HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their walls. This was evidenced by 3 penetrations in the facility's walls. This affected 2 buildings and 2 of 13 main building smoke compartments. This could result in the spread of smoke to other locations in the facility.

Findings:

During a facility tour with staff on 1/28/10, the walls in the facility were observed.

Main Building:

1. At 3:22 p.m., there was an approximately 5 inch by 3 inch penetration in the wall below the desk in the private branch exchange room located in the emergency room. The penetration was in the lower corner of the wall.

2. At 4:04 p.m., there was an approximately 1 inch by 2 inch penetration in the storage room across from room 8 in the family birthing center. The penetration was located in the left hand wall behind the television stand.

Barton Memorial Hospital Community Clinic Building:

1. On 1/27/10 at 2:55 p.m., there were 5 approximately 1/2 diameter penetrations in the file room wall behind the microwave oven.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were obstructed from closing or latching, 1 door that failed to release from it's magnetic holding device, and 1 door that had penetrations in it. This affected 3 buildings and 8 of 13 main building smoke compartments. This could result in a delay to contain a fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Main Building:

1. On 1/27/10 at 4:36 p.m., the door to the shower room by room 305 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 1/28/10 at 8:36 a.m., the door to room 415 was obstructed from closing by a bed frame positioned in the swing path of the door.

3. On 1/28/10 at 1:42 p.m., the door to room 222 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck inside the door.

4. On 1/28/10 at 1:44 p.m., the door to room 224 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by a smoke seal on the door frame.

5. On 1/28/10 at 1:58 p.m., the door to room 225 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

6. On 1/28/10 at 2:41 p.m., the door to the equipment storage room by room 210 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin on the door was taped.

7. On 1/28/10 at 2:49 p.m., the door to the 2nd floor nurse manager's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

8. On 1/28/10 at 2:50 p.m., the door to the 2nd floor staff/nurse supervisor's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

9. On 1/28/10 at 3:00 p.m., the door to the storage room across from room 218 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

10. On 1/28/10 at 3:33 p.m., the door to the post anesthesia care unit by the surgery director's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck inside the door.

11. On 1/28/10 at 4:06 p.m., the door to the storage room across from room 8 in the family birthing center was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was dragging on the floor which obstructed the door from closing.

12. On 1/28/10 at 4:26 p.m., the door to x-ray room 3 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

13. On 1/28/10 at 4:34 p.m., the door to the MRI room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the air pressure difference

14. On 1/28/10 at 4:37 p.m., the door to the ultrasound/mammography waiting room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

15. On 1/28/10 at 4:40 p.m., the door to the nuclear medicine room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

16. On 1/28/10 at 4:42 p.m., the door to the radiologist's office by the nuclear medicine room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

17. On 1/28/10 at 4:43 p.m., the door to the radiologist's office by the viewing room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

18. On 1/28/10 at 4:45 p.m., the door to the viewing room in medical imaging was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

19. On 1/29/10 at 11:30 a.m., the door from the corridor to physical therapy/rehabilitation department was held open by a magnetic holding device. The door failed to release from the magnetic holder when the fire alarm system was activated.

20. On 1/29/10 at 12:00 p.m., the door to storage room B in the surgery department was obstructed from closing by a cart that was positioned in the swing path of the door.

21. On 1/29/10 at 12:16 p.m., the door to the sub-sterile room between operating rooms 3 and 4 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was missing a latching pin.

Barton Memorial Hospital Community Clinic Building:

1. On 1/27/10 at 2:45 p.m., the door to the nurse practitioner's office by exam room 7 was obstructed from closing by a trash bin positioned in the swing path of the door.

Barton Medical Clinic at Sierra at Tahoe Building:

1. On 1/29/10 at 9:36 a.m., the door from the staircase to the first aid room had 5 approximately 1/2 inch diameter penetrations in the upper corner of the door.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This affected 1 building and 2 of 13 main building smoke compartments. This could result in the spread of smoke from one smoke compartment to another.

Findings:

During a facility tour with staff, the facility's smoke barrier walls were observed.

Main Building:

1. On 1/27/10 at 1:33 p.m., there was an approximately 8 inch by 10 inch square penetration in the smoke barrier wall by the physical therapy/rehabilitation department. The penetration was in the central wall above the smoke barrier doors.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by 1 smoke barrier door that failed to latch and 1 smoke barrier door that was obstructed from closing. This affected 1 building and 3 of 13 main building smoke compartments. This could result in a delay to contain a fire to a smoke compartment.

Findings:

During a facility tour with staff, the facility's smoke barrier doors were observed.

Main Building;

1. On 1/28/10 at 9:17 a.m., the smoke barrier doors by the kitchen were equipped with self closing devices. The doors were held open to their fullest extent and allowed to close. 1 of 2 door leafs failed to latch. The door closed fast and bounced back then closed without latching.

2. On 1/29/10 at 11:37 a.m., the smoke barrier doors by the medical staff services office were equipped with self closing devices. The doors were held in the open position by magnetic holding devices wired to the fire alarm system. The fire alarm system was activated and 1 of 2 door leafs failed to close. The door was obstructed from closing due to air pressure difference. There was an approximately 1 foot gap between the door leafs.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by 2 doors to hazardous areas that were equipped with self closing devices that failed to latch the doors. This affected 1 building and 2 of 13 main building smoke compartments. This could result in a delay to contain a fire to a hazardous area.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Main Building:

1. On 1/28/10 at 12:11 p.m., the skilled nursing storage room located by the physical therapy/rehabilitation department was observed. The room was greater than 100 square feet and housed combustible storage items. The door to the room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by air pressure difference.

2. On 1/28/10 at 2:57 p.m., the door to the soiled linen room by room 225 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on document review and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to have a complete 5-year inspection on their sprinkler risers and 4 sprinklers that were missing escutcheon rings. This affected 1 building and 13 of 13 main building smoke compartments. This could result in a delayed sprinkler response in the event of a fire.

NFPA 25, 1998 edition
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-3.2 Gauges shall be replaced every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
10-2.2 Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years.

Findings:

During a facility tour with staff, the facility's automatic sprinkler system was observed.

Main Building:

1. During document review on 1/27/10, the last 5 year inspection report for the facility's 7 sprinkler risers were observed. The 5 year report was dated 10/27/08. The report failed to list what procedures were performed. The facility's most recent sprinkler quarterly inspection was reviewed. The last quarterly inspection was completed on 1/20/10. The quarterly inspection indicated that the piping has never been checked for obstructive materials, the gauges had not been tested, calibrated or replaced within the past 5 years, and the alarm valves and associated trim had not been internally inspected within the past 5 years. A statement from the facility's sprinkler system vendor, faxed on 2/1/10, indicated that those areas had not been checked during the last 5 year inspection. The facility's risers are currently tagged with a 5 year service tag dated 10/27/08.

2. On 1/28/10 at 12:11 p.m., the sprinkler in the skilled nursing storage room located by the physical therapy/rehabilitation department was missing an escutcheon ring.

3. On 1/28/10 at 2:42 p.m., the sprinkler in the equipment storage room located by room 210 was missing an escutcheon ring.

4. On 1/28/10 at 2:49 p.m., the sprinkler in the 2nd floor nurse manager's office was missing an escutcheon ring.

5. On 1/29/10 at 12:04 p.m., the sprinkler in the housekeeping closet located in the surgery department was missing an escutcheon ring.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by the storage of items in the corridor near an emergency exit and an egress path from an emergency exit that was obstructed by the accumulation of snow. This affected 1 building and 2 of 13 main building smoke compartments. This could result in a delayed evacuation due to obstructions in a means of egress.

Findings:

During a facility tour with staff, the facility's means of egress were observed.

Main Building:

1. On 1/27/10 at 4:04 p.m., 4 wheel chairs, 1 geriatric chair, and 1 patient lift device were positioned in the corridor near the emergency exit located by room 306. Staff 2 indicated that those items are stored there because of limited space in resident rooms.

2. On 1/28/10 at 9:26 a.m., the path from the emergency exit for the occupational health services department was observed. Directly outside the emergency exit was an accumulation of snow approximately 1 foot high. The snow was present from the emergency exit to a paved sidewalk approximately 30 feet away. Staff 3 indicated that the occupational health services department may treat patients with limited mobility. Staff 3 said that the exit door is sometimes used by patients as an indiscrete way to exit.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by 3 oxygen E cylinders that were free standing and unsecured and 1 door to an oxygen storage room that failed to latch. This affected 1 building and 1 of 13 main building smoke compartments. This could result in an increased risk of an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the facility's storage of oxygen gas was observed.

Main Building:

1. On 1/27/10 at 4:44 p.m., 2 of approximately 120 oxygen E cylinders were free standing and unsecured in the facility's outdoor oxygen storage room. The oxygen storage room was a detached structure from the main building.

2. On 1/28/10 at 3:14 p.m., 1 of 8 oxygen E cylinders were free standing and unsecured in the oxygen storage room across from room 2 in the emergency room.

3. On 1/28/10 at 3:15 p.m., the door to the oxygen storage room, across from room 2 in the emergency room, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame. There were 8 oxygen E cylinders in the room.

Based on document review and interview, the facility failed to maintain the humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to monitor and maintain 5 of 5 operating rooms with a 35 percent relative humidity or greater. This affected 1 building and 1 of 13 main building smoke compartments. This could result in a fire to occur due to electrostatic charges in an oxygen enriched environment in conjunction with flammable anesthetics.

NFPA 99, 1999 Edition
5.4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review, the facility's humidity levels in anesthetizing locations were observed.

Main Building:

1. On 1/28/10 to 1/29/10, the facility's relative humidity records in anesthetizing locations were observed. The facility's temperature and humidity control policy and procedure, dated 1/26/10, was reviewed. The facility's policy was, "to maintain a comfort controlled environment adjusting temperature and humidity as needed." The procedure indicated that levels would be monitored so as not to exceed 60 percent relative humidity. There was no lower relative humidity range specified in the policy and procedure.

The facility kept a monthly log of relative humidity levels for 5 of 5 operating rooms. A log from 1/28/10 indicated that 5 of 5 operating room relative humidity levels were 31 percent or lower with the lowest relative humidity level being 22.5 percent. A log from 1/2/10 indicated that 5 of 5 operating room relative humidity levels were 29.5 percent or lower with the lowest relative humidity level being 21.5 percent.

Staff 1 indicated that the facility did not monitor the relative humidity levels on a daily basis. Upon request, the facility generated a relative humidity level report that showed a relative humidity reading approximately every 5 minutes. The report detailed the relative humidity in operating room 1 from 8:06 p.m. on 1/18/10 to 11:07 a.m. on 1/28/10. The relative humidity levels were not consistently maintained at a level of 35 percent or greater. The relative humidity level dropped to as low as 16 percent during that time span. The relative humidity level never exceeded 40.5 percent during that time span.

Based on document review and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to complete an annual load bank test on 3 of 3 emergency generators. This affected 1 building and 13 of 13 main building smoke compartments. This could result in the facility being without power due to a malfunctioning emergency generator.

Findings:

During document review, the facility's emergency generator records were observed.

Main Building;

1. On 1/27/10, the facility's emergency generator records were observed. The facility conducts weekly load tests for 3 of 3 emergency generators. Staff 1 indicated that the load tests do not reach 30 percent of the generators' full load for the weekly load test. The emergency generators are powered by diesel fuel. The facility has a contract with a vendor valid from 4/1/09 to 3/31/11 to perform routine maintenance and conduct annual load bank tests on the emergency generators. The last load bank test completed on the emergency generators was conducted on 6/17/07.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by electrical receptacles that were missing or had broken faceplates, high powered appliances that were plugged into surge protected multi-outlet extension cords, and surge protected multi-outlet extension cords that were plugged into other surge protected multi-outlet extension cords. This affected 2 buildings and 6 of 13 main building smoke compartments. This could increase the risk of an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Main Building:

1. On 1/27/10 at 4:08 p.m., an electrical receptacle behind the bed-side shelf in room 308 had a broken faceplate.

2. On 1/28/10 at 8:34 p.m., an electrical receptacle and television outlet behind the television on the central shelf in room 414 was missing a faceplate. Electrical wiring was exposed.

3. On 1/28/10 at 8:35 p.m., an electrical receptacle and television outlet behind the television on the central shelf in room 415 was missing a faceplate. Electrical wiring was exposed.

4. On 1/28/10 at 2:02 p.m., a miniature refrigerator in the 2nd floor social service office was plugged into a surge protected multi-outlet extension cord.

5. On 1/28/10 at 2:48 p.m., computer equipment was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord at the 2nd floor med/surgery nurses' station.

6. On 1/28/10 at 3:42 p.m., an electrical receptacle below the desk at the family birthing center nurses' station was missing a faceplate. Electrical wiring was exposed.

7. On 1/28/10 at 4:48 p.m., a portable air conditioning unit in the radiology front office was plugged into a surge protected multi-outlet extension cord. The warning tag on the portable air conditioning unit said, "do not use an extension cord."

Barton Memorial Hospital Community Clinic:

1. On 1/27/10 at 2:56 p.m., a microwave oven and a miniature refrigerator in the file room were plugged to 1 surge protected multi-outlet extension cord.

2. On 1/27/10 at 3:05 p.m., a data receptacle in exam room 8 was missing a faceplate.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of 8 alcohol based hand rub dispensers over or adjacent to an ignition source in both corridors and rooms. This affected 1 building and 4 of 13 main building smoke compartments. This could result in an increased potential for an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the facility's alcohol based hand rub dispensers were observed. The hand rub the facility used was 70% isopropanol by volume.

Main Building:

1. On 1/27/10 sat 4:44 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 3 feet directly above an electrical receptacle in the 300 wing corridor.

2. On 1/28/10 at 2:03 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 5 feet directly above a surge protected multi-outlet extension cord in the 2nd floor social service office. The extension cord was in use and was plugged into an electrical wall receptacle.

3. On 1/28/10 at 2:10 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 5 inches directly to the left of a light switch/electrical receptacle in the distinctive clinical services office.

4. On 1/28/10 at 2:21 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 17 inches directly over a light switch in room 1 of the intensive care unit.

5. On 1/28/10 at 2:35 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 5 inches directly to the right of a light switch/electrical receptacle in room 200.

6. On 1/28/10 at 2:36 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 4 inches directly to the right of a light switch/electrical receptacle in room 206.

7. On 1/28/10 at 2:37 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 7 inches directly to the left of a light switch/electrical receptacle in room 208.

8. On 1/28/10 at 2:38 p.m., an alcohol based hand rub dispenser was mounted on the wall approximately 4 inches directly to the right of a light switch/electrical receptacle in room 210.

Based on observation, the facility failed to maintain the integrity of their walls. This was evidenced by 3 penetrations in the facility's walls. This affected 2 buildings and 2 of 13 main building smoke compartments. This could result in the spread of smoke to other locations in the facility.

Findings:

During a facility tour with staff on 1/28/10, the walls in the facility were observed.

Main Building:

1. At 3:22 p.m., there was an approximately 5 inch by 3 inch penetration in the wall below the desk in the private branch exchange room located in the emergency room. The penetration was in the lower corner of the wall.

2. At 4:04 p.m., there was an approximately 1 inch by 2 inch penetration in the storage room across from room 8 in the family birthing center. The penetration was located in the left hand wall behind the television stand.

Barton Memorial Hospital Community Clinic Building:

1. On 1/27/10 at 2:55 p.m., there were 5 approximately 1/2 diameter penetrations in the file room wall behind the microwave oven.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were obstructed from closing or latching, 1 door that failed to release from it's magnetic holding device, and 1 door that had penetrations in it. This affected 3 buildings and 8 of 13 main building smoke compartments. This could result in a delay to contain a fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Main Building:

1. On 1/27/10 at 4:36 p.m., the door to the shower room by room 305 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 1/28/10 at 8:36 a.m., the door to room 415 was obstructed from closing by a bed frame positioned in the swing path of the door.

3. On 1/28/10 at 1:42 p.m., the door to room 222 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck inside the door.

4. On 1/28/10 at 1:44 p.m., the door to room 224 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by a smoke seal on the door frame.

5. On 1/28/10 at 1:58 p.m., the door to room 225 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

6. On 1/28/10 at 2:41 p.m., the door to the equipment storage room by room 210 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin on the door was taped.

7. On 1/28/10 at 2:49 p.m., the door to the 2nd floor nurse manager's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

8. On 1/28/10 at 2:50 p.m., the door to the 2nd floor staff/nurse supervisor's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

9. On 1/28/10 at 3:00 p.m., the door to the storage room across from room 218 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

10. On 1/28/10 at 3:33 p.m., the door to the post anesthesia care unit by the surgery director's office was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck inside the door.

11. On 1/28/10 at 4:06 p.m., the door to the storage room across from room 8 in the family birthing center was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was dragging on the floor which obstructed the door from closing.

12. On 1/28/10 at 4:26 p.m., the door to x-ray room 3 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

13. On 1/28/10 at 4:34 p.m., the door to the MRI room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the air pressure difference

14. On 1/28/10 at 4:37 p.m., the door to the ultrasound/mammography waiting room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

15. On 1/28/10 at 4:40 p.m., the door to the nuclear medicine room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

16. On 1/28/10 at 4:42 p.m., the door to the radiologist's office by the nuclear medicine room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

17. On 1/28/10 at 4:43 p.m., the door to the radiologist's office by the viewing room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

18. On 1/28/10 at 4:45 p.m., the door to the viewing room in medical imaging was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

19. On 1/29/10 at 11:30 a.m., the door from the corridor to physical therapy/rehabilitation department was held open by a magnetic holding device. The door failed to release from the magnetic holder when the fire alarm system was activated.

20. On 1/29/10 at 12:00 p.m., the door to storage room B in the surgery department was obstructed from closing by a cart that was positioned in the swing path of the door.

21. On 1/29/10 at 12:16 p.m., the door to the sub-sterile room between operating rooms 3 and 4 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was missing a latching pin.

Barton Memorial Hospital Community Clinic Building:

1. On 1/27/10 at 2:45 p.m., the door to the nurse practitioner's office by exam room 7 was obstructed from closing by a trash bin positioned in the swing path of the door.

Barton Medical Clinic at Sierra at Tahoe Building:

1. On 1/29/10 at 9:36 a.m., the door from the staircase to the first aid room had 5 approximately 1/2 inch diameter penetrations in the upper corner of the door.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This affected 1 building and 2 of 13 main building smoke compartments. This could result in the spread of smoke from one smoke compartment to another.

Findings:

During a facility tour with staff, the facility's smoke barrier walls were observed.

Main Building:

1. On 1/27/10 at 1:33 p.m., there was an approximately 8 inch by 10 inch square penetration in the smoke barrier wall by the physical therapy/rehabilitation department. The penetration was in the central wall above the smoke barrier doors.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by 1 smoke barrier door that failed to latch and 1 smoke barrier door that was obstructed from closing. This affected 1 building and 3 of 13 main building smoke compartments. This could result in a delay to contain a fire to a smoke compartment.

Findings:

During a facility tour with staff, the facility's smoke barrier doors were observed.

Main Building;

1. On 1/28/10 at 9:17 a.m., the smoke barrier doors by the kitchen were equipped with self closing devices. The doors were held open to their fullest extent and allowed to close. 1 of 2 door leafs failed to latch. The door closed fast and bounced back then closed without latching.

2. On 1/29/10 at 11:37 a.m., the smoke barrier doors by the medical staff services office were equipped with self closing devices. The doors were held in the open position by magnetic holding devices wired to the fire alarm system. The fire alarm system was activated and 1 of 2 door leafs failed to close. The door was obstructed from closing due to air pressure difference. There was an approximately 1 foot gap between the door leafs.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by 2 doors to hazardous areas that were equipped with self closing devices that failed to latch the doors. This affected 1 building and 2 of 13 main building smoke compartments. This could result in a delay to contain a fire to a hazardous area.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Main Building:

1. On 1/28/10 at 12:11 p.m., the skilled nursing storage room located by the physical therapy/rehabilitation department was observed. The room was greater than 100 square feet and housed combustible storage items. The door to the room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by air pressure difference.

2. On 1/28/10 at 2:57 p.m., the door to the soiled linen room by room 225 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on document review and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to have a complete 5-year inspection on their sprinkler risers and 4 sprinklers that were missing escutcheon rings. This affected 1 building and 13 of 13 main building smoke compartments. This could result in a delayed sprinkler response in the event of a fire.

NFPA 25, 1998 edition
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-3.2 Gauges shall be replaced every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
10-2.2 Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years.

Findings:

During a facility tour with staff, the facility's automatic sprinkler system was observed.

Main Building:

1. During document review on 1/27/10, the last 5 year inspection report for the facility's 7 sprinkler risers were observed. The 5 year report was dated 10/27/08. The report failed to list what procedures were performed. The facility's most recent sprinkler quarterly inspection was reviewed. The last quarterly inspection was completed on 1/20/10. The quarterly inspection indicated that the piping has never been checked for obstructive materials, the gauges had not been tested, calibrated or replaced within the past 5 years, and the alarm valves and associated trim had not been internally inspected within the past 5 years. A statement from the facility's sprinkler system vendor, faxed on 2/1/10, indicated that those areas had not been checked during the last 5 year inspection. The facility's risers are currently tagged with a 5 year service tag dated 10/27/08.

2. On 1/28/10 at 12:11 p.m., the sprinkler in the skilled nursing storage room located by the physical therapy/rehabilitation department was missing an escutcheon ring.

3. On 1/28/10 at 2:42 p.m., the sprinkler in the equipment storage room located by room 210 was missing an escutcheon ring.

4. On 1/28/10 at 2:49 p.m., the sprinkler in the 2nd floor nurse manager's office was missing an escutcheon ring.

5. On 1/29/10 at 12:04 p.m., the sprinkler in the housekeeping closet located in the surgery department was missing an escutcheon ring.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by the storage of items in the corridor near an emergency exit and an egress path from an emergency exit that was obstructed by the accumulation of snow. This affected 1 building and 2 of 13 main building smoke compartments. This could result in a delayed evacuation due to obstructions in a means of egress.

Findings:

During a facility tour with staff, the facility's means of egress were observed.

Main Building:

1. On 1/27/10 at 4:04 p.m., 4 wheel chairs, 1 geriatric chair, and 1 patient lift device were positioned in the corridor near the emergency exit located by room 306. Staff 2 indicated that those items are stored there because of limited space in resident rooms.

2. On 1/28/10 at 9:26 a.m., the path from the emergency exit for the occupational health services department was observed. Directly outside the emergency exit was an accumulation of snow approximately 1 foot high. The snow was present from the emergency exit to a paved sidewalk approximately 30 feet away. Staff 3 indicated that the occupational health services department may treat patients with limited mobility. Staff 3 said that the exit door is sometimes used by patients as an indiscrete way to exit.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by 3 oxygen E cylinders that were free standing and unsecured and 1 door to an oxygen storage room that failed to latch. This affected 1 building and 1 of 13 main building smoke compartments. This could result in an increased risk of an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the facility's storage of oxygen gas was observed.

Main Building:

1. On 1/27/10 at 4:44 p.m., 2 of approximately 120 oxygen E cylinders were free standing and unsecured in the facility's outdoor oxygen storage room. The oxygen storage room was a detached structure from the main building.

2. On 1/28/10 at 3:14 p.m., 1 of 8 oxygen E cylinders were free standing and unsecured in the oxygen storage room across from room 2 in the emergency room.

3. On 1/28/10 at 3:15 p.m., the door to the oxygen storage room, across from room 2 in the emergency room, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame. There were 8 oxygen E cylinders in the room.

Based on document review and interview, the facility failed to maintain the humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to monitor and maintain 5 of 5 operating rooms with a 35 percent relative humidity or greater. This affected 1 building and 1 of 13 main building smoke compartments. This could result in a fire to occur due to electrostatic charges in an oxygen enriched environment in conjunction with flammable anesthetics.

NFPA 99, 1999 Edition
5.4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review, the facility's humidity levels in anesthetizing locations were observed.

Main Building:

1. On 1/28/10 to 1/29/10, the facility's relative humidity records in anesthetizing locations were observed. The facility's temperature and humidity control policy and procedure, dated 1/26/10, was reviewed. The facility's policy was, "to maintain a comfort controlled environment adjusting temperature and humidity as needed." The procedure indicated that levels would be monitored so as not to exceed 60 percent relative humidity. There was no lower relative humidity range specified in the policy and procedure.

The facility kept a monthly log of relative humidity levels for 5 of 5 operating rooms. A log from 1/28/10 indicated that 5 of 5 operating room relative humidity levels were 31 percent or lower with the lowest relative humidity level being 22.5 percent. A log from 1/2/10 indicated that 5 of 5 operating room relative humidity levels were 29.5 percent or lower with the lowest relative humidity level being 21.5 percent.

Staff 1 indicated that the facility did not monitor the relative humidity levels on a daily basis. Upon request, the facility generated a relative humidity level report that showed a relative humidity reading approximately every 5 minutes. The report detailed the relative humidity in operating room 1 from 8:06 p.m. on 1/18/10 to 11:07 a.m. on 1/28/10. The relative humidity levels were not consistently maintained at a level of 35 percent or greater. The relative humidity level dropped to as low as 16 percent during that time span. The relative humidity level never exceeded 40.5 percent during that time span.

Based on document review and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to complete an annual load bank test on 3 of 3 emergency generators. This affected 1 building and 13 of 13 main building smoke compartments. This could result in the facility being without power due to a malfunctioning emergency generator.

Findings:

During document review, the facility's emergency generator records were observed.

Main Building;

1. On 1/27/10, the facility's emergency generator records were observed. The facility conducts weekly load tests for 3 of 3 emergency generators. Staff 1 indicated that the load tests do not reach 30 percent of the generators' full load for the weekly load test. The emergency generators are powered by diesel fuel. The facility has a contract with a vendor valid from 4/1/09 to 3/31/11 to perform routine maintenance and conduct annual load bank tests on the emergency generators. The last load bank test completed on the emergency generators was conducted on 6/17/07.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by electrical receptacles that were missing or had broken faceplates, high powered appliances that were plugged into surge protected multi-outlet extension cords, and surge protected multi-outlet extension cords that were plugged into other surge protected multi-outlet extension cords. This affected 2 buildings and 6 of 13 main building smoke compartments. This could increase the risk of an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Main Building:

1. On 1/27/10 at 4:08 p.m., an electrical receptacle behind the bed-side shelf in room 308 had a broken faceplate.

2. On 1/28/10 at 8:34 p.m., an electrical receptacle and television outlet behind the television on the central shelf in room 414 was missing a faceplate. Electrical wiring was exposed.

3. On 1/28/10 at 8:35 p.m., an electrical receptacle and television outlet behind the television on the central shelf in room 415 was missing a faceplate. Electrical wiring was exposed.

4. On 1/28/10 at 2:02 p.m., a miniature refrigerator in the 2nd floor social service office was plugged into a surge protected multi-outlet extension cord.

5. On 1/28/10 at 2:48 p.m., computer equipment was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord at the 2nd floor med/surgery nurses' station.

6. On 1/28/10 at 3:42 p.m., an electrical receptacle below the desk at the family birthing center nurses' station was missing a faceplate. Electrical wiring was exposed.

7. On 1/28/10 at 4:48 p.m., a portable air conditioning unit in the radiology front office was plugged into a surge protected multi-outlet extension cord. The warning tag on the portable air conditioning unit said, "do not use an extension cord."

Barton Memorial Hospital Community Clinic:

1. On 1/27/10 at 2:56 p.m., a microwave oven and a miniature refrigerator in the file room were plugged to 1 surge protected multi-outlet extension cord.

2. On 1/27/10 at 3:05 p.m., a data receptacle in exam room 8 was missing a faceplate.