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MERCY MCCUNE BROOKS HOSPITAL
No Description Available
Tag No.: K0062
Based on observation and interview the facility failed to maintain all ceiling mounted sprinkler heads free of obstructions to the spray pattern. This deficient practice affects all occupants in the facility. The facility census was 15.
Findings included:
1. Observation, during a tour of the facility conducted on the afternoon of 06/05/12 at 2:02 PM, showed boxes on the top shelf on the pharmacy storage room to be approximately 12 inches from the deflector of the ceiling mounted sprinkler head.
2. Staff P, Maintenance Manager, confirmed at that time the clearance between the boxes and the sprinkler head was less than 18 inches.
Section 8.5.6.1 of the National Fire Protection Association (NFPA 13) states the clearance between the deflector and the top of storage shall be 18in. (457 mm) or greater.
No Description Available
Tag No.: K0069
Based on document review and interview the facility failed to conduct a semi-annual inspection of the range hood suppression system in the kitchen. This deficient practice affects all occupants in the facility. The facility census was 15.
Findings included:
1. Review of the facility kitchen range hood suppression system inspection documents, conducted on the morning of 06/05/12, showed the last two inspections of the range hood suppression system by an outside contractor had occurred on March 7, 2011 and the latest inspection occurring on April 19, 2012.
2. During an interview on 06/05/12 at 3:50 PM, Staff P Maintenance Manager, stated that an inspection of the range hood suppression system was not being conducted on a semi-annual basis.
Section 8-2 of the National Fire Protection Association (NFPA 96) states: An inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons.
No Description Available
Tag No.: K0076
Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was 15.
Findings included:
1. Observation, during a tour of the facility conducted on the afternoon of 06/05/12 at 1:20 PM, showed four " H " size tanks of Nitrogen secured by one chain, four " H " size tanks of Nitrous Oxide secured by one chain 13 ' H " size tanks containing various gases secured by one chain.
2. Staff P, Maintenance Manager, confirmed at that time the portable medical gas cylinders were not individually secured.
Section 5.1.3.3.2 of the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.