HospitalInspections.org

Facility failed to maintain exit signs in accordance with the 2000 edition of the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the folowing:

Surveyor observed between 11:00 and 11:45 am on 3/13/13 that access to exits in corridor between main nurse station and emergency room (ER) and in the corridor containing the computed tomography (CT) room were not completely marked and that copy of posted evacuation plan was outdated and needs to be revised accordingly. smoke barriers were also not clearly identified on evacuation map.

Facility failed to maintain access to exits in accordance with the 2000 editon of NFPA 101. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 3/13/13 that one of two cross corridor control doors outside of Emergency waiting area was latched at the top which restricts access to exits.

Facility failied to maintain lighting in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed between 1:00 and 1:30 pm on 1/13/13 that in corridor leading to CT two of four life safety lighting fixtures were missing bulbs .

Facility failied to provide emergency exit lighting in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed between 11:00 and 11:45am on 3/13/13 that a lighted directional sign was missing from corridor at cross corridor control door outside of emergency waiting area.

Facility failed to maintain records of fire alarm testing in accordance with the 1999 edition of NFPA 72, Nationa Fire Alarm Code. Findings included the following:

Surveyor observed between 9:30 and 10 am on 3/13/13 that records of annual fire alarm inspection did not state that fire alarm system was in compliance with NFPA 72.

Facility failed to maintain portable fire extinguishers in accordance with the NFPA 10, Standard for Portable Fire Extinguishers. Findings included the following:

Surveyor observed between 10 and 10:30 am on 3/13/13 that in the kitchen, commerical cooking equipment protection did not include "Class K" extinguisher with placard to read "fire protection system shall be activated prior to use of the fire extinguisher".

Facility failed to maintain mechanical equipment in accordance with the 1999 edition of the Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 90A. Findings included the following:

Surveyor observed between 11:00 and 11:45am on 3/13/13 that exhaust fans in staff toilet room and janitor room were not functioning and that the manometer gauge on the final filter in the mechanical room containing the vacuum pump was not also not functioning.

Faclity failed to maintain cooking equipment protection and inspections in accordance with the 1998 edition of the Standard for Ventilation Control and Fire Protection of Commercial Cooking equipment, NFPA 96. Findings included the following:

Surveyor observed between 9:30 and 10 am on 3/13/13 that records of inspection and servicing of the commercial cooking fire protection equipment indicated that inspections were annual not every six months as required.

Facilty failed to maintain corridora clear from obstructions in accordance with the 2000 edition of NFPA 101. Findings include the following:

Surveyor observed between 11:00 and 11:45 on 3/13/13 that one of eight exits was partially blocked by red bag waste bags in container and boxes.

Facility failed to maintain records of inspections of biomedical equipment in accordance with the 1999 edition of NFPA 99. Findings included the following:

Surveyor observed between 9:30 and 10:00 am on 3/13./13 that records for testing three of three defibrolators did not indicate semi-annual testing for critical equipment in accordance with NFPA 99: 7-6.2.1.

Facility failed to maintain medical gas alarms in accordance with 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed between 10:00 and 10:30 am on 3/13/13 that two of two status lights on medical gas alarm panels outside main nurse station and on corridor wall of emergency room were not lighted.

Facilty failed to maintain records of generator inspections in accordance with the 1999 edition of NFPA 110. Findings included the following:

Surveyor observed between 9:30 and 10 am on 3/13/13 that inspection records did not include log of weekly inspection of generator, which reportedly is on a automatic weekly start cycle.

Facility failed to maintain electrical receptacle testing in accordance with the 1999 editon of NFPA 99. Findings included the following:

Surveyor observed between 9:30 and 10:00 am on 3/13/13 that records did not include testing of patient care receptacles as follows (NFPA 99: 3-3.3.3:

Physical integrity of each receptacle (visual)
Continuity of the grounding of each receptacle (test)
Correct polarity of hot and neutral connections in each receptacle (test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Testing intervals (NFPA 99: 7-6.2.1):
General care areas tested annually
Critical care areas tested semi-annually
wet location tested annually.