HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.2.1.9.1.3

This deficiency affects 1 of 1 pair of power doors.

Findings include:

During a tour of the facility, the surveyor observed the pair of cross-corridor power doors between the Emergency Department Hall and the Operating Department Hall did not have a sign on the egress side that reads: "IN EMERGENCY, PUSH TO OPEN".

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the exit discharges per the requirements of:

2012 NFPA 101, 19.2.7, and 7.7

This deficiency affects 1 of 1 exits.

Findings include:

During a tour of the facility, the surveyor observed that the path from the South Med/Surge exit door to the public way was paved most of the distance from the building but stopped approximately 25' from the public way, therefore not providing a hard-packed all-weather travel surface the entire distance to the public way.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency affects one storage room.

Findings include:

During a tour of the facility, the Medical Record's Storage Room's door did not have a self-closing device; this room was over 50 sq. ft. with storage of excessive amounts of paper stored in card board boxes (combustibles). Room located across from Physical Therapy of Bldg. 0202.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects the appliances under the kitchen hood.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.

A member of maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h)

This deficiency affects all of the smoke detectors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7
2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following:

(1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.2.1, 14.2.1,and13.6.2.1

This deficiency affects the automatic sprinkler system.

Findings include:

During the review of the documentation, the facility failed to provide the following documentation:

1. Of conducting the automatic sprinkler internal pipe inspection within the past 5 years.

2. The riser gauges being replaced or calibrated within the past 5 years.

3. The backflow preventer being tested within the past 12 months.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.2.1, 14.2.1,and13.6.2.1

This deficiency affects the automatic sprinkler system.

Findings include:

During the review of the documentation, the facility failed to provide the following documentation:

1. Of conducting the automatic sprinkler internal pipe inspection with in the past 5 years.

2. The riser gauges being replaced or calibrated within the past 5 years.

3. The backflow preventer being tested with in the past 12 months.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain the permitted smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (5), (6)

This deficiency affects 1 of 2 buildings.

Findings include:

During a tour of the facility, the surveyor observed the permitted smoking area for the Chemical Dependency Unit had the following deficiencies:

1. The facility failed to provide an ashtray of noncombustible material

2. The metal container with self-closing cover device was full of combustibles, such as cigarette boxes and styrofoam cups

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.5.4, 11.6.2.3 (11), 11.6.5.1, 11.6.5.2, and 11.6.5.3

This deficiency affects all the Med Gas Room cylinders and back-up oxygen cylinders.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to protect the outside cylinders against continuous exposure to direct rays of the sun where extreme temperatures prevail and from the ground beneath to prevent rusting at the following locations:

A. The back-up "K" oxygen cylinders

B. The empty "K" oxygen cylinders at the back of the Medical Gas Room

2. In the Medical Gas Storage Room the facility failed to:

A. Properly chain or support seven (7) - 24 cu. ft. oxygen cylinders and twelve (12) - "K" cylinders

B. Segregate full and empty cylinders stored together

C. Mark empty cylinders to avoid confusion

A member of the maintenance staff was present when this deficiency was identified.