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Based on observation, the facility failed to maintain the integrity of the building construction, providing a 1 hour separation, by failing to ensure that penetrations in walls and ceilings are sealed with fire rated material. This deficient practice can result in the spread of fire and/or smoke to other areas of the facility, affecting 8 of 18 smoke compartments main hospital and 1 of 1 smoke compartments outpatient cancer center.

Findings:

During a tour of the facility, penetrations were observed at the following times and locations:
a)On 2/8/10, at 11:28 a.m., a four 6 in. unsealed vertical conduit pipes, 2 in the floor and 2 in the ceiling, were observed in room 4026.
b) On 2/8/10, at 11:47 a.m., 2 quarter size unsealed penetrations were observed in the south wall of room 4021.
c) On 2/8/10, at 11:54 a.m., two dime sized unsealed penetrations were observed in the north wall of room 4014.
d) On 2/8/10, at 1:30 p.m., a fire smoke damper junction box cover was observed missing, ceiling of room 3034.
e) On 2/8/10, at 1:36 p.m., a four 6 in. unsealed vertical conduit pipes, 2 in the floor and 2 in the ceiling, were observed in the MIS Data room, by room 3047.
f) On 2/8/10, at 2:07 p.m., room 2025 had 4 ceiling tiles missing, a 5 in. x 3 in. hole was observed in the ceiling where the tiles were missing.
g) On 2/8/10, at 2:20 p.m., a 4 in. unsealed vertical conduit pipe was observed in the south ceiling of room 2038B.
h) On 2/8/10, at 2:53 p.m., a 1 in. unsealed conduit pipe was observed in the west wall of room 1112, xray department.
i) On 2/8/10, at 3:20 p.m., four 8 in. unsealed vertical conduit pipes were observed in the MIS closet of room 1065B.
j) On 2/9/10, at 10:39 a.m., a 1/8 in. unsealed penetration around a 1/2 in. conduit pipe was observed in the west wall, room 1033A.
k) On 2/9/10, at 2:47 p.m., a 1/2 in. unsealed conduit pipe was observed in the west wall of room B033C.


Outpatient Cancer Center:
a) On 2/9/10, at 3:40 p.m., three 8 in. unsealed conduit pipes, one 1 in. unsealed conduit pipe were observed in the west wall and a 1/2 in. unsealed conduit pipe was observed in the south wall, cancer center, electrical room.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing and latching. Corridor doors are required to close and latch and capable of resisting the passage of smoke, roller latches are not permitted. Should the corridor door be equipped with a self-closing device, the self-closing device must closed and latch the door in the event of a fire to prevent the spread of fire and/or smoke to or from other areas of the facility. This deficient practice affected 12 of 18 smoke compartments.

Findings:


During a tour of the facility the following deficiencies were observed at the following times and locations:
a) On 2/8/10, at 11:35 a.m., the door to the PIXIS room, nursing station 4th floor, was observed propped open by a rubber door wedge.
b) On 2/8/10, at 11:48 a.m., 4 dime sized unsealed penetration were observed in the corridor door to room 4022.
c) On 2/8/10, at 12:06 p.m., the corridor door to room 406 failed to latch.
d) On 2/8/10, at 1:26 p.m., the corridor door to room 401 required more than 5lbs to open/close.
e) On 2/8/10, at 1:30 p.m., the door to the PIXIS room, nursing station 3rd floor, was equipped with a self-closing device, the arm of the self-closure was disconnected. 8 pin sized unsealed penetrations were observed in the back of the door and 1 quarter sized unsealed penetration was observed in the door frame.
f) On 2/8/10, at 1:45 p.m., 4 pin sized unsealed penetrations were observed in the corridor door to room 306. This door also required more than 5lbs. to open/close.
g) On 2/8/10, at 2:15 p.m., the PIXIS room, nursing station 2nd floor, was equipped with a self-closing device, the arm to the self-closure was disconnected.
h) On 2/8/10, at 2:25 p.m., the corridor door to room 215 was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
i) On 2/8/10, at 3:10 p.m., a roller latch was observed on the corridor door to X-Ray room 1073, roller latches are prohibited.
j) On 2/9/10, 10:02 a.m., the 1st floor exit door, leading to an exterior exit door located between the cafeteria entrance an administration was equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
k) On 2/9/10, at 10:06 a.m., the corridor door to room 1042, was equipped with a self-closing device, the arm to the self-closure was disconnected.
l) On 2/9/10, at 10:18 a.m., 4 dime sized unsealed penetrations were observed in the door frame of the cafeteria corridor doors.
m) On 2/9/10, at 10:20 a.m., the door to the kitchen leading from the cafeteria was equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
n) On 2/9/10, at 10:55 a.m., the 1st floor, central supply double doors, were observed, the right leaf of the door was propped open by a wooden door wedge. The left leaf of the door was observed obstructed by 15 boxes of various supply items and 11 mail bins. 8 unsealed quarter size penetrations were observed in the left leaf of the door and 4 quarter size penetrations were in the door frame.
o) On 2/9/10, at 11:00 a.m., 2 dime size unsealed penetrations were observed in the corridor door and door frame to the coding office, 1st floor.
p) On 2/9/10, at 11:04 a.m., 2 dime sized unsealed penetrations were observed in the door frame to room 1020.
q) On 2/9/10, at 11:15 a.m., the corridor door to the O.R. reception office was observed obstructed by boxes and personal belongings.
r) On 2/9/10, at 11:19 a.m., the O.R. decon room 1082, was obstructed by a piece of medical equipment.
s) On 2/9/10, at 11:22 a.m., the corridor door to room 1087, O.R. department, was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
t) On 2/9/10, at 11:36 a.m., the double doors to data closet 1131B were observed obstructed and could not be opened. The doors were obstructed with joint works equipment for the O.R. Department. The equipment covered approximately a 5ft. x 3ft. area in front of the double doors.
u) On 2/9/10, at 11:40 a.m., the door frame to the clean utility room, O.R. recovery area, had 2 dime sized unsealed penetrations in the door.
v) On 2/9/10, at 11:50 a.m., the corridor door to room 1186 was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
w) On 2/9/10, at 2:18 p.m., the corridor door to biohazard room 1175D was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
x) On 2/9/10, at 2:56 p.m., the corridor door to room B062C was observed propped open by a wooden door wedge.

Based on observation, the facility failed to clearly identify exit routes for the dietary department to the loading dock. This deficient practice could potentially delay egress should the dietary department need to be evacuated, affecting all dietary staff members.


Findings:

During a tour of the facility, on 2/9/10, at 10:40 p.m., the exit door by room 1008 located in the dietary department (kitchen) was observed. The facility failed to post an exit sign identifying a secondary path of egress from the kitchen cooking area. The exit door by room 1008 lead to an exterior exit and is not identified as an exit.

Based on observation, the facility failed to ensure that smoke barrier walls were intact and would prevent the passage of smoke. Penetrations in the smoke barrier walls, must be sealed with fire rated material to ensure the smoke barrier walls meets the 1 1/2 hour fire rated requirement. Failure to maintain smoke barrier walls, sealing penetrations with approved fire rated material, could potentially cause fire and/or smoke to spread rapidly through the building without smoke barriers intact. This deficient practice affected 3 of 18 smoke compartments.

Findings:

During a tour of the facility the following smoke barrier walls were observed deficient at the following times and locations:
a. On 2/8/10, at 1:05 p.m., the smoke barrier wall located by the center stairwell, 4th floor, had a 3 in. unsealed conduit pipe.
b. On 2/8/10, at 2:00 p.m., the smoke barrier wall located by room 314, 3rd floor, had been repaired. The sheet rock had been cut and replaced. The sheet rock repaired had a 1/4 in. horizontal unsealed line 8ft. long between the new sheet rock and the old sheet rock. The center of the wall had a 1/4 in. vertical unsealed line.
c) On 2/8/10, at 2:15 p.m., the smoke barrier wall located by room 302, had a 3 in. unsealed conduit pipe.

Based on observation, the facility failed to ensure that all smoke barrier cross-corridor doors closed and latched. Failure to maintain smoke barrier cross-corridor doors could potentially cause fire and/or smoke to spread rapidly throughout the building. This deficient practice affected 1 of 18 smoke compartments.

Findings:

During a tour of the facility on 2/9/10, at 10:26 a.m., the cross-corridor fire doors located by room 1026A, 1st floor, failed to close and latch when tested.

Based on observation the facility failed to provide a self-closing corridor door to storage room 416. The facility is utilizing this room to store patient mattresses. Failure to ensure hazardous areas are maintained and self-closing doors are provided could result in potential harm to all residents and staff members in 1 of 3 smoke compartments on the 4th floor.

Findings:During a tour of the facility on 2/8/10, at 1:00 p.m., room 416 was observed. The room is being utilized as a storage room for patient mattresses. An interview was conducted with staff C at 1:02 p.m., staff C stated the hospital sometimes rents specialty mattresses and the regular mattress are stored in this room until the rental mattress is returned. Room 416 had 14 mattresses stored and 2 beds. The door was not equipped with a self-closing.

Based on record review and staff interview, the facility failed to maintain and test the emergency lighting for the cancer center. This was evidenced by a lack of documentation for monthly and annual testing of emergency lighting system. This finding affected one of one smoke compartments within the outpatient facility. Failure to maintain and test emergency lighting could potentially result in delayed evacuation and/or injury in the event of an emergency.


Findings:

Outpatient Cancer Center:During record review on 2/10/10, at 11:40 a.m., the facility failed to provide documentation for the 30 second monthly inspection and 1 1/2 hour annual testing of the emergency lighting system for the cancer center. The cancer center's emergency lighting is battery powered. An interview was conducted with staff N at 11:42 a.m., staff N stated that they facility was not testing the emergency lighting for the cancer center.

I. Based on observation, the facility failed to maintain glow in the dark exit signs as evidence by NFPA 101, 2000 Edition. Such exit signs come with a 10-20 life. The facility failed to change expired exit signs. This finding affected 2 of 18 smoke compartments. Failure to maintain and test emergency exit signs could potentially result in delayed evacuation and/or injury in the event of an emergency.

As evidence by:
NFPA 101, 2000 Edition:
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign
placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for
internally illuminated signs.


Findings:

During a tour of the facility exit signs were observed expired at the following times and locations:
a) On 2/9/10, at 10:15 a.m., the exit sign located above the corridor door inside room 1052 expired 9/09. The facility failed to replace the expired exit sign.
b) On 2/9/10, at 2:40 p.m., 2 exit signs were observed posted by room B0462. Both exit signs expired 9/09. The facility failed to replace the 2 expired exit signs.
c) On 2/9/10, at 2:49 p.m., 2 exit signs were observed posted by room B062C. Both exit signs expired 9/09. The facility failed to replace the 2 expired exit signs.






II. Based on observation, and record review and staff interview, the facility failed maintain and test battery operated exit signs in accordance with NFPA 101, 2000 edition. This was evidenced by a lack of documentation for monthly and annual testing of its battery powered emergency exit signs. This finding affected 4 of 4 smoke compartments within the outpatient facility/cancer center. The outpatient facility is a 4 story building. Failure to maintain and test emergency exit signs could potentially result in delayed evacuation and/or injury in the event of an emergency.

As evidence by:
NFPA 101, 2000 Edition:
7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code?.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign
placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for
internally illuminated signs.


Findings:

Outpatient Cancer Center
During record review, on 2/10/10, at 11:30 a.m., the facility failed to provide documentation for the following:
a. The facility failed to provide documentation for the monthly inspection/testing of battery operated exit signs.
b. The facility failed to provide documentation for the annual inspection/testing of battery operated exit signs.

Based on document review and staff interview, the facility failed to conduct disaster drills twice per year, at 6 month intervals, as evidence by NFPA 99, 1999 Edition, 11-5.3.9. The facility failed to ensure a hard copy of the fire and disaster manual was available upon request. Failure to conduct disaster drills semi-annually for staff members in the main hospital and outpatient facility, providing training to all staff members to ensure staff have knowledge of what to do if a disaster should occur, could result in potential harm and/or the death to all residents and/or all staff members. Failure to provide a hard copy fire and disaster manual and provide inservice to staff where to locate the hard copy fire and disaster manual should the facility lose power and have no access to online resources/manuals during a fire and/or disaster, could cause potential harm and/or death to 53 of 53 patients and all staff members.


11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.


Findings:


I. During document review on 2/10/10, at 4:10 p.m., the facility failed to conduct semi-annual disaster drills for the main facility and outpatient cancer center. The facility conducted disaster drills on 4/29/09 and 12/14/09. The disaster drills were held 8 months apart.

II. During document review on 2/10/10 at 11:50 a.m., the facility was asked for a hard copy of the fire and disaster manual. Staff B stated that they did not have a hard copy of a disaster manual available, the hard copy manual was sent to Roseville, California, a week or so ago for review. They facility had an online copy of the fire and disaster manual and could print one out, however it would take a couple of hours. At 4:00 p.m., the facility was able to produce a hard copy of the fire and disaster manual, the manual was printed out for review.

Based on record review, and staff interview, the facility failed to conduct simulated fire drills for the outpatient facility, one per quarter, per shift, at various times, as evidence by NFPA 101, 4.7.2. The facility failed to ensuring all staff on duty participate in simulated fire drills. Ensuring staff is familiar with the facilities fire and disaster policy and procedures and location of manual activated alarm devices. Failure to conduct fire drills one per quarter, per shift, at various times, under varied conditions, could result in a lack of staff knowledge in the event of a fire and/or disaster affecting all residents and staff members in the outpatient facility.

As evidence by:
NFPA 101, 2000 Edition:
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.


Findings:

During record review on 2/10/10, at 11:30 a.m., the facility failed to provide fire drill records, one per quarter, per shift for the outpatient cancer center. The facility conducted one fire drill on 9/25/09 during a 12 month period.

Based on record review, and staff interview, the facility failed to maintain, test and inspect the fire alarm system and fire alarm system devices to ensure the system and all devices attached to the fire alarm system function properly, as evidence by NFPA 72, 7-3.2, 7-1.2.2 and NFPA 90A 3-4.7. Failure to maintain the fire alarm system and fire alarm system devices could result in potential harm to all residents and staff, if the fire alarm system and/or fire alarm system devices fail to function.


As evidence by the following:
NFPA 72, 7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

NFPA 90A, 1999 edition, 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
NFPA 90A, 1999 edition, 3-4.5.1 All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
NFPA 90A, 1999 edition, 5-1 General.
NFPA 90A, 1999 edition, 5-1.1* An acceptance test shall be performed to determine that the protective measures required in this standard function when needed in order to restrict the spread of fire and smoke.
NFPA 90A, 1999 edition, 5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.


Findings:

During record review on 2/10/10, at 1:20 p.m., documentation for fire smoke damper inspection/testing was reviewed. The facility inspects and tests fire smoke dampers internally. An interview was conducted with the Director of plant operations, the staff member responsible for inspecting and certifying the fire smoke dampers does not have the required certification to inspect and certify fire smoke dampers.

Based on observation, document review and staff interview, the facility failed to maintain and test, the fire alarm equipment/devices to ensure a reliable functioning fire alarm system. Failure to maintain and test the fire alarm system and equipment monthly as evidence by 7-3.2, could result in potential harm to all residents and staff members, should the fire alarm system and/or a fire alarm device fail to operate during a fire and/or disaster.


Findings:During a tour of the facility the following deficiencies were observed at the following times and locations:a) On 2/9/10, at 10:35 a.m., the fire roll down door located in the dietary department seperating the kitchen from the cafeteria was observed. An interview was conducted with staff C at 10:36 a.m. Staff C stated that the fire roll down door was broken and had been bolted shut and no longer closed upon activation of the fire alarm system/smoke detector provided as designed. The roll down door was altered and now rolls down manually. The fire roll down door was still tied into the fire alarm system and not maintained as designed.
b) On 2/9/10, at 11:15 a.m., the manual pull station located by room 1080 was observed obstructed by a surgery cart.
c) On 2/9/10, at 2:25 p.m., the Halon system for the cell cite was observed. The Halon was last serviced 7/09. On 2/10/10, at 2:45 p.m., documentation for a current Halon service was requested. An interview was conducted with staff A at 3:40 p.m., staff A, stated that they did not have a current Halon certification on file for the cell site. The Halon system is to be serviced every 6 months and was due for service 1/10.


Outpatient Cancer Center:
a) During record review on 2/10/10, at 11:45 a.m., the outpatient cancer center was asked to provide an annual certification of the fire alarm system. The facility failed to provide records for an annual certification/inspection of the fire alarm system.

Based on observation, the facility failed to maintain and test the sprinkler system and/or sprinkler system devices. The sprinkler system sprinkler heads were observed dusty/dirty or corroded. Sprinkler head escutcheon plates are to be tightly fitted to the ceiling. Failure to provide maintain sprinkler heads and escutcheon, could result in a sprinkler system malfunction. Malfunction of the sprinkler system could potentially affect all staff and residents in 18 of 18 smoke compartments in the main hospital.
Findings:
During a tour of the facility, the following deficiencies were observed at the following times and locations:
a) On 2/08/10, at 11:10 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in room 4028B.
b) On 2/08/10, at 11:20 a.m., a 1/2 in. gap was observed around 1 of 2 sprinkler escutcheon plates located in room 4024.
c) On 2/08/10, at 11:26 a.m., a 1/2 in. gap was observed around 1 of 2 sprinkler escutcheon plates located in room 4026C.
d) On 2/08/10, at 11:36 a.m., the sprinkler escutcheon plate located in the bathroom of room 4009 was observed missing.
e) On 2/08/10, at 11:38 a.m., a 1/2 in. gap was observed around 1 of 5 sprinkler escutcheon plates located in room 4013.
f) On 2/08/10, at 11:38 a.m., 5 of 5 sprinkler escutcheon plates in room 4013 were observed painted.
g) On 2/08/10, at 11:40 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon located in room 4026A.
h) On 2/08/10, at 11:44 a.m., masking tape was observed placed over 1 of 2 sprinkler heads , room 4019.
i) On 2/08/10, at 11:44 a.m., masking tape was observed placed of 1 of 1 sprinkler heads located in the bathroom of room 4019.
j) On 2/08/10, at 11:50 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon located in room 4022
k) On 2/08/10, at 11:52 a.m., a 1/2 in. gap was observed around 2 of 2 sprinkler escutcheon plates located in room 4016.
l) On 2/08/10, at 12:02 p.m., a 1/2 in. gap was observed around 1 of 2 sprinkler escutcheon plates located in room 4010.
m) On 2/08/10, at 12:06 p.m., a 1/2 in. gap was observed around 2 of 3 sprinkler escutcheon plates located in room 4008.
n) On 2/08/10, at 12:06 p.m., a 1/2 in. gap was observed around 1 of 1 sprinkler escutcheon plates located in the bathroom of room 4008.
o) On 2/08/10, at 12:09 p.m., a 1/2 in. gap was observed around 1 of 3 sprinkler escutcheon plates located in room 4004.
p) On 2/08/10, at 1:20 p.m., a 1/2 in. gap was observed around 1 of 2 sprinkler escutcheon plates located in room 4047.
q) On 2/08/10, at 1:28 p.m., a 1/2 in. gap was observed around 1 of 1 sprinkler escutcheon plates located in the bathroom of room 4003.
r) On 2/08/10, at 1:30 p.m., a 1/2 in. gap was observed around 1 of 3 sprinkler escutcheon plates located in room 4007.
s) On 2/08/10, at 1:32 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon located in the corridor, 3rd floor, by the center elevator.
t) On 2/08/10, at 1:39 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in room 3027B.
u) On 2/08/10, at 1:39 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in room 3048.
v) On 2/08/10, at 1:50 p.m., 1 of 3 sprinkler escutcheon plates were observed missing in room 3002.
w) On 2/08/10, at 2:21 p.m., a 1/2 in. gap was observed around 2 of 3 sprinkler escutcheon plates located in room 207.
x) On 2/08/10, at 2:23 p.m., a 1/2 in. gap was observed around 2 of 5 sprinkler escutcheon plates located in room 209.
y) On 2/08/10, at 2:27 p.m., a 1/2 in. gap was observed around 1 of 3 sprinkler escutcheon plates located in room 204.
z) On 2/08/10, at 2:27 p.m., a 1/2 in. gap was observed around 1 of 1 sprinkler escutcheon plates located in the bathroom of room 204.
aa) On 2/08/10, at 2:54 p.m., the sprinkler head located in the mammography room, 1st floor, was observed dirty/dusty.
bb) On 2/09/10, at 10:36 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the dietary kitchen by the victory refrigerators.
cc) On 2/09/10, at 10:40 a.m., 2 of 2 sprinkler heads and escutcheon plates were observed corroded in the walk in freezer and refrigerator, dietary department.
dd) On 2/09/10, at 11:06 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located inside the medical records office, 1st floor, by entry door.
ee) On 2/09/10, at 11:10 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in room 1031, 1st floor, by entry door.
ff) On 2/09/10, at 2:00 p.m., the sprinkler escutcheon plate located in the emergency department, 1st floor corridor by room 1150 was observed missing.
gg) On 2/09/10, at 2:18 p.m., the sprinkler head located in the emergency department by room 1, 1st floor, was observed dirty/dusty.
hh) On 2/09/10, at 2:32 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the corridor by room B006A.
ii) On 2/09/10, at 2:34 p.m., a 1/2 in. gap was observed around 1 of 4 sprinkler escutcheon plate located inside the engineering office, reception area.
jj) On 2/09/10, at 2:36 p.m., the sprinkler head located in room B042 was observed dirty/dusty.
kk) On 2/09/10, at 2:39 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located inside room B040.
ll) On 2/10/10, at 3:00 p.m., the facility failed to physically test the sprinkler system devices quarterly. Documentation provided for quarter 1, January 2010 and quarter 3, July 2009, 2 of 4 quarterly sprinkler system inspection, were noted as visual inspections, the contracted company documented "visual inspection" and did not initiate sprinkler system devices during those 2 quarterly inspections.




Outpatient Cancer Center Building:
a) On 2/10/10, at 11:20 a.m., during record review the facility failed to provide documentation for the initial sprinkler system certification for the outpatient cancer center building. The sprinkler system was installed 1/06.
b) On 2/10/10, at 11:25 a.m., during record review the facility failed to provide documentation for the annual sprinkler system certification/inspection for the cancer center building.
c) On 2/10/10, at 11:30 a.m., during record review the facility failed to provide 3 of 4 quarterly sprinkler inspections. Documentation for quarter 1 was provided and conducted March 2009. Documentation for quarters 2 - 4 was not provided.

Based on observation, the facility failed to provide accessible fire extinguishers , as evidence by, NFPA 10, 1-6.6, and 1-6.10. Failure to provide accessible portable fire extinguishers, at approved heights could delay staff from assisting in a fire and potentially cause fire and smoke to spread rapidly through the facility, affecting 4 of 18 smoke compartments.


As evidence by:
NFPA 10-1-6.6, Fire extinguishers shall not be obstructed or obscured from view.
NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom
of the fire extinguisher and the floor be less than 4 in.(10.2 cm).


Findings:

During a tour of the facility at the following times and locations the following fire extinguishers were observed deficient:
a) On 2/08/10, at 11:28 a.m., the metal cabinet housing the fire extinguisher located by room 4038 was jammed shut and could not be opened without force.
b) On 2/09/10, at 3:12 p.m., the metal cabinet housing the fire extinguisher located by room 3064 was jammed shut and could not be opened without force.

Outpatient Cancer Center:
a) On 2/09/10, at 3:40 p.m., the fire extinguisher located in room 1034 was not mounted.

Based on observation, the facility failed to maintain the corridors to full width. The facility is utilizing the corridors for storage of medical equipment and other items, obstructing the corridors and impeding the path of egress. Failure to maintain unobstructed corridors, could result in a potential delay if staff should have to evacuate the facility/facilities in the event of a fire and/or disaster. This deficient practice affected all patients in the emergency department, intensive care unit and the surgery/operating department.

Findings:

a) During a tour of the facility on 2/09/10, from 11:00 a.m., through 4:15 p.m., The 1st floor corridor, between the I.C.U and O.R was observed. A 5ft. wide x 8ft. long section of the corridor was observed obstructed by approximately 50-60 joint work equipment containers.
b) During a tour of the facility on 2/09/10, at 2:00 p.m., through 2/11/10 at 11:00 a.m., the emergency department corridors/hallways were observed obstructed. The emergency department utilizes the corridor isles as a "fast track" area. 8 Gurneys are stationed permanently in the corridors/hallways, along with folding privacy curtains between the gurneys. The "fast track" triage area by room 1167, stored 1 desk, 1 scale, 1 bedside table, 1 treatment cart, 3 chairs, 1 heart pressure machined and 1 portable x-ray machine.

Based on observation, and staff interview, the facility failed to provide curtains that are flame retardant and meet the specifications, as evidence by 10.3.1. Failure to provide decorations and/or curtains that meet the flame spread rating requirements could cause fire and/or smoke to spread rapidly during a fire, affecting 2 of 2 smoke compartments on the 2nd floor.



As evidence by:
NFPA 101, 2000 Edition:

10.3.1* Where required by the applicable provisions of this code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings:

During a tour of the facility on 2/08/10, at 2:03 p.m., 3 of 3 alcoves on the 2nd floor, located in the corridor were observed covered with hanging curtains. Documentation was asked to be provided for the flame spread rating of the hanging curtains. On 2/09/10, at 3:00 p.m., an interview was conducted with maintenance staff, staff stated the curtains were not flame retardant.

Based on observation, the facility failed protect its medical gas storage areas in accordance with NFPA 99, 1999 edition. Failure to provide proper signage, and store medical gas cylinders in a room free from combustible materials could potentially increase the spread of fire affecting 2 of 2 smoke compartments within the outpatient facility and 18 of 18 smoke compartments.

As evidence by: NFPA 99, 1999 Edition:
4-3.1.1.2:
Storage Requirements (Location, Construction Arrangement), # 4 - # 7,
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code,for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials.
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitroxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4 3.5.2.2.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 43.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING


Findings:
During a tour of the the main hospital and outpatient facility, the following deficiencies were observed at the following times and locations:
a) On 2/08/10, at 11:10 a.m., the two storage containers located outside by the bulk oxygen tank were observed. Container one stored 3 free standing "E" oxygen cylinders, 3 uncapped "H" oxygen cylinders, 1 "E" oxygen cylinder sat upon a red biohazard waste container. Container two stored 1 "E" oxygen cylinder with various flammable supplies and decorations. An interview was conducted with the safety officer at 11:15 a.m., the safety officer was asked if these containers were used to store oxygen, the safety officer replied "No oxygen is suppose to be stored in these sheds".
b) On 2/08/10, at 1:32 p.m., 4 "E" oxygen tanks were observed stored in the designated oxygen storage closet, 3rd floor, nursing supply closet. The closet contained flammable supplies, plastic, paper and other nursing supply. The light switch/electrical outlets were not the required 5 feet from the ground. The designated storage closet did not have a sign stating medical gas was stored in this room.
c) On 2/08/10, at 1:33 p.m., 1 "E" oxygen cylinder was observed freely standing in room 3045.
d) On 2/08/10, at 2:10 p.m., 7 "E" oxygen cylinders were observed stored in the designated storage room, the OB recovery room. Various flammable items, nursing supplies, OB supplies were observed also stored in this room. The designated storage closet did not have a sign stating medical gas was stored in this room.
e) On 2/08/10, at 2:59 p.m., 8 "E" oxygen cylinders were observed stored in the designated storage room 1102. The storage room was full of flammable materials. The light switch/electrical outlets were not at the required height. The designated storage closet did not have a sign stating medical gas was stored in this room.
f) On 2/9/10, at 11:20 a.m., 6 medical gas "E" cylinders, 1 medical air cylinder, 1 nitrogen oxide cylinder and 4 oxygen cylinders. The room was also used as a storage room, flammable materials were stored in this room along with the medical gas cylinders. The light switch/outlets were not at the approved height. The designated storage closet did not have a sign stating medical gas was stored in this room.
g) On 2/9/10, at 11:40 a.m., 1 "E" oxygen cylinder was observed lying on the floor in the O.R. managers office.
h) On 2/09/10, at 1:35 p.m., 6 "E" oxygen cylinders were observed stored in the designated storage room for the ICU. The room also stored flammable materials, clean linen and nursing supplies. The light switch/outlets were not at the approved height. The designated storage closet did not have a sign stating medical gas was stored in this room.
i) On 2/09/10, at 2:18 p.m., 6 "E" oxygen cylinders were observed in the designated storage room for the E.D. The designated storage room contained flammable materials, nursing supplies and other E.D. supplies. The light switch/outlets were not the required height. The designated storage closet did not have a sign stating medical gas was stored in this room.
j) On 2/09/10, at 2:29 p.m., 6 "E" oxygen cylinders were observed stored in the designated storage room for the E.R, room 1171. The room also stored flammable materials, clean linen and nursing supplies. The light switch/outlets were not at the approved height. The designated storage closet did not have a sign stating medical gas was stored in this room.

Based on record review and staff interview, the facility failed to review the laboratory policy and procedures annually. Failure to ensure the laboratory's policy and procedures are reviewed annually and training provided annually to laboratory staff members could result in potential harm to all laboratory staff members.

Findings:

During document review, on 2/09/10, at 4:00 p.m., the facility failed to provide annual staff training/inservice documentation and laboratory policy and procedures that were reviewed annually. Documentation provided showed the last review of the policy and procedures for lab safety was done in during 2008.

Based on document review, and staff interview, the facility failed to provide a policy and procedure that defines the roles and responsibilities of laboratory employees, during a disaster. Failure to ensure laboratory staff are training on their roles and responsibilities specific to the laboratory during a fire and/or disaster could result in potential harm to all laboratory staff members and 2 of 18 smoke compartments.

Findings:

During document review, on 2/09/10, at 4:00 p.m., the facility failed to provide a written policy specific to the lab, that included, alarm actuation, evacuation of the lab, shut down procedures for lab equipment, and provisions to control emergencies if one should occur in the lab.

Based on observation, the facility failed to maintain, and utilize the receptacles and/or building electrical components safely, as evidence by NFPA 70, 400-8, 240-4, and HCFA transmittal notice 22-99. Failure to maintain, test and utilize all receptacles within the building could result in potential harm to all staff and residents in 5 of 18 smoke compartments.


As evidence by:
NFPA 70, 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords 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 ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Also, HCFA transmittal notice 22-99, prohibits surge protectors to be used for appliances such as microwaves, coffee pots, toasters and refrigerators.

NFPA 70, article 240-4 1999 edition, Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords, and fixtures 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). Fixtures 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 mean cor providing this protection.
(b) Supply cord of listed appliance or portable lamps. Where flexible cord or tinsel cord is approved for and used with specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210.
Also, HCFA transmittal notice 22-99, prohibits the use of extension cords without overcurrent protection (surge protectors).


Findings:

During a tour of the facility, the following deficiencies were observed at the following times and locations:
a) On 2/08/10, at 11:40 a.m., a daisy chained (one surge protector plugged into another surge protector) was observed in use in room 4017. A refrigerator was observed plugged into the surge protectors.
b) On 2/08/10, at 11:50 a.m., a refrigerator was observed plugged into a surge protector in room 4018.
c) On 2/08/10, an I.V. pump was observed plugged into a surge protector in room 3002, bed A.
d) On 2/09/10, at 2:20 p.m., a refrigerator and a microwave were observed plugged into a surge protector, room B036.
e) On 2/09/10, at 3:10 a.m., a refrigerator and a microwave were observed plugged into a surge protector, room B062.