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JANE TODD CRAWFORD HOSPITAL
Gas and Vacuum Piped Systems - Maintenance Pr
Tag No.: K0907
Based on interview and record review, the facility failed to ensure the Piped in Gas and Vacuum System was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect staff, patients, and other occupants of the building.
The findings include:
A Life Safety Code survey was conducted on 02/13/18 at 10:00 AM with the Director of Maintenance (DOM).
Review of a Medical Piped Gas Inspection report dated 11/01/17, revealed the facility had one (1) Master Alarm Panel, twelve (12) Zone Valves, two (2) Sources, and eight (8) Patient Terminals associated with the piped in gas and vacuum system that failed to meet the inspection requirements. This system must be properly maintained to perform as intended.
Interview with the DOM on 02/13/18 at 10:00 AM revealed the facility had received a repair quote dated 11/14/17 that detailed the cost to have the repairs made but the facility had not yet initiated the repairs to the system.
The findings were revealed to the Administrator upon exit.