HospitalInspections.org

K-012

Based upon observation and interview, it was determined the building construction type and height does not meet regulations in all areas of the entire building.

Findings include:

Observation on August 1, 2012, at 9:30 am revealed the building construction type exceeds the height requirements for this type of construction. This condition is acceptable per FSES conducted on June 28, 2005.

Interview with Director of Plant Services (DPS) on August 1, 2012, at 9:30 am confirmed the above condition exists and is acceptable per FSES.

K-029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on two of three floors.

Findings include:

Observation on July 31, 2012, between 10:30 am and 1:25 pm revealed hazard areas doors lacked positive latching at the following locations:
1. Third floor Soiled Utility room door across from patient room 305.
2. First floor Medical Records Storage room door.
3. First floor Delivery Room Soiled Utility door.
4. First floor Mechanical Room door near Gift shop.

Interview with DPS on July 31, 2012, at 1:25 pm confirmed the above listed doors lacked positive latching and the subsequent correction of Item #1 during the time of the survey.

K-064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on one of three floors.

Findings include:

Observation on August 1, 2012, at 10:00 am revealed the first floor Administration had a fire extinguisher that was not readily visible by the exit to outside.

Interview with DPS on August 1, 2012, at 10:00 am confirmed the fire extinguisher was not visible and the subsequent correction during the time of the survey.

K-077

Based upon observation and interview, the piped in medical gas system does not comply with regulations on one of three floors.

Findings include:

Observation on July 31, 2012, at 10:45 am revealed patient room 302 had medical gas (vacuum) lines that were not labelled.

Interview with DPS on July 31, 2012, at 10:45 am confirmed the vacuum lines were not labelled.

K-147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of three floors.

Findings include:

1. Observation on July 31, 2012, at 12:45 pm revealed the first floor Risk Management office was utilizing a multiple outlet extension cord.

Interview with DPS on July 31, 2012, at 12:45 pm confirmed the utilization of a multiple outlet extension cord and the subsequent correction during the time of the survey.

2. Observation on July 31, 2012, between 1:00 pm and 1:05 pm revealed the facility had electrical panels that were blocked by carts at the following locations:
A. First floor O.R. Soiled Utility room.
B. First floor Cysto room.

Interview with DPS on July 31, 2012, at 1:05 pm confirmed the electrical panels listed above were blocked by carts and the subsequent correction during the time of the survey.

K-211

Based upon observation and interview, alcohol based hand sanitizers (ABHS) are not installed or stored according to regulations on one of three floors.

Findings include:

Observation on August 1, 2012, at 9:45 am revealed an ABHS located above and electrical outlet in the first floor X-Ray room 4.

Interview with DPS on August 1, 2012, at 9:45 am confirmed the ABHS located above an electrical outlet.