Nursing Investigation Results -

Pennsylvania Department of Health
GRANDVIEW SURGERY & LASER CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GRANDVIEW SURGERY & LASER CENTER
Inspection Results For:

There are  18 surveys for this facility. Please select a date to view the survey results.

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GRANDVIEW SURGERY & LASER CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 07541500
Component 01
Main Building, 1st Floor

Based on a Relicensure Survey completed on January 15, 2020, it was determined that Grandview Surgery & Laser Center was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a four-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


28 Pa. Code 569.2 STANDARD Gas Equipment -Cylinder and Container Storage:State only Deficiency.
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas cylinder to be secured, which serves the entire component.

Finding include:

1. Observation on January 15, 2020, at 9:45 AM revealed approximately eight H-size medical gas cylinders were unsecured, in the Med-Gas Manifold room.

Interview at the time of the exit conference with the Administrator on January 15, 2020, at 10:15 AM confirmed the cylinders were not secured.



 Plan of Correction - To be completed: 01/22/2020

1. All cylinders located inside the gas house will be secured with existing chains.
2. Administrator or designee will complete a weekly random audit of the gas house for compliance for 3 months. If any issues are noted they will be addressed at that time and audits may be extended if necessary.
3. Necessary teammates will be educated and reinforced the importance of keeping all cylinders chained within the gas house at all times. Education will be completed by 1/31/2020.

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