HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 8/03/2011, while being accompanied by the Director of Quality Improvement and Director of Facility Maintenance, the facility failed to provide an exit sign marking the egress path out the building. The exit sign, located at the end of the third floor patient wing ' s egress corridor, did not indicate the direction of egress via a chevron type indicator. A sign with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent

Based on observations during the survey walk of the facility on the morning of 8/03/2011, while being accompanied by the Director of Quality Improvement and Director of Facility Maintenance, the facility failed to maintain proper clearance from the fire sprinkler head. Boxes sat less then 18 " underneath sprinkler head in the kitchen ' s food storage room

Based on observations during the survey walk of the facility on the morning of 8/03/2011, while being accompanied by the Director of Quality Improvement and Director of Facility Maintenance, the facility failed to secure one med gas canister which was located in the fourth floor men ' s toilet. The canister tank shall be stored in an one hour rated room, including a 45 minute door with closure and the canister must be individually secured to prevent failing or turning over

Based on review of records during the survey of facility on the afternoon of 8/03/2011, while being accompanied by the Director of Quality Improvement and Director of Facility Maintenance, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested as follows: receptacle testing in patient care areas should be at least annually. Currently there are no critical care areas. Facility must initiate a log to retain these records

Based on observations during the survey walk of the facility on the afternoon of 8/03/2011, while being accompanied by the Director of Quality Improvement and Director of Facility Maintenance, the facility failed to assure that the essential electrical system was in full compliance. NCTP was supplied with power from the life safety branch of the essential electrical system. It could not be determined what NCTP meant. Verify its function and determine if it needs to be moved to the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch