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Tag No.: K0012
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the fire resistive construction of the building, this has the potential for the passage of smoke throughout the building in the event of a fire. This finding was acknowledged at the time of the survey by the facility engineer. The finding was:
1. In the patient holding care area of the special procedure unit there is a hole in the wall.
NOTE: THIS DEFICIENCY WAS CORRECTED AT THE TIME OF THE SURVEY.
Tag No.: K0018
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the fire rated doors in the building, this has the potential for the passage of smoke throughout the facility in the event of a fire, this these findings were acknowledged by the facility engineers at the time of the survey. The findings were:
1. Door #3-N-004 Equipment room failed to close and latch.
2. Door #2-E-009 Old ER failed to close and latch.
3. The door to the Cardiac Care soiled workroom failed to close and latch.
4. The door to the mechanical Rm by the Twinkle Gift Shop failed to close and latch.
5. The door to the Soiled Holding in L&D across from Resident room #6 failed to close and latch.
6. The door #1-E-038 stairwell by Dialyses Storage room failed to close and latch.
7. The door #4-W-028 Occupational Therapy failed to close and latch.
8. The cross corridor fire separation doors #A-W-024B failed to close and latch.
9. The door to the soiled utility by OR #8 failed to close and latch.
10. The door from the OR nurses station to the OR east failed to close and latch.
11. The cross corridor fire separation doors by OR #5 failed to close and latch.
NOTE: THESE DEFICIENCIES WERE CORRECTED AT THE TIME OF THE SURVEY.
Tag No.: K0046
During the facility tour on July 17, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the emergency egress lighting in the building capable of illuminating the path of egress in the event of a fire, this has the potential to delay the evacuation of staff from the building in the event of a fire. These findings were acknowledged at the time of the survey by the facility engineer. The findings were:
1. In the main electrical room of the new hospital there is an emergency egress light that failed to function on back-up power.
2. In the elevator equipment room in the new hospital there was an emergency egress light that failed to function on back-up power.
Tag No.: K0062
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the sprinkler system free of obstructions, this has the potential to delay the activation of the sprinkler head in the event of a fire. This finding was acknowledged at the time of the survey by the facility engineer. The finding was:
1. The sprinkler head in the Bed repair storage room #1-E-010 is sprayed with fire proofing.
Tag No.: K0012
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the fire resistive construction of the building, this has the potential for the passage of smoke throughout the building in the event of a fire. This finding was acknowledged at the time of the survey by the facility engineer. The finding was:
1. In the patient holding care area of the special procedure unit there is a hole in the wall.
NOTE: THIS DEFICIENCY WAS CORRECTED AT THE TIME OF THE SURVEY.
Tag No.: K0018
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the fire rated doors in the building, this has the potential for the passage of smoke throughout the facility in the event of a fire, this these findings were acknowledged by the facility engineers at the time of the survey. The findings were:
1. Door #3-N-004 Equipment room failed to close and latch.
2. Door #2-E-009 Old ER failed to close and latch.
3. The door to the Cardiac Care soiled workroom failed to close and latch.
4. The door to the mechanical Rm by the Twinkle Gift Shop failed to close and latch.
5. The door to the Soiled Holding in L&D across from Resident room #6 failed to close and latch.
6. The door #1-E-038 stairwell by Dialyses Storage room failed to close and latch.
7. The door #4-W-028 Occupational Therapy failed to close and latch.
8. The cross corridor fire separation doors #A-W-024B failed to close and latch.
9. The door to the soiled utility by OR #8 failed to close and latch.
10. The door from the OR nurses station to the OR east failed to close and latch.
11. The cross corridor fire separation doors by OR #5 failed to close and latch.
NOTE: THESE DEFICIENCIES WERE CORRECTED AT THE TIME OF THE SURVEY.
Tag No.: K0046
During the facility tour on July 17, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the emergency egress lighting in the building capable of illuminating the path of egress in the event of a fire, this has the potential to delay the evacuation of staff from the building in the event of a fire. These findings were acknowledged at the time of the survey by the facility engineer. The findings were:
1. In the main electrical room of the new hospital there is an emergency egress light that failed to function on back-up power.
2. In the elevator equipment room in the new hospital there was an emergency egress light that failed to function on back-up power.
Tag No.: K0062
During the facility tour on July 18, 2013 from 0800 to 1530 it was observed that the facility failed to maintain the sprinkler system free of obstructions, this has the potential to delay the activation of the sprinkler head in the event of a fire. This finding was acknowledged at the time of the survey by the facility engineer. The finding was:
1. The sprinkler head in the Bed repair storage room #1-E-010 is sprayed with fire proofing.