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GOOD SHEPHERD SPECIALTY HOSPITAL
No Description Available
Tag No.: K0018
Based on observation and interview, it was determined the facility failed to maintain corridor openings in six locations, affecting two of two smoke compartments.
Findings include:
1. Observation on February 02, 2016, between 10:10 a.m. and 10:50 a.m. revealed the following:
a. 10:10 a.m., the fourth floor, Housekeeping corridor door was held open by unapproved means (wash cloth.)
b. 10:14 a.m., the fourth floor, GS 4001 Patient Room door lacked positive latching when coupled with the corresponding door frame assembly.
c. 10:15 a.m., the fourth floor, GS 4003 Patient Room door lacked smoke-tight integrity when coupled with the corresponding door frame assembly.
d. 10:16 a.m., the fourth floor, GS 4004 Patient Room door lacked smoke-tight integrity when coupled with the corresponding door frame assembly.
e. 10:22 a.m., the fourth floor, Clean Supply Room door was held open by unapproved means (tape.)
f. 10:50 a.m., the third floor, Therapy Manager's Office door was held open by unapproved means (three ring binder/notebook.)
Exit interview with Facilities Manager between 11:00 a.m. and 11:15 a.m. on February 02, 2016, confirmed the corridor opening deficiencies.
No Description Available
Tag No.: K0029
Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures in four locations, affecting two of two smoke compartments.
Findings include:
1. Observation on February 02, 2016, between 10:28 a.m. and 10:48 a.m. revealed the following:
a. 10:28 a.m., the fourth floor, Soiled Utility Room doors (2) were held open by unapproved means (tape.)
b. 10:48 a.m., the third floor, Soiled Utility Room doors (2) were held open by unapproved means (tape.)
Exit interview with Facilities Manager between 11:00 a.m. and 11:15 a.m. on February 02, 2016, confirmed the hazardous area enclosure deficiencies.
No Description Available
Tag No.: K0062
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two smoke compartments.
Findings include:
1. Observation on February 02, 2016, at 10:07 a.m. revealed a penetration of the suspended ceiling assembly within the fourth floor, Housekeeping Room.
Exit interview with Facilities Manager between 11:00 a.m. and 11:15 a.m. on February 02, 2016, confirmed the automatic sprinkler system deficiency.
No Description Available
Tag No.: K0076
Based on observation and interview, it was determined the facility failed to maintain two oxygen storage rooms in four locations, affecting two of two smoke compartments.
Findings include:
1. Observation on February 02, 2016, between 10:22 a.m. and 10:55 a.m. revealed the following:
a. 10:22 a.m., the fourth floor, Oxygen Storage Room doors (2) were held open by unapproved means (tape.)
b. 10:55 a.m., the third floor, Oxygen Storage Room doors (2) were held open by unapproved means (tape.)
Exit interview with Facilities Manager between 11:00 a.m. and 11:15 a.m. on February 02, 2016, confirmed the medical gas storage room deficiencies.
No Description Available
Tag No.: K0147
Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of two smoke compartments.
Findings include:
1. Observation on February 02, 2016, at 10:12 a.m. revealed the fourth floor, Electrical Room door was held open by unapproved means (tape.)
Exit interview with Facilities Manager between 11:00 a.m. and 11:15 a.m. on February 02, 2016, confirmed the electrical systems room deficiency.