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HSHS GOOD SHEPHERD HOSPITAL INC
Illumination of Means of Egress
Tag No.: K0281
Based on observation and staff interview, the illumination of the exit discharge portion of the means of egress is not provided as required. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.
Findings include:
On 11/29/2022 at 1:15pm, while in the company of the FPO, it was observed that exit discharge lighting was not confirmed to not be illuminated at all times during business hours or operated by a listed switch controller per 39.2.8, 7.8.1.2. Furthermore, redundancy was not observed to be provided so that failure of one unit does not result in illumination levels less than .2 ft-candles in any designated area per 7.8.1.4.
Illumination of Means of Egress
Tag No.: K0281
Based on observation and staff interview, the illumination of the exit discharge portion of the means of egress is not provided as required. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.
Findings include:
On 11/29/2022 at 1:45pm, while in the company of the FPO, it was observed that exit discharge lighting was not confirmed to not be illuminated at all times during business hours or operated by a listed switch controller per 7.8.1.2. Furthermore, redundancy was not observed to be provided so that failure of one unit does not result in illumination levels less than .2 ft-candles in any designated area per 7.8.1.4.
Gas and Vacuum Piped Systems - Other
Tag No.: K0902
Based on observation the facility lacks compliant protection of the medical gas piping system. Failure to install and maintain this installation could result in failure of the piping system. This deficient practice could affect patients, staff, and visitors.
The findings are:
A. On 11/29/2022 at 12:15pm, while in the company of the FPO, it was observed on the First Floor in the Physical Therapy/Cardiac Rehab suite that medical gas system piping above the ceiling is supported by a dissimilar metal not in accordance with NFPA 99-2012, 5.1.10.11.4.2. and not otherwise properly insulated to comply with NFPA 99-2012, 5.1.10.11.4.4.
B. On 11/29/2022 at 12:45pm, while in the company of the FPO, it could not be confirmed that electrical bonding of the building's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011, 250.104 (B).
Electrical Systems - Receptacles
Tag No.: K0912
Based upon observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.
The finding is:
On November 29, 2022, while in the company of the FPO, it was observed that electrical receptacles within six feet of a sink are not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).
Locations observed include:
1. at 12:25pm First Floor, Laboratory 140
2. at 12:32am Second Floor, Pantry 218