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PICKENS COUNTY MEDICAL CENTER
Cooking Facilities
Tag No.: K0324
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Based on documentation and interview, the facility failed to maintain the kitchen hood exhaust system per the requirements of:
2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 11.4, and 11.6.1
Findings include:
On 01/11/2018, during a tour of the facility from 8:00 am to 3:00 pm, the facility failed to provide the kitchen hood exhaust system's semi annual inspection report for the past six months. The only inspection report the facility provided was dated 04/2017.
A member of the maintenance staff was present when this deficiency was identified.
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Alcohol Based Hand Rub Dispenser (ABHR)
Tag No.: K0325
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Based on review of documentation and interview, the facility failed to maintain the alcohol-based hand-rub (ABHR) dispensers per the requirements of:
2012 NFPA 101, 19.3.2.6(11) (f)
This deficiency could affect all patients.
Findings include:
On 01/11/2018, during a tour of the facility from 8:00 am to 3:00 pm, the facility failed to provide documentation regarding the testing each time a new alcohol-based hand-rub (ABHR) dispenser refill is installed.
A member of the maintenance staff was present when this deficiency was identified.
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Sprinkler System - Maintenance and Testing
Tag No.: K0353
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Based on observation and interview, the facility failed to maintain the automatic sprinkler system pipes from external loads per the requirements of:
2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.2.2.2
This deficiency could affect 20 patients.
Findings include:
On 01/11/2018, during a tour of the facility from 8:00 am to 3:00 pm, the surveyor observed several blue cable wires hung/tied to the automatic sprinkler system pipes above the ceiling in the Endoscopy Waiting Room at the smoke barrier on the 2nd floor.
A member of the maintenance staff was present when this deficiency was identified.
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Electrical Systems - Other
Tag No.: K0911
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Based on observation and interview, the facility failed to maintain the electrical wiring and equipment per the requirements of:
2012 NFPA 99, 6.3.2.1
2011 NFPA 70, 314.28 (C)
This deficiency could affect 10 patients.
Findings include:
On 01/11/2018, during a tour of the facility from 8:00 am to 3:00 pm, the surveyor observed an electrical junction box missing it's cover above the ceiling at the smoke barrier in "Lab Batier Room".
A member of the maintenance staff was present when the deficiency was found.