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Tag No.: K0374
Based on observation and staff interview, it was determined the facility failed to ensure that fire barrier doors and smoke barrier doors were constructed and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.
Findings include:
Observation on 08/16/23 at approximately 10:33 a.m., revealed the one (1)-hour rated smoke barrier doors, near the Inpatient Unit Nursing Admin Office, were bowed at the top and bottom and exceeded the 1/8-inch requirement at the meeting edges along the top and bottom of the doors.
Observation on 08/16/23 at approximately 11:01 a.m., revealed the one (1)-hour rated smoke barrier doors, near the IT Work Room on the Materials Hallway, were bowed at the bottom and exceeded the 1/8-inch requirement at the meeting edges along the bottom of the doors.
Observation on 08/16/23 at approximately 12:55 p.m., revealed the one (1)-hour rated smoke barrier doors, near the Main Lobby of the Cardiopulmonary Hallway, were bowed at the top and bottom and exceeded the 1/8-inch requirement at the meeting edges along the top and bottom of the doors.
Observation on 08/16/23 at approximately 1:01 p.m., revealed the one (1)-hour rated smoke barrier doors, near Computed Tomography (CT) going toward the Emergency Department on the Long Hallway, were bowed at the top and bottom and exceeded the 1/8-inch requirement at the meeting edges along the top and bottom of the doors.
Interview on 08/16/23 at approximately 1:03 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.
Tag No.: K0511
Based on observation and staff interview, it was determined the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.
Findings include:
Observation on 08/15/23 at approximately 1:22 p.m., revealed a two (2)-prong extension cord (residential) being used to power a residential rotary tool (Dremel Tool) in C-Pod Exam Room 4 of the Physician Center.
Interview on 08/15/23 at approximately 1:23 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.
Tag No.: K0781
Based on observation and staff interview, it was determined the facility failed to ensure that portable space heaters were not used in patient care areas in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.
Findings include:
Observation on 08/15/23 at approximately 1:31 p.m., revealed a space heater being used in the A-Pod Procedure Room A of the Physician Center.
Interview on 08/15/23 at approximately 1:32 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.
Tag No.: K0914
Based on document review and staff interview, it was determined the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 16.
Findings include:
Document review on 08/15/23 at approximately 2:14 p.m., revealed no documentation was available for review to show that additional testing was performed at intervals defined by documented performance data for hospital-grade receptacles at the patient bed locations throughout the facility. The previous inspections for electrical receptacles at the patient bed locations were dated 04/14/22 through 08/11/22.
Interview on 08/15/23 at approximately 2:15 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Administrative Officer at the exit interview on 08/16/23 at approximately 3:36 p.m.