HospitalInspections.org

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the corridor doors had positive latches in compliance with CMS regulations.

The corridor doors to all patient rooms had roller latches.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that exit signage was in full compliance with NFPA 101, 19.2.10.1, and 7.10.

The exterior exit door in the MD office wing did not have an exit sign.

Based on observations made during a review of policies on the morning of 04/08/10 with the maintenance director, and the administrator, the facility failed to assure that the following procedure was being implemented.

Grounding system testing was not being performed in accordance with NFPA 99, 3.3.2. There were no logs showing that electrical receptacles in patient care areas were being tested at least annually.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the medical gas alarm system was in full compliance with NFPA 99, 4.3.1.2.2.

There were two medical gas master alarm panels in the hospital, and neither one was operational.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) There were no emergency receptacles at the generator set location.

(2) The pharmacy did not have any task illumination on emergency power.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the electrical wiring and equipment was in full compliance with NFPA 70, 700.9 or 517.19.

Emergency electrical panels and automatic transfer switches were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT as applicable to identify which branch of the essential electrical system they served.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the corridor doors had positive latches in compliance with CMS regulations.

The corridor doors to all patient rooms had roller latches.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that exit signage was in full compliance with NFPA 101, 19.2.10.1, and 7.10.

The exterior exit door in the MD office wing did not have an exit sign.

Based on observations made during a review of policies on the morning of 04/08/10 with the maintenance director, and the administrator, the facility failed to assure that the following procedure was being implemented.

Grounding system testing was not being performed in accordance with NFPA 99, 3.3.2. There were no logs showing that electrical receptacles in patient care areas were being tested at least annually.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the medical gas alarm system was in full compliance with NFPA 99, 4.3.1.2.2.

There were two medical gas master alarm panels in the hospital, and neither one was operational.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the Type I essential electrical system (EES) was in full compliance with NFPA 99, 3.4.2.2.2.

The following conditions were found:-

(1) There were no emergency receptacles at the generator set location.

(2) The pharmacy did not have any task illumination on emergency power.

Based on observations made during the tour of the facility on the morning of 04/08/10 with the maintenance director, the facility failed to assure that the electrical wiring and equipment was in full compliance with NFPA 70, 700.9 or 517.19.

Emergency electrical panels and automatic transfer switches were not labeled 'LIFE SAFETY', 'CRITICAL', or 'EQUIPMENT as applicable to identify which branch of the essential electrical system they served.