HospitalInspections.org

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain corridor doors to be free from obstructions to closing to positive latch as required. 19.3.6.3

Findings:

1. The following corridor doors were observed to be obstructed from self-closing to latch by floor wedges: the EMS Director office, the EMS office, X-ray #2, the OB area pantry, and the X-ray film storage room.

2. The following doors were obstructed from positive latching by tape and gauze being used to prevent the bolt from accessing the latch plate: Housekeeping Supply closet and PACS.

These observations were made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain the fire sprinkler system to be installed as required per NFPA 13.

Findings:

An orphaned sidewall sprinkler head from a remodel project was observed in the Materials Management area. The sidewall head was within 4' of two newly installed pendant heads. Pendant heads must be spaced at least 6' apart.

This observation was made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not construct and maintain the nitrous oxide compressed gas manifold room in accordance with the requirements of NFPA 99.

Findings:

1. The door accessing the manifold room did not have a label or documentation indicating that the door was rated to be at least an hour as required for manifold supply rooms.

2. The light switch inside the room was observed to be installed at less than the required height of 60 inches above the finished floor surface as required.

These observations were made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not store oxygen cylinders in accordance with the requirements of NFPA 99.

Findings:

The Respiratory Supplies storage room was observed to also contain 17 E-tanks. The maximum number permitted in any one smoke compartment is 12 E-tanks unless located in a dedicated storage room.

This observation was made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain electrical power cords in accordance with NFPA 70, The National Electrical Code.

Findings:

A 3 prong electrical plug was observed hanging from the ceiling in the pharmacy area. The plug and cord were lacking the protective outer sheath, and was extending through a corner of the lay-in acoustic ceiling grid where it could be subject to damage.

This observation was made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain corridor doors to be free from obstructions to closing to positive latch as required. 19.3.6.3

Findings:

1. The following corridor doors were observed to be obstructed from self-closing to latch by floor wedges: the EMS Director office, the EMS office, X-ray #2, the OB area pantry, and the X-ray film storage room.

2. The following doors were obstructed from positive latching by tape and gauze being used to prevent the bolt from accessing the latch plate: Housekeeping Supply closet and PACS.

These observations were made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain the fire sprinkler system to be installed as required per NFPA 13.

Findings:

An orphaned sidewall sprinkler head from a remodel project was observed in the Materials Management area. The sidewall head was within 4' of two newly installed pendant heads. Pendant heads must be spaced at least 6' apart.

This observation was made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not construct and maintain the nitrous oxide compressed gas manifold room in accordance with the requirements of NFPA 99.

Findings:

1. The door accessing the manifold room did not have a label or documentation indicating that the door was rated to be at least an hour as required for manifold supply rooms.

2. The light switch inside the room was observed to be installed at less than the required height of 60 inches above the finished floor surface as required.

These observations were made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not store oxygen cylinders in accordance with the requirements of NFPA 99.

Findings:

The Respiratory Supplies storage room was observed to also contain 17 E-tanks. The maximum number permitted in any one smoke compartment is 12 E-tanks unless located in a dedicated storage room.

This observation was made in the presence of the Director of Plant Engineering.

Based on observation during the life safety survey completed on 06/04/2015, the hospital did not maintain electrical power cords in accordance with NFPA 70, The National Electrical Code.

Findings:

A 3 prong electrical plug was observed hanging from the ceiling in the pharmacy area. The plug and cord were lacking the protective outer sheath, and was extending through a corner of the lay-in acoustic ceiling grid where it could be subject to damage.

This observation was made in the presence of the Director of Plant Engineering.