HospitalInspections.org

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

1. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General the facility failed to provide a satifactory record of tests
on the Electrical Power Distribution and Grounding Systems. This is required annually in
general care areas, and semi-annually in critical areas.


2. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General, rooms B.234.10, B234.10.2, B234.11 did not have
the required 18 in. of clearance between the deflector and the top of storage as required
by NFPA 13, 1999: 5-5.6 "Clearance to Storage".

3. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General, the STORAGE ALCOVE in the LAB (near electrical
panels) did not have the required sprinkler head.

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

Based on observations made during review of the logs, policies and procedures of the facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and Maintenance Mechanical General, the facility failed to provide acceptable documentation of any of the interior finishes.

1. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General the facility failed to provide a satifactory record of tests
on the Electrical Power Distribution and Grounding Systems. This is required annually in
general care areas, and semi-annually in critical areas.


2. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General, rooms B.234.10, B234.10.2, B234.11 did not have
the required 18 in. of clearance between the deflector and the top of storage as required
by NFPA 13, 1999: 5-5.6 "Clearance to Storage".

3. Based on observations made during review of the logs, policies and procedures of the
facility between the hours of 8:30 am and 3:30 pm, while accompanied by the Director
Of Facilities, Safety Officer, Manager Clinical Engineering OPS, Biomed Tech II, and
Maintenance Mechanical General, the STORAGE ALCOVE in the LAB (near electrical
panels) did not have the required sprinkler head.