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MEMORIAL HERMANN FIRST COLONY HOSPITAL
No Description Available
Tag No.: K0018
Facility failed to maintain corridor doors in accordance with the 2000 edition of the Life Safety Code, National Fire Protection Association (NFPA) 101. Findings included:
Surveyor observed between 1:00 and 2:00 pm on 08/08/12 that in nursing unit wedge was holding open door to isolation suite and that double acting doors to toilet room and assisted bathing were not smoke resistant.
No Description Available
Tag No.: K0050
Facility failed to maintain records of fire drills in accordance with the 2000 edition of NFPA 101. Findings included the following:
Surveyor observed between 11:00 and 11:30 am on 08/08/12 that facility records did not include fire drills once per quarter per shift in the last year.
No Description Available
Tag No.: K0051
Facility failed to maintain fire alarm system in accordance with 2000 edition of the Life Safety Code, NFPA 101. Findings included:
Surveyor observed between 1:00 and 1:30 pm on 08/08/12 that exit to outside the building from staff lounge to outside did not have manual pull station.
No Description Available
Tag No.: K0130
Facility failed to maintain 1. disaster drills in accordance with the 1999 edition of the Standard for Health Care, NFPA 99 and 2. records of heating, ventilating, air conditioning (HVAC) filter changes in accordance with Hospital Licensing Rules. Findings included the following:
Surveyor observed between 1:00 and 2:00 pm on 08/08/12 that
1. last record of disaster drill occurred on 5/11/11. This is not semiannual basis in accordance with NFPA 99, 1999: 11-5.3.9 Drills.
2. no record of HVAC filter changes was available onsite in accordance with HLR 13.3162(d)(3)(D)(ii) Filtration Requirements.
No Description Available
Tag No.: K0145
Facility failed to maintain electrical distribution system in accordance with the 1999 edition of NFPA 99, Standard for Health Care Facilities. Findings included the following:
Surveyor observed between 1:00 and 2:00 pm on 08/08/12 that distribution panel ELS outside the building had directory which did not indicate fire alarm for circuit #15 although the breaker had a label next to indicating fire alarm circuit. Further, the distribution panel EEQ had an opening and it was not possible to determine that airborne isolation room exhaust fan was powered by emergency system.