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ASCENSION ST VINCENT MERCY
No Description Available
Tag No.: K0143
1. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring was separated within a one hour fire barrier enclosure. This deficient practice could affect 5 residents on the third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff near the oxygen storage room.
Findings include:
Based on observation on 07/12/11 at 11:50 a.m. with the Maintenance Supervisor, the fire rating tag found on the corridor door to the oxygen transfer room on third floor south hall indicated it was a twenty minute fire rated door. Based on interview on 07/12/11 at 11:51 a.m. observation with the Maintenance Supervisor, it was confirmed the door to the oxygen storage room where it was acknowledged oxygen transfer occurs was a twenty minute fire rated door which would not maintain a one hour fire rated enclosure.
2. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring had a sign posted indicating oxygen transferring was occurring in the oxygen storage room. This deficient practice could affect 5 residents on the third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff near the oxygen storage room.
Findings include:
Based on observation on 07/12/11 at 11:55 a.m. with the Maintenance Supervisor, the oxygen transfer room where oxygen transfer occurs on third floor south hall where liquid oxygen containers were stored and used to transfill oxygen, lacked a sign posted on the oxygen storage room door indicating the transfer of oxygen was being conducted at this site. Based on interview on 07/12/11 at 11:57 a.m. with the Maintenance Supervisor, it was acknowledged oxygen transfers takes place but a sign to indicate such conduct was not posted on the door or available anywhere else in the facility.
3. Based on observation and interview, the facility failed to ensure 1 of 1 switches and 2 of 2 outlets were positioned five feet above the floor in the oxygen storage room on third floor, south hall where oxygen transfer occurs. NFPA 99, 1999 Edition Standard for Health Care Facilities, Section 8-3.1.11.2(f) requires electrical fixtures in oxygen storage locations shall meet 4-3.1.1.2(a)11(d) which requires ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 feet above the floor to avoid physical damage. This deficient practice could affect an 5 residents on third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff.
Findings include:
Based on observation on 07/12/11 at 11:59 a.m. with the Maintenance Supervisor, there was one electrical switch installed inside the oxygen room on the east wall located four feet above the floor and two electrical outlets installed inside the oxygen room on the south wall which were located eight inches above the floor. Based on interview on 07/12/11 at 12:02 p.m. with the Maintenance Supervisor, it was acknowledged the electrical wall fixtures were located less than five feet above the floor.
LIFE SAFETY CODE STANDARD
Tag No.: K0143
1. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring was separated within a one hour fire barrier enclosure. This deficient practice could affect 5 residents on the third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff near the oxygen storage room.
Findings include:
Based on observation on 07/12/11 at 11:50 a.m. with the Maintenance Supervisor, the fire rating tag found on the corridor door to the oxygen transfer room on third floor south hall indicated it was a twenty minute fire rated door. Based on interview on 07/12/11 at 11:51 a.m. observation with the Maintenance Supervisor, it was confirmed the door to the oxygen storage room where it was acknowledged oxygen transfer occurs was a twenty minute fire rated door which would not maintain a one hour fire rated enclosure.
2. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring had a sign posted indicating oxygen transferring was occurring in the oxygen storage room. This deficient practice could affect 5 residents on the third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff near the oxygen storage room.
Findings include:
Based on observation on 07/12/11 at 11:55 a.m. with the Maintenance Supervisor, the oxygen transfer room where oxygen transfer occurs on third floor south hall where liquid oxygen containers were stored and used to transfill oxygen, lacked a sign posted on the oxygen storage room door indicating the transfer of oxygen was being conducted at this site. Based on interview on 07/12/11 at 11:57 a.m. with the Maintenance Supervisor, it was acknowledged oxygen transfers takes place but a sign to indicate such conduct was not posted on the door or available anywhere else in the facility.
3. Based on observation and interview, the facility failed to ensure 1 of 1 switches and 2 of 2 outlets were positioned five feet above the floor in the oxygen storage room on third floor, south hall where oxygen transfer occurs. NFPA 99, 1999 Edition Standard for Health Care Facilities, Section 8-3.1.11.2(f) requires electrical fixtures in oxygen storage locations shall meet 4-3.1.1.2(a)11(d) which requires ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 feet above the floor to avoid physical damage. This deficient practice could affect an 5 residents on third floor, north hall which is adjacent to third floor, south hall as well as visitors and staff.
Findings include:
Based on observation on 07/12/11 at 11:59 a.m. with the Maintenance Supervisor, there was one electrical switch installed inside the oxygen room on the east wall located four feet above the floor and two electrical outlets installed inside the oxygen room on the south wall which were located eight inches above the floor. Based on interview on 07/12/11 at 12:02 p.m. with the Maintenance Supervisor, it was acknowledged the electrical wall fixtures were located less than five feet above the floor.