HospitalInspections.org

.

Based on observation, the facility failed to maintain the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.2.1

This deficiency could affect approximately 25 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:30 am to 4:45 pm, the surveyor observed when exiting the OR going into the ER/Radiology corridor, the exit sign at the OR cross corridor doors had a chevron-type indicator directing egress to the left (no exit), instead of straight thru cross corridor doors.

A member of the maintenance staff was present when the deficiency was identified.

.

.

Based on review of documentation, the facility failed to maintain the kitchen hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 11.4, Table 11.4, and 11.6

This deficiency could affect approximately 15 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:30 am to 4:45 pm, the facility failed to provide documentation of a kitchen hood cleaning being conducted within the past 6 months. The last documented cleaning was 02/2019.

A member of the maintenance staff was present when this deficiency was identified

.

.

Based on observation, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of:

2012 NFPA 101, 19.3.2.6 (8)

This deficiency could affect approximately 10 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 1:00 pm to 4:30 pm, the surveyor observed an ABHR Dispenser was mounted directly above electrical receptacles (ignition source) in the Back Hall Lab.

A member of maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to install an Alcohol-Based Hand-Rub (ABHR) Dispenser per the requirements of:

2012 NFPA 101, 19.3.2.6 (8)

This deficiency could affect approximately 10 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:45 am to 4:45 pm, the surveyor observed an ABHR Dispenser was mounted directly above a light switch (ignition source) in the C.T. Room.

A member of maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to ensure synchronization of the visible notification devices for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.3.1, and 9.6.3.5
2010 NFPA 72, 18.5.4.4.7

This deficiency could affect approximately 15 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 1:00 pm to 4:30 pm, the surveyor observed three fire alarm notification devices in the field of view not flashing in synchronization in the OR Suite during activation of fire alarm system.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, and 8.5.4.2

This deficiency could affect approximately 15 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:30 am to 4:45 pm, the surveyor observed several section of 1' x 4' ceiling tiles were missing and broken in Mechanical Room (1) next to E.R..

A member of the maintenance staff was present when this deficiency was identified.

.


41792

.

Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, and 8.5.4.2

This deficiency could affect approximately 15 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:30 am to 4:45 pm, the surveyor observed two 1' x 4' ceiling tiles were missing and broken in the 2nd Floor Phone/Data Room across from Patient Room 218.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, and 8.5.4.2

This deficiency could affect approximately 5 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 1:00 pm to 4:30 pm, the surveyor observed several two inch holes in the ceiling tiles in Gowning Room Two.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, review of documentation and interview, the facility failed to maintain the automatic sprinklers per the requirements of:

2012 NFPA 101, 9.7.5, and 9.7.8
2011 NFPA 25, 5.2.4.1, 5.1.1.2, and Table 5.1.1.2

This deficiency could affect approximately 40 occupants, and two smoke compartments.

Findings include:

On 01/07/2020, during a tour of the facility from 1:00 pm to 4:30 pm,:
1. The facility failed to provide documentation of monthly inspections on the wet sprinkler riser gauges.
2. The facility provided the following documentation for quarterly inspections:
Johnson Controls - 11/14/2019
Johnson Controls - 09/09/2019
Johnson Controls - 05/20/2019
Johnson Controls - 03/05/2019

A member of the maintenance staff and administrator was present, when this deficiency was identified.

.

.

Based on review of documentation and observation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.2.4.1

This deficiency could affect approximately all occupants.

Findings include:

On 01/08/2020, during a tour of the facility from 8:00 am to 11:30 am, the surveyor observed the facility failed to provide documentation on the monthly inspections for the wet gauges.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

This deficiency could affect approximately 10 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 9:45 am to 4:45 pm, the surveyor observed a portable fire extinguisher next to OR 3 was installed approximately 65" from the floor to the top of the fire extinguishers.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on review of documentation, the facility failed to maintain the dampers (smoke/fire/ceiling) per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2010 NFPA 80, 19.4, and 19.5
2012 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 105, 6.5.2

This deficiency could affect approximately 25 occupants.

Findings include:

On 01/07/2020, during a tour of the facility from 1:00 pm to 4:30 pm, the facility failed to provide documentation of testing the dampers (smoke/fire/ceiling) within the past 4 years.

A member of the maintenance staff was present when this deficiency was identified.

.

Based on review of documentation, the facility failed to maintain the HVAC smoke dampers per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 5.4.8.2
2010 NFPA 105, 6.5.2

This deficiency could affect approximately all occupants.

Findings include:

On 01/08/2020, during a tour of the facility from 8:00 am to 11:30 am, the facility failed to provide documentation of testing the smoke dampers within the past 6 years.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency could affect approximately 20 occupants.

Findings include:

On 01/08/2020, during a tour of the facility from 8:00 am to 11:30 am, the surveyor observed an unsecured oxygen cylinder (approximately 24 cu. ft.) in the OR Holding/Recovery Room.

A member of the maintenance staff was present when this deficiency was identified.