 15# of force to open and close; had uneven concrete grade upon exit from the structure; directional exit gate was not spring loaded. ( 2 ) Egress Door in the 1968 Wing of the facility had an uneven grade upon exit from the structure
This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.
Vertical Openings - Enclosure
Tag No.: K0311
The facility failed to comply with Life Safety Code ( 19.3.1.1 through 19.3.1.6 )
This deficient practice could affect the safety of all ( 7 ) the residents, staff and visitors within the smoke compartment/ Facility.
Findings Include:
On facility tour between 12:30 PM and 05:30 PM on 07/30/2018, observations and staff interview revealed the following:
Observation during the inspection of the Data / Telephone Room revealed vertical penetrations
This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.
Cooking Facilities
Tag No.: K0324
The facility failed to comply with Life Safety Code ( 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 )
This deficient practice could affect the safety of all ( 7 ) the residents, staff and visitors within the smoke compartment/ Facility.
Findings Include:
On facility tour between 12:30 PM and 05:30 PM on 07/30/2018, observation and documentation reviewed revealed the following:
Documentation review indicated that the Facility did not have appropriate records for the Kitchen Hood Suppression System ( missing previous 6 mo record )
This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.
Electrical Systems - Maintenance and Testing
Tag No.: K0914
The facility failed to comply with Life Safety Code ( 6.3.4 (NFPA 99) )
This deficient practice could affect the safety of all ( 7 ) the residents, staff and visitors within the smoke compartment/ Facility.
Findings Include:
On facility tour between 12:30 PM and 05:30 PM on 07/30/2018, observation and documentation reviewed revealed the following:
Documentation review indicated that the Facility has not completed electrical outlet testing ( baseline polarity & tension testing )
This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
The facility failed to comply with Life Safety Code ( 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 )
This deficient practice could affect the safety of all ( 7 ) the residents, staff and visitors within the smoke compartment/ Facility.
Findings Include:
On facility tour between 12:30 PM and 05:30 PM on 07/30/2018, observations and staff interview revealed the following:
Observation during the inspection of the Facility revealed a refrigerator plugged into a power strip ( 2nd FL - RM 252 )
This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.