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LAWRENCE COUNTY MEMORIAL HOSPITAL
Doors with Self-Closing Devices
Tag No.: K0223
Based on obervation, the facility failed to maintain the smoke compartment as required. this deficiency could affect all patients, staff and visitors if the smoke is allowed to travel from one smoke compartment to adjoining smoke compartment.
The Findings include:
On 12/01/20 at 2:00pm during the survey process while accompanied with the DeF, it was observed the west pair of smoke doors which swings in the same directions by the CT Suite with one door installed with metal astragel, did not close due to mal function of the door co-ordinator. 19.2.2.2.7 and 7.2.1.8.2.
Ramps and Other Exits
Tag No.: K0227
Based on observation, the exit discharge was not maintained as required. This deficiency could affect all patients, staff and visitors, if the exit discharge is deficient.
The Findings include:
On 12/01/20 at 2:05pm , while accompanied with DeF, the southwest exit discharge is through landing and ramp. The landing approx. 2' -0" above the grade with not vertical barriers/railings .19.2.7 and 7.7.
Electrical Equipment - Testing and Maintenanc
Tag No.: K0921
Based on observation, the Emergency Generator emergency stop switch and annunciator panel was found not installed as required. This deficeincy could effect any or all patients being treated due to not being alarmed in a timely manner.
Finding includes:
On 12/01/20 at 2:30pm while accompanied with the DeF the following deficiencies were observed:
1. Emergency Generator's annunciation panel was not installed at a location not readily observable., NFPA 110 1999 3-5.6.1 and 99 1999 3-41.1.1.5.
2. Emergency Generator emergency stop switch was not installed. NFPA 110 1999 3-5.5.6.