HospitalInspections.org

No Emergency Lighting in the OR.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that in the Operating Room, there was no Back-up battery lighting. This could jeopardize patients in case of a total power failure. According to NFPA 101, 2000, 7.9.2.2, "The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply.

No Exit directional sign.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that there was no Illuminated Directional Sign at the Main Lobby and the Outpatient Clinic. This condition could jeopardize patents and staff in case of an emergency if power was disrupted and the Emergency Generator did not start. According to NFPA 101, 2000, 7.10.5.1, "Every sign required by 7.10.1.2, or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitable illuminated by a reliable light source."

No updated letter on Fire Plan.
The Findings Include:
During document review October 19, 2010, with Maintenance, it was noted that they had not updated their Fire Plan with an Approval Letter from the Local AHJ. According to NFPA 101, 2000, 19.7.2.2. Staff knowledge of the Fire Plan in case of Fire.

No Exhaust fans.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that the Outpatient Clinic bathroom for rooms
#6 and #7, did not have an Exhaust fan. Also the Soiled Storage Closet in the X-ray hall, and some Patient Bathrooms. This condition could jeopardize patients and staff with noxious odors. According to AIA Guidelines 2001, 59A, 3.081, "Exhaust fans are required in all Patient Isolation rooms, Soiled Workrooms, Toilets & Baths, Janitors, Decontamination, Dish washing, Laundry and Soiled Linen Storage rooms."

Unsupported O2 cylinders.
The Findings Include:
On tour October 19,2010, with Maintenance, it was noted in the outside Tank Farm, there were (7) unsupported "H" cylinders. This condition could jeopardize staff if one of the bottles should tip over.
According to NFPA 99, (2002), 5.1.3.3.2, (7), "Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full or empty, from falling."

No Documentation of Receptacle testing.
The Findings Include:
During Document Review, October 19, 2010, with Maintenance, it was noted that there was no Documentation of Receptacle testing. Without this testing it could jeopardize the safety of patients and staff. According to NFPA 99, (2002), 4.3.2.2.9.3, (B), "Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months
and NFPA 70,, Maintenance and Testing of Electrical Systems.

No Emergency Lighting in the OR.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that in the Operating Room, there was no Back-up battery lighting. This could jeopardize patients in case of a total power failure. According to NFPA 101, 2000, 7.9.2.2, "The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply.

No Exit directional sign.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that there was no Illuminated Directional Sign at the Main Lobby and the Outpatient Clinic. This condition could jeopardize patents and staff in case of an emergency if power was disrupted and the Emergency Generator did not start. According to NFPA 101, 2000, 7.10.5.1, "Every sign required by 7.10.1.2, or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitable illuminated by a reliable light source."

No updated letter on Fire Plan.
The Findings Include:
During document review October 19, 2010, with Maintenance, it was noted that they had not updated their Fire Plan with an Approval Letter from the Local AHJ. According to NFPA 101, 2000, 19.7.2.2. Staff knowledge of the Fire Plan in case of Fire.

No Exhaust fans.
The Findings Include:
On tour October 19, 2010, with Maintenance, it was noted that the Outpatient Clinic bathroom for rooms
#6 and #7, did not have an Exhaust fan. Also the Soiled Storage Closet in the X-ray hall, and some Patient Bathrooms. This condition could jeopardize patients and staff with noxious odors. According to AIA Guidelines 2001, 59A, 3.081, "Exhaust fans are required in all Patient Isolation rooms, Soiled Workrooms, Toilets & Baths, Janitors, Decontamination, Dish washing, Laundry and Soiled Linen Storage rooms."

Unsupported O2 cylinders.
The Findings Include:
On tour October 19,2010, with Maintenance, it was noted in the outside Tank Farm, there were (7) unsupported "H" cylinders. This condition could jeopardize staff if one of the bottles should tip over.
According to NFPA 99, (2002), 5.1.3.3.2, (7), "Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full or empty, from falling."

No Documentation of Receptacle testing.
The Findings Include:
During Document Review, October 19, 2010, with Maintenance, it was noted that there was no Documentation of Receptacle testing. Without this testing it could jeopardize the safety of patients and staff. According to NFPA 99, (2002), 4.3.2.2.9.3, (B), "Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months
and NFPA 70,, Maintenance and Testing of Electrical Systems.