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GREATER BATON ROUGE SURGICAL HOSPITAL
No Description Available
Tag No.: K0017
Based on visual observation this sprinklered facility failed to assure that all areas within or open to a corridor were protected. Systems are provided to assure the protection of occupants and the integrity of the means of egress which are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 10 of 10 patients.
Findings:
During the facility tour, between the hours of 8:00 am and 4:00 pm, the corridor within the Pre-Op Area had a space open to the corridor that was not covered by smoke detection and not in full view of the nurses station.
No Description Available
Tag No.: K0050
Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 10 of 10 residents.
2 of 4 quarters in 2009-2010 were deficient.
Findings:
During the record review, between the hours of 8:00 am and 4:00 pm, the documentation for the following drills could not be provided:
1. 2nd Quarter, 2010 (April-June) 7am-7pm shift and 7pm-7am shift.
2. 3rd Quarter, 2010 (July-September) 7pm-7am shift
No Description Available
Tag No.: K0056
Based on visual observation the facility failed to assure that all required components were a part of the automatic sprinkler system. The sprinkler system provides early warning of a fire emergency. The deficient practice had the potential to affect 10 of 10 residents.
Findings:
During the facility tour, between the hours of 8:00 am and 4:00 pm, it was observed that the back flow preventor, on the exterior of the building, was not insulated to prevent freezing when temperatures reach under 42 degrees.
No Description Available
Tag No.: K0144
Based on visual observation and record review, the facility failed to assure that the weekly inspection program on the emergency generator was conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 10 of 10 residents.
3 of 12 months were deficient.
Findings:
During the record review, between the hours of 8:00 am and 4:00pm, documentation for the weekly inspection of the emergency generator was not available for the months of May, June and July, 2010.