HospitalInspections.org

Based on observation the facility failed to provide adequate separation between the hospital and the adjacent clinic.

The inspector observed, while accompanied by The CEO and The Director of the Plant Maintenance during the hours of the inspection from 1:00 PM to 3:00 PM on 05/25/2016 that there were the following issues. They were the following issues.

There was not a 2 hour wall to deck between the hospital and the clinic. In addition, the doors in this wall were unrated, hallow core doors.

Based on observation the facility failed to provide adequate protection of the corridors.

The inspector observed, while accompanied by The CEO and The Director of the Plant Maintenance during the hours of the inspection from 1:00 PM to 3:00 PM on 05/25/2016 that there were the following issues with the corridor separation. In the portion of the hospital that was not fire sprinklered, the walls did not go to the deck.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by The CEO and The Director of the Plant Maintenance during the hours of the inspection from 1:00 PM to 3:00 PM on 05/25/2016 that there were the following issues

They were: 1) at the cross corridor doors at the ER Lobby, 2) at the cross corridor door to the kitchen, and 3) at the cross corridor door to the clinic.

The inspector observed, while accompanied by The CEO and The Director of the Plant Maintenance during the hours of the inspection from 1:00 PM to 3:00 PM on 05/25/2016 that there were the following issues. They were the following issues.

A.) There were no label provided for the essential electrical panel and transfer switch panel. The label shall be easily identifiable as life safety, critical or equipment branch and in distinct color label.

The inspector observed, while accompanied by The CEO and The Director of the Plant Maintenance during the hours of the inspection from 1:00 PM to 3:00 PM on 05/25/2016 that there were the following issues. They were the following issues.

A) The facility failed to provide a history of records for the Line Isolation Monitor testing at inpatient care areas per NFPA 99: 3-3.3.3.
B)
" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "