HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to maintain the required 1 hour fire-rating for the west wall of the MED GAS STORAGE ROOM. There were multiple unsealed penetrations.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to provide the required Exit Signage at various EXIT CORRIDOR locations throughout the facility. These locations were identified and documented for the facility. There are 9 such locations where exit signs are to be added. Additionally, 1 existing exit sign location was identified as improper for an exit sign. The facility needs to remove the sign from CORRIDOR of DECONTAM ROOM.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to provide a log indicating consistent, systematic compliance with requirement for quarterly fire drills on each shift.

Based on observations made during the survey of the facility between the hours of 1:30 pm and 5:00 pm while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to comply in regards to the following:

60 " A.F.F. in MED GAS STORAGE ROOM - An electrical receptacle was located less than 60 " A.F.F. This does not comply with the following:
NFPA 99, 2002: 5.1.3.3.2(5) " Locations for central supply systems and the storage of medical gases shall be compliant with NFPA 70 National Electric Code, for ordinary locations, with electrical devices located at or above 1520mm (5 ft) above finished floor to avoid physical damage. "

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to maintain the required 1 hour fire-rating for the west wall of the MED GAS STORAGE ROOM. There were multiple unsealed penetrations.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to provide the required Exit Signage at various EXIT CORRIDOR locations throughout the facility. These locations were identified and documented for the facility. There are 9 such locations where exit signs are to be added. Additionally, 1 existing exit sign location was identified as improper for an exit sign. The facility needs to remove the sign from CORRIDOR of DECONTAM ROOM.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to provide a log indicating consistent, systematic compliance with requirement for quarterly fire drills on each shift.

Based on observations made during the survey of the facility between the hours of 1:30 pm and 5:00 pm while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that the facility failed to comply in regards to the following:

60 " A.F.F. in MED GAS STORAGE ROOM - An electrical receptacle was located less than 60 " A.F.F. This does not comply with the following:
NFPA 99, 2002: 5.1.3.3.2(5) " Locations for central supply systems and the storage of medical gases shall be compliant with NFPA 70 National Electric Code, for ordinary locations, with electrical devices located at or above 1520mm (5 ft) above finished floor to avoid physical damage. "

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Human Resources Director, IT Director, and Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually