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OSF SACRED HEART MEDICAL CENTER
No Description Available
Tag No.: K0021
K021 New
A) (New 6/28/12) The 1st floor Lab suite northwest double egress door has a door closer with a hold open device that is not designed to release the door upon activation of the fire alarm system. Also, a smoke detector is not installed within five feet of the door in accordance with 7.2.1.8.
Failure to install and maintain fire doors could result in spread of fire and smoke to patient areas.
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No Description Available
Tag No.: K0025
K025 (New)
A) From observation, the surveyor finds that the Lobby Level of the Lobby Level of the 1980 Building was very recently renovated. The specifics of this renovation are not available. However, based on the extent of renovation, the surveyors find that 18.3.7.1 (2) is applicable. The provider has not demonstrated how two smoke compartments are provided in accordance wit 18.3.7.1.
It is the intent of this citation to remove the information provided in the PoC under K038 G and to revise and resubmit the information under K025.
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No Description Available
Tag No.: K0046
K046 New
A) (New 6/28/12) The surveyor finds that emergency lighting is not installed and maintained in accordance 7.9.3 of NFPA 101 - 2000.
The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0", it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.
1) The Mobile Unit has emergency lighting fixtures with batteries. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of these lighting fixtures in the mobile unit in accordance with 7.9.3.
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No Description Available
Tag No.: K0052
K052 New
K046 New
A) (New 6/28/12) The surveyor finds that the Mobile Unit fire alarm system is not and maintained NFPA 72- 1999.
The surveyor finds that the provider brings in a Mobile PET/CT Unit once a week and parks it in the Clean Loading Dock. The unit is used strictly for outpatient diagnostics. Because of its proximity to the Hospital, less than 5'-0" it has been evaluated as part of the Hospital; however it does not constitute a fire hazard to the Hospital. This mobile unit has been evaluated as a Business Occupancy under Chapter 39 of NFPA 101 and it does not comply.
1) The Mobile Unit has a limited fire alarm system. The tag on the main fire alarm panel for the unit indicates that it was last tested in March of 2011. No documentation of testing or maintenance was available for 2012. The Mobile Unit and/or the Hospital lacks written documentation, on site, for the testing and maintenance of this fire alarm system.
Failure to test and maintain the fire alarm system could cause failure of the system during a fire.
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