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Based on observation, the facility failed to maintain an exit component (stairway exit door latch) so as to protect the stairway against migrating fire and smoke.

Failure to maintain exit components puts patients, staff and visitors of the facility at risk from fire and smoke.

Findings Include:

On 4/5/2012, surveyor #3 and #4 observed that the Stair 3 Fire exit door failed to self-latch during the facility tour with the Facilities Director (Staff Member #10) and the Facilities Supervisor (Staff Member #11). Attempts by the Lead Engineer (Staff Member #12) to fix the door latch at time of the tour were unsuccessful.

Based on observations, the facility failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

a. On 4/3/2012:
1. Missing sprinkler escutcheon in the Echocardiogram room;
2. Misaligned sprinkler head 3rd floor nurse's station;
3. No sprinkler coverage found in 3rd floor electrical room (across from room 315); and
4. Sprinkler head recessed above ceiling tile, 3rd floor West storage room.

b. On 4/4/2012:
Two missing sprinkler escutcheons in the nuclear medicine "Hot Lab".

c. On 4/5/2012:
1. Missing sprinkler escutcheon in SPD; and
2. Obstructed sprinkler head (next to overhead light box) in SPD storage room.

d. On 4/6/2012:
Missing sprinkler escutcheon in Admin Office Space 1st floor.

Based on observation and interview, the facility failed to maintain relative humidity above 35% in procedure rooms containing medical gases.

Failure on the part of the facility to be able to control the relative humidity in locations where anesthetics are being used puts patients and staff at risk from fire or static electricity discharge.

Findings include:

On a tour of the facility 4/5/2012, the computer system monitoring plant functions registered a relative humidity reading of 12.5% in Operating Suite #4. This finding was confirmed by the Facilities Supervisor (Staff Member #11), and was corrected the following morning. An alarm feature was set to alert the Facility staff and OR staff (via PBX) if the relative humidity dropped below the desired level.

Based on observation, the facility failed to properly contain oil-soaked rags in the elevator equipment room.

Failure to properly contain items soaked in flammable liquid poses a risk of fire to patients, staff and visitors.

Findings include:

On a facility tour of the elevator equipment room on 4/3/2012, surveyor #4 observed that oil-soaked rags were left in a bucket and not contained in a firebox. This was confirmed by the Facilities Director (Staff Member #10) and Lead Engineer (Staff Member #12).

Based on observations, the facility failed to ensure that electrical wiring was maintained as required in accordance with NFPA 70, National Electrical Code. 9.1.2

Failure to appropriately maintain the electrical wiring may result in delay in cutting or restoring power to electrical circuits in the event of fire or other emergency and put patients, staff and visitors at risk of fire.

Findings include:

a. 4/3/2012: Apparatus blocking access to electrical panel on the 4th floor. Corrected during survey;

b. 4/3/2012: Unlabeled breakers in electrical panel box "4CUPS-A"; and

c. 4/4/2012: Uncovered junction box in the 2nd Floor Electrical Room.

Based on observation, the facility failed to maintain an exit component (stairway exit door latch) so as to protect the stairway against migrating fire and smoke.

Failure to maintain exit components puts patients, staff and visitors of the facility at risk from fire and smoke.

Findings Include:

On 4/5/2012, surveyor #3 and #4 observed that the Stair 3 Fire exit door failed to self-latch during the facility tour with the Facilities Director (Staff Member #10) and the Facilities Supervisor (Staff Member #11). Attempts by the Lead Engineer (Staff Member #12) to fix the door latch at time of the tour were unsuccessful.

Based on observations, the facility failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

a. On 4/3/2012:
1. Missing sprinkler escutcheon in the Echocardiogram room;
2. Misaligned sprinkler head 3rd floor nurse's station;
3. No sprinkler coverage found in 3rd floor electrical room (across from room 315); and
4. Sprinkler head recessed above ceiling tile, 3rd floor West storage room.

b. On 4/4/2012:
Two missing sprinkler escutcheons in the nuclear medicine "Hot Lab".

c. On 4/5/2012:
1. Missing sprinkler escutcheon in SPD; and
2. Obstructed sprinkler head (next to overhead light box) in SPD storage room.

d. On 4/6/2012:
Missing sprinkler escutcheon in Admin Office Space 1st floor.

Based on observation and interview, the facility failed to maintain relative humidity above 35% in procedure rooms containing medical gases.

Failure on the part of the facility to be able to control the relative humidity in locations where anesthetics are being used puts patients and staff at risk from fire or static electricity discharge.

Findings include:

On a tour of the facility 4/5/2012, the computer system monitoring plant functions registered a relative humidity reading of 12.5% in Operating Suite #4. This finding was confirmed by the Facilities Supervisor (Staff Member #11), and was corrected the following morning. An alarm feature was set to alert the Facility staff and OR staff (via PBX) if the relative humidity dropped below the desired level.

Based on observation, the facility failed to properly contain oil-soaked rags in the elevator equipment room.

Failure to properly contain items soaked in flammable liquid poses a risk of fire to patients, staff and visitors.

Findings include:

On a facility tour of the elevator equipment room on 4/3/2012, surveyor #4 observed that oil-soaked rags were left in a bucket and not contained in a firebox. This was confirmed by the Facilities Director (Staff Member #10) and Lead Engineer (Staff Member #12).

Based on observations, the facility failed to ensure that electrical wiring was maintained as required in accordance with NFPA 70, National Electrical Code. 9.1.2

Failure to appropriately maintain the electrical wiring may result in delay in cutting or restoring power to electrical circuits in the event of fire or other emergency and put patients, staff and visitors at risk of fire.

Findings include:

a. 4/3/2012: Apparatus blocking access to electrical panel on the 4th floor. Corrected during survey;

b. 4/3/2012: Unlabeled breakers in electrical panel box "4CUPS-A"; and

c. 4/4/2012: Uncovered junction box in the 2nd Floor Electrical Room.