HospitalInspections.org

Based on observations during the facility walk-through with the director of facilities management, COO, and RN/quality manager, on 03/12/2014, it was noted that there were no spare sprinkler heads for the fire sprinkler system, stored at a sprinkler cabinet within the facility as per NFPA 13(2002)6.2.9. However during the facility walk-through on 03/13/2014 the director of facilities management staff had located the spare sprinkler cabinet. It contained approximately 12 spare heads, of the same type. For this size of facility no fewer thatn 24 spare heads are required, and shall include all types and ratings of installed heads. The cabinet shall be permanently located in the maintenance area near the sprinkler riser or maintenance shop and be visible to maintenance staff.

Based on observations during the facility walk-through with the director of facilities management, COO, and RN/quality manager on 03/12/2014, it was observed that the medical gas tanks at the manifold location, were not secured properly to prevent overturning as per NFPA 99(2002) 5.1.3.3.2(7). The tanks were loosely chained in large groupings and not individually secured to prevent overturning.

Based on a review of the records and discussions with the director of facilities management on 03/12 & 12/2014, the facility was not testing the electrical outlets in patient care areas on a semi-annual (for critical care areas) or annually (for noncritical patient care areas) as required by NFPA 99(2002)8.5.2.1.2. Testing of receptacles in patient care areas shall include physical integrity, continunity of grounding, correct polarity, and retention force. The facility shall establish policies and protocols for the testing of electrical systems in patient care areas.

Based on observations during the facility walk-through with the director of facilities management, COO, and RN/quality manager, on 03/12/2014, it was noted that there were no spare sprinkler heads for the fire sprinkler system, stored at a sprinkler cabinet within the facility as per NFPA 13(2002)6.2.9. However during the facility walk-through on 03/13/2014 the director of facilities management staff had located the spare sprinkler cabinet. It contained approximately 12 spare heads, of the same type. For this size of facility no fewer thatn 24 spare heads are required, and shall include all types and ratings of installed heads. The cabinet shall be permanently located in the maintenance area near the sprinkler riser or maintenance shop and be visible to maintenance staff.

Based on observations during the facility walk-through with the director of facilities management, COO, and RN/quality manager on 03/12/2014, it was observed that the medical gas tanks at the manifold location, were not secured properly to prevent overturning as per NFPA 99(2002) 5.1.3.3.2(7). The tanks were loosely chained in large groupings and not individually secured to prevent overturning.

Based on a review of the records and discussions with the director of facilities management on 03/12 & 12/2014, the facility was not testing the electrical outlets in patient care areas on a semi-annual (for critical care areas) or annually (for noncritical patient care areas) as required by NFPA 99(2002)8.5.2.1.2. Testing of receptacles in patient care areas shall include physical integrity, continunity of grounding, correct polarity, and retention force. The facility shall establish policies and protocols for the testing of electrical systems in patient care areas.