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Tag No.: A0620
Based on observation, interview, and policy review, the hospital failed to ensure safe practices for food handling in regards to disposing of unlabeled and expired foods. The total census at the time of the survey was 319 patients.
Findings Included:
On 12/05/12 during an environmental tour of the kitchen from 8:20 AM to 10:00 AM, an observation was made in a walk-in cooler. There were three containers of mozzarella cheese with an expiration date of 11/27/12, one container of queso mozzarella fresco with an expiration date of 12/04/12, one case of yogurt with an expiration date of 12/04/12, a package of sliced yellow cheese opened and wrapped in plastic wrap with an expiration date of 10/30/12, a package of what Staff H stated was cream cheese opened with no label and no expiration date, and a box of carrots opened on 10/23/12. Staff H stated that Staff I was responsible to dispose of expired items. These findings were confirmed with Staff H in an interview 12/05/12 at 9:00 AM. Staff H stated that opened packages of produce should be used within seven days. Staff H did dispose of the carrots upon discovery they were opened on 10/23/12.
On 12/05/12 at 4:30 PM the hospital's policy entitled IC-04 Storage of Food and Supplies (last reviewed 03/2011) was reviewed. This policy was approved by Staff H 03/2011. The policy stated, "All stored food is to be covered and properly labeled with content and date and disposed of once the item has reached its expiration date."
Tag No.: A0700
REVISED
Based on observations, staff interviews, and review of relative humidity logs and architectural building schematics, the physical environment is not maintained in a manner safe from fire in regards to exit directional signage, smoke barrier penetrations, smoke barrier doors, soiled utility rooms, delayed egress locks and doors, exit discharge lighting, K-type fire extinguisher, kitchen hood suppression system, obstructed linen chute, trash bins in unprotected area, medical gas storage, relative humidity levels, hyperbaric room fire doors, quarterly sprinkler inspections, and unprotected electrical panels. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
During this visit, 12/03/12 through 12/07/12, tour was conducted in the facility with
Staff A1, C3, D4, E5, and I9. Observations were conducted in the main campus buildings and offsite locations. During this visit, the following were identified and verified by facility staff:
The facility lacked directional exit signs in the path of egress.
The facility failed to ensure smoke barriers were intact and without penetrations.
Smoke barrier doors were observed with gaps between leafs or doors failed to latch when equipped with latching hardware.
Soiled utility rooms were observed with smoke barrier penetrations or door failed to latch into the frame.
The facility was equipped with 2 delayed egress doors in the path of exit, and failed to ensure the doors were labeled with signage on how to operate the doors. The time frames for opening the doors with pushing pressure exceeded the 15 second requirement.
Exit discharges were not adequately illuminated.
The facility failed to ensure a K-type fire extinguisher was equipped with an inspection placard.
The facility failed to update the kitchen hood suppression system to a UL-300 system.
The facility failed to ensure the linen chute was free from obstructed linens.
Portable trash bins exceeding 32 gallon were not stored in a fire rated protected room.
The facility failed to secure medical gas cylinders and failed to ensure one medical gas room had an electrical switch that was at least 5 feet above the floor level.
The facility failed to ensure relative humidity in anesthetizing areas equipped with piped-in oxygen was equal to greater than 35%.
Fire doors in a hyperbaric room failed to close and latch into the frame.
The facility failed to ensure quarterly sprinkler inspections were conducted in off-site locations.
An unprotected electrical panel was observed in a staff work area.
Refer to A0709.
Tag No.: A0709
Based on observations, staff interviews, and review of relative humidity logs and architectural building schematics, the facility failed to meet the provisions of the Life Safety Code related to fire safety in regards to exit directional signage, smoke barrier penetrations, smoke barrier doors, soiled utility rooms, delayed egress locks and doors, exit discharge lighting, K-type fire extinguisher, kitchen hood suppression system, linen chute, trash bins in unprotected area, medical gas storage, relative humidity levels, hyperbaric room fire doors, quarterly sprinkler inspections, and unprotected electrical panels. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
During this visit, 12/03/12 through 12/07/12, tour was conducted in the facility with
Staff A1, C3, D4, E5, and I9. Observations were conducted in the main campus buildings and offsite locations. During this visit, the following were identified and verified by facility staff:
The facility lacked directional exit signs in the path of egress.
The facility failed to ensure smoke barriers were intact and without penetrations.
Smoke barrier doors were observed with gaps between leafs or doors failed to latch when equipped with latching hardware.
Soiled utility rooms were observed with smoke barrier penetrations or door failed to latch into the frame.
The facility was equipped with 2 delayed egress doors in the path of exit, and failed to ensure the doors were labeled with signage on how to operate the doors. The time frames for opening the doors with pushing pressure exceeded the 15 second requirement.
Exit discharges were not adequately illuminated.
The facility failed to ensure a K-type fire extinguisher was equipped with an inspection placard.
The facility failed to update the kitchen hood suppression system to a UL-300 system.
The facility failed to ensure the linen chute was free from obstructed linens.
Portable trash bins exceeding 32 gallon were not stored in a fire rated protected room.
The facility failed to secure medical gas cylinders and failed to ensure one medical gas room had an electrical switch that was at least 5 feet above the floor level.
The facility failed to ensure relative humidity in anesthetizing areas equipped with piped-in oxygen was equal to greater than 35%.
Fire doors in a hyperbaric room failed to close and latch into the frame.
The facility failed to ensure quarterly sprinkler inspections were conducted in off-site locations.
An unprotected electrical panel was observed in a staff work area.
Refer to A0710.
Tag No.: A0710
Based on observations, staff interviews, and review of relative humidity logs and architectural building schematics, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association, related to fire safety in regards to exit directional signage, smoke barrier penetrations, smoke barrier doors, soiled utility rooms, delayed egress locks and doors, exit discharge lighting, K-type fire extinguisher, kitchen hood suppression system, linen chute, trash bins in unprotected area, medical gas storage, relative humidity levels, hyperbaric room fire doors, quarterly sprinkler inspections, and unprotected electrical panels. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 319.
Findings include:
During this visit, 12/03/12 through 12/07/12, tour was conducted in the facility with
Staff A1, C3, D4, E5, and I9. Observations were conducted in the main campus buildings and offsite locations. During this visit, the following were identified and verified by facility staff:
The facility lacked directional exit signs in the path of egress. Refer to K22
The facility failed to ensure smoke barriers were intact and without penetrations. Refer to K25.
Smoke barrier doors were observed with gaps between leafs or doors failed to latch when equipped with latching hardware. Refer to K27.
Soiled utility rooms were observed with smoke barrier penetrations or door failed to latch into the frame. Refer to K29.
The facility was equipped with 2 delayed egress doors in the path of exit, and failed to ensure the doors were labeled with signage on how to operate the doors. The time frames for opening the doors with pushing pressure exceeded the 15 second requirement. Refer to K38.
Exit discharges were not adequately illuminated. Refer to K45.
The facility failed to ensure a K-type fire extinguisher was equipped with an inspection placard. Refer to K64.
The facility failed to update the kitchen hood suppression system to a UL-300 system. Refer to K69.
The facility failed to ensure the linen chute was free from obstructed linens. Refer to K71 in Building 1.
Portable trash bins exceeding 32 gallon were not stored in a fire rated protected room. Refer to K75.
The facility failed to secure medical gas cylinders and failed to ensure one medical gas room had an electrical switch that was at least 5 feet above the floor level. Refer to K76.
The facility failed to ensure relative humidity in anesthetizing areas equipped with piped-in oxygen was equal to greater than 35%. Refer to K78.
Fire doors in a hyperbaric room failed to close and latch into the frame. Refer to K130.
The facility failed to ensure quarterly sprinkler inspections were conducted in off-site locations. Refer to K130.
An unprotected electrical panel was observed in a staff work area. Refer to K147.