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Based on observation, the facility failed to maintain the corridor construction with a one- half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This deficient practice affected one of six smoke compartments on the Third Floor, and one of eight smoke compartments on the Second Floor of the Main Hospital. At the General Hospital this deficiency affected one of eight smoke compartments on the First Floor, and one of eight smoke compartments on the Second Floor. This could potentially result in the spread of smoke and or fire

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, corridor walls were observed in the following locations:

St Joseph's Hospital
1. At 2:00 p.m., the ceiling in the room next to the Third Floor Occupational Therapy Office had an approximately four inch unsealed penetration in it.
2. At 2:15 p.m., the Second Floor Short Stay Nurses Station had eight 3/4 inch unsealed penetrations in the wall, where a television bracket had been removed.
3. At 2:45 p.m., the Second Floor Break Room had two 3/4 inch penetrations in the wall.
4. At 2:46 p.m., the Second Floor Dressing Room had four 3/4 inch penetrations in the ceiling.

General Hospital5. At 11:46 a.m., the Functional Capacity Testing Room had an approximately 12 inch by 12 inch unsealed penetration in the ceiling.
6. At 2:45 p.m., the Server Administrator ' s Office had a three inch unsealed penetration in the wall behind the door.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested, and by a corridor door that failed to resist the passage of smoke. This deficient practice affected staff and patients in one of eight smoke compartments on the Second Floor, and one of eight smoke compartments on the First Floor of St. Joseph's Hospital. At the General Hospital these findings affected four of eight smoke compartments on the First Floor. At the Outpatient North Coast Surgery Center these findings affected two of two smoke compartments. This could result in the spread of smoke and/or fire into other areas of the facility.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, doors were tested in the following locations:

St. Joseph's Main Campus
1. At 2:20 p.m., the Second Floor corridor door identified as number 1262 had three 1/2 to 3/4 inch penetrations in it, near the door knob.
2. At 2:25 p.m. the Pantry door in the Second Floor Short Stay Post Anesthesia Care Unit did not positive latch when released from an open position.
3. At 2:35 p.m., the Post Anesthesia Care Unit Nurses ' Station door was approximately 80 percent covered with loose papers. Staff removed the papers at that time.
4. At 3:00 p.m., the corridor door between Surgery and Short Stay did not positive latch when tested.
5. At 3:42 p.m., the corridor door to Prenatal did not positive latch when released from an open position.
6. At 4:15 p.m., the south facing leaf of the corridor door to the Second Floor Emergency Room did not positive latch when tested.


During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, doors were tested in the following locations:

7. At 8:58 a.m., the door between the kitchen and serving area had a cart holding the door open which impeded it from closing.

General Hospital Campus
8. At 11:50 a.m., the door to the room identified as the First Floor Phlebotomy Supervisor's Office did not positive latch when released from an open position.
9. At 12:15 p.m., the door to the First Floor Regional Foundation Manager's Office did not positive latch when released from an open position.
10. At 1:58 p.m., the door to the Patient Accounts South Office did not positive latch when released from an open position.
11. At 2:19 p.m., the door to Second Floor Rehabilitation did not positive latch when released from its magnetic hold-open device.
12. At 2:45 p.m., the door to the Second Floor IPAW Office did not positive latch when released from an open position.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, doors were tested in the following locations:

North Coast Surgery Center
13. At 10:02 a.m., the door to the Family Waiting Room had a kick type door stop attached to the bottom of the door.
14. At 10:03 a.m., the door to the Doctor ' s Office had a kick-type door stop attached to the bottom of the door.
15. At 10:05 a.m., the door to the Pathology Laboratory had a door wedge holding the door open.
16. At 10:08 a.m., the door to the Anesthesia Room did not positive latch when released from an open position.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls, in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the smoke/fire barrier walls. This deficient practice affected two of eight smoke compartments on the Second Floor, and two of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the General Hospital, these findings affected two of seven smoke compartments on the Basement Level, and two of eight smoke compartments on the First Floor. This could result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, smoke/fire barrier walls were observed in the following locations:

St. Joseph's Hospital
1. At 1:55 p.m., the two-hour fire barrier wall located on the Second Floor above the drop down ceiling between the Intensive Care Unit and the 1954 portion of the building had a two inch unsealed penetration caused by a metal sleeve. This sleeve was also not sealed around the outside.
2. At 2:45 p.m., the two hour fire-rated wall located in the Basement above the drop down ceiling between Nuclear Medicine and the 1954 portion of the building had a six inch galvanized sprinkler pipe that was cut in half, and was penetrating the fire barrier on one side. Inspection of the opposite side of the fire barrier did not show the galvanized pipe; it did, however, have a two inch metal sleeve with blue data cable traveling through it that was unsealed on the end.

General Hospital
3. At 3:05 p.m., the smoke barrier wall in the Basement above the drop down ceiling between the Storage and the Linen areas had an approximately 12 inch by 12 inch unsealed penetration above in the space between the floor above and the ceiling.
4. At 3:25 p.m., the smoke barrier wall located above the drop down ceiling between Occupational Health and the corridor had a two inch sleeve penetrating the barrier. The fire caulking was displaced in the sleeve, causing a one and one-half inch opening through the barrier.

Based on observation, the facility failed to maintain cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire as evidenced by cross-corridor doors that failed to close and latch when tested. This deficient practice affected all staff and patients in four of eight smoke compartments on the Second Floor of St. Joseph's Hospital, and two of eight smoke compartments on the Second Floor of the General Hospital. At the North Coast Surgery Center these findings affected two of two smoke compartments. This could result in the spread of smoke and/or fire from one compartment to another.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, cross corridor doors were observed at the following locations:

St. Joseph's Hospital
1. At 3:44 p.m., the cross corridor doors near Echo Interpretation did not positive latch when tested.
2. At 4:45 p.m., the cross corridor door left leaf facing Surgery Scheduling did not positive latch when tested.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, cross corridor doors were observed in the following locations:

General Hospital
3. At 2:30 p.m., the right door leaf facing south of the cross corridor doors between the Second Floor Rehabilitation and the General Acute Care portion of the building did not positive latch when tested.

North Coast Surgery Center
4. At 10:15 a.m., the cross corridor doors near the Staff Break Room and the Sterile Core did not positive latch when tested during fire alarm testing.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by corridor doors to storage rooms and hazardous areas which did not have self-closing devices on them, and doors protecting hazardous area that failed to release during alarm testing. This deficient practice affected one of eight smoke compartments on the First Floor, and one of four smoke compartments on the Basement Level of St. Joseph's Hospital. This could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director between 1/25/11 and 1/26/11, hazardous area enclosures were observed in the following locations:

1. On 1/25/11, at 5:30 p.m., the corridor doors protecting the Dining/Kitchen area did not release from their magnetic hold-open devices during activation of the fire alarm by a manual pull station.
2. At 2:50 p.m., the Intensive Care Unit Break Room had a microwave oven, a toaster, and a coffee pot plugged into a power strip. This room did not have a self-closing device on the door.
3. On 1/26/11, at 9:40 a.m., the Basement Level Medical Records Room was not equipped with a self-closing device on the corridor door. This room measured approximately 15 by 30 feet in size.

Based on observation, the facility failed to protect all of its hazardous areas in accordance with 2000 NFPA 101. This was evidenced by a gift shop which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, was not equipped with a self-closing mechanism on the door, and was in a non-sprinklered portion of the building. This deficient practice affected one of eight smoke compartments at the General Hospital, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the General Hospital with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, at 2:12 p.m., the Gift Shop located in the First Floor Lobby did not have a self-closing mechanism on the corridor door, and was in a non-sprinklered portion of the building. This Gift Shop had a large amount of combustible gifts and merchandise in it.

Based on observation and interview, the facility failed to provide emergency illumination in accordance with 1999 NFPA 99 and 2000 NFPA 101. This was evidenced by a lack of battery-powered emergency lighting units in anesthetizing locations, a lack emergency egress lights in unlit areas, and egress/exit lights which did not function when tested. This deficient practice affected five of five operating rooms at St. Joseph's Hospital, one of one smoke compartment at the Sleep Center, and one of two smoke compartments at the Outpatient Imaging Center. This could result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages. At the Outpatient Services these findings could potentially result in injury and/or a delay in evacuation in the event of an emergency.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.


7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.2.2* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

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.

7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, Operating Rooms were observed without battery back-up emergency lighting units in the following locations:

St. Joseph's Hospital
1. At 3:36 p.m., the Second Floor Delivery Operating Room did not have battery- operated emergency lighting units mounted on the walls or in the ceiling light fixtures
2. At 4:30 p.m., the Second Floor Operating Rooms 1 and 5 were observed. These Operating Rooms did not have battery back-up emergency lighting units mounted on the walls or ceiling light fixtures. When asked, Staff AS 3 stated that they did not know if there were battery back-up lights in the ceiling light fixture.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, battery-powered emergency lighting was observed at the following locations:

Sleep Center
3. At 11:26, the Sleep Center did not have emergency battery-powered lighting units installed in the facility. This Sleep Center provides care of patients during the night between 7:00 p.m. and 7:00 a.m. This facility does not have a back-up power supply; therefore, if the normal power were interrupted, the building would be dark inside.

Out Patient Imaging Center
4. At 12:16 p.m., the emergency egress/exit light at the bottom of the stairs near the exit did not function when tested.
5. At 12:17 p.m., the emergency egress/exit light leading to Ultra Sound did not function when tested.
Staff AS1 stated that the lighting units are not tested routinely, but rather that the batteries are changed annually.
This facility does not have a back-up power supply; therefore, if the normal power were interrupted, the building would be dark inside. The hours of operation for the Imaging Center were from 7:00 p.m., to 7:00 a.m.

Based on observation and interview, the facility failed to maintain its fire alarm system, in accordance with 1999 NFPA 72, as evidenced by fire alarm initiating devices failing to activate the fire alarm control panel or produce an audible alarm. This deficient practice affected staff and patients in one of eight smoke compartments on the First Floor, and one of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the North Coast Surgery Center, these findings affected two of two smoke compartments. This could potentially result in a delay in response from firefighters and/or staff in the event of a fire or other emergency if no early warning is received.

Findings:

During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, the following devices did not function when tested:

1. At 5:26 p.m., smoke detector number 19-2 in the Basement Cath Laboratory did not activate the Fire Alarm Control Panel (FACP) when tested. Staff sprayed another detector in same smoke compartment, and it did activate the FACP.

During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/26/11 the following devices did not function properly when tested:

2. At 10:40 a.m., the smoke detector located near the First Floor two hour fire wall between the Urgent Care/Business Office and the East Wing failed to produce an audible alarm when activated.

North Coast Surgery Center
During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, the Inspectors Test Valve water flow failed to activate the FACP within the required 90 seconds. Staff stated that they would notify the vendor to make the repairs. Later during record review at 3:00 p.m., Administrative Staff provided documentation that the flow alarm had been repaired, tested, and met the 90 second requirement.

Based on record review, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors, in accordance with 2000 NFPA 72, 7-3.2.1., as evidenced by incomplete documentation for smoke-sensitivity testing. This deficient practice affected all staff and residents at St. Joseph ' s Hospital and the General Hospital, and could potentially result in deficiencies with the smoke detectors going unnoticed.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review on 1/24/2011 at 2:30 p.m., the facility failed to provide complete documentation indicating that the smoke detectors had been tested for sensitivity. Documentation titled "Fire Alarm Inspection Testing for 2010", stated that testing was conducted on 11/23/2010. The documentation provided stated that the "sensitivity testing was next due in 2012, and meets standard 2010". Documentation provided for the testing failed to include results for each detector tested, and sensitivity range information.

Based on observation, the facility failed to protect its smoking areas in accordance with 2000 NFPA 101 19.7.4. This was evidenced by failing to provide safety-type ash trays and proper containers to dispose of cigarette butts where smoking is allowed. This deficient practice affected one of two smoking areas outside of the facility, and could result in the ignition of fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer on 1/25/11, at 11:25 a.m., the designated Staff Smoking Area located on the southwest side of the facility did not have a safety-type ash tray available. The ash tray that was provided was an open top container built into the top of a trash can. Staff removed the container at that time.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A, as evidenced by dampers that were not inspected within a six year period. This deficient practice affected 17 of 164 dampers inspected at St. Joseph's Hospital, and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 6 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.


Findings:

During a review of the facility's documentation on 1/26/11, at 8:00 a.m., documentation provided for damper inspections dated October of 2010 indicated that of the 164 dampers inspected, 17 dampers could not be inspected due to a lack of access to the dampers. Staff AS1 stated that a company was contracted to finish inspecting the dampers. Documentation was provided indicating that a company was being contracted to complete the work.

Based on record review and interview, the facility failed to maintain its cooking facilities, in accordance with 1998 NFPA 96, as evidenced by a deficiency noted on the annual kitchen hood suppression report that had not been corrected. This deficient practice affected one of seven smoke compartments on the first floor of St. Joseph's Hospital, and could result in the spread of smoke and/or fire.

3-2.3 Grease filter shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filter shall be tight fitting and firmly held in place.

Findings:

During record review on 1/24/2011 at 2:30 p.m., documentation provided for the annual kitchen hood suppression system inspection and service stated in the deficiencies that the 16 inch grill filter did not fit and could allow flame to spread. When asked, Staff AS1 stated that a new grill filter was being constructed to replace the old one.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This deficient practice affected all staff and patients in one of eight smoke compartments on the Second Floor, and one of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the General Hospital, these findings affected all staff and patients in one of eight smoke compartments on the first floor, and could result in the ignition of fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, portable electric heaters were observed in the following locations:

1. At 3:50 p.m., a portable electric heater was observed in the Second Floor Registration Office. This heater had the coils visible, and a high temperature warning on top.
2. At 1:55 p.m., the First Floor Accounts Office had a portable electric heater that was 1500 watts, and had a three foot clearance high temperature warning.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress in an exit corridor. This deficient practice had the potential to affect all staff and patients in one of eight smoke compartments on the Third Floor at St. Joseph's Hospital, and one of eight smoke compartment on the Second Floor at the General Hospital, and could result in injury or a delay in evacuation in the event of an emergency.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, exit corridors were observed in the following locations:

St. Joseph's Hospital
1. At 2:10 p.m., the exit corridor located near the Third Floor South Exit had two cribs and two beds stored in the corridor against the wall. At 2:45 p.m., these items were still stored in the same location.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, exit corridors were observed in the following locations:

General Hospital
2. At 3:00 p.m., the corridor in Two West had approximately nine boxes, two pallets, and computer equipment stored near the cross-corridor doors. During an inspection of the smoke barrier walls on 1/27/11, at 1:55 p.m., the items in the corridor were had been moved to allow a greater egress width, but were still in the same location.

Based on observation, the facility failed to protect its medical compressed gas storage area, in accordance with 1999 NFPA 99, as evidenced by cylinders which were stored secured together instead of individually, and cylinders more than 300 cubic feet of oxygen stored outside of an enclosure, that was open to the room. This deficient practice affected one of eight smoke compartments on the Second Floor, and one of eight smoke compartments on the First Floor of the General Hospital. This could result in damage to the cylinders if they were to fall, and the spread of smoke and/or fire.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, compressed gas storage was observed in the following locations:

General Hospital
1. At 11:05 a.m., the Maintenance Shop located on the first floor had six H size compressed gas tanks chained together on one side of the room.
2. At 2:22 p.m., the Second Floor Rehabilitation Room had 16 E size oxygen tanks stored in a rack, and four E size tanks stored in individual tank stands near the rack.

Based on document review and interview, the facility failed to maintain the relative humidity in its anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by documented humidity levels lower than the required minimum 35 percent, and by a failure to correct and record actions taken. This deficient practice had the potential to affect staff and patients in two of five operating rooms at St. Joseph's Hospital by increasing the risk of fire.

Findings:

During record review on 1/27/11 at 3:00 p.m., documentation provided titled "O.R. Environmental Check" showed that one humidity point each day was recorded. These data points (noted below), indicated that the humidity levels that were recorded were below the required minimum 35 percent humidity for the following number of days each month in 2010:

Operating Room 1
January: four days below 35 percent
February: one day below 35 percent
March: 13 days below 35 percent
April: ten days below 35 percent
May: five days below 35 percent
November: one day below 35 percent
December: two days below 35 percent

OB Operating Room
January: eight days below 35 percent
February: nine day below 35 percent
March: 14 days below 35 percent
April: 12 days below 35 percent
May: seven days below 35 percent
June: one day below 35 percent
September: three days below 35 percent
October: one day below 35 percent
November: seven days below 35 percent
December: 17 days below 35 percent

The Humidity Log showed one humidity reading for each day of the month. They did not show any actions taken or note if the humidity was adjusted back into the 35 percent or higher range. When asked, Staff AS1 stated that the Maintenance was not notified of the humidity levels when they were out of range.

Based on document review and staff interview, the facility failed to provide a remote annunciator, complete documentation of generator inspections, and emergency task lighting in accordance with 1999 NFPA 110. This was evidenced by the failure to provide a generator annunciator in a readily observed location, failure to document weekly generator inspections, and provide battery back-up emergency task lighting at generator locations. This finding affected all staff and residents at St. Joseph's Hospital, the General Hospital, and the North Coast Surgery Center. This could result in deficiencies with the generator going unnoticed, and the generator not functioning properly during a loss of normal power.

3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency
or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less
than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

NFPA 110, 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.
Exception: This requirement shall not apply to units housed outdoors.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, generator set locations were observed in the following locations:

St. Joseph's Hospital
1. At 11:15 a.m., Generator 2 (1312E) was inside of an enclosure which did not have a battery back-up task light installed.
2. At 11:35 a.m., Generator 4 (1310E) was inside of an enclosure which did not have a battery back-up task light installed.
When asked about the remote generator annunciator, AS2 stated that if the power went out, Maintenance Staff would make rounds to the different annunciators which were located as follows:
For Generator 1310 E, the annunciator is located at the PBX which is staffed from 5:00 a.m. to 10:00 p.m.
For Generators 1312E and 1313, the annunciator is located in the Boiler Rooms.
For Generator 1311E, the annunciator is located in the Basement in the Fire alarm Panel Room.

3. During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, at 11:05 a.m., the generator set location was observed at the General Hospital. This generator was located in an enclosure which did not have a battery back-up task light installed.
When asked about the location of the Generator annunciator at the General Hospital, Staff AS2 stated that it was in the Maintenance Shop. This location is a periodically unattended location. Staff AS1 stated that they may be able to monitor the annunciator using the fire alarm monitoring company.

North Coast Surgery Center
During document review at the Surgery Center facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11 at 10:36 a.m., the generator log indicated that the generator was tested under load for 30 minutes each month. The log did not, however, document any of the weekly visual inspections. Staff AS2 stated that the generators are inspected weekly, but not documented in the generator log book for the Surgery Center.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, and failure to maintain clearance in front of electrical panels. This deficient practice affected four of four floors at St. Joseph's Hospital, one of three floors at the General Hospital, the North Coast Surgery Center, and the Sleep Center, and could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, electrical wiring and equipment were observed in the following locations:

St. Joseph's Hospital
1. At 11:45 a.m., the Fourth Floor Outside Storage Room had traction equipment lying on the floor, in front of an electrical panel.
2. At 12:04 p.m., the Pediatrics Nurses Station had a power strip suspended above the floor, with an extension cord plugged into it.
3. At 12:10 p.m., the Fourth Floor Nurses Station had a power strip suspended above the floor, with a cord partially unplugged from it
4. At 1:20 p.m., the Third Floor Outcome Manager's Office had a coffee pot plugged into a power strip, which was being used as an extension cord.
5. At 1:30 p.m., the Third Floor Break Room had a microwave oven plugged into a power strip.
6. At 1:59 p.m., the Third Floor Doctors Sleep Room had a microwave oven and a refrigerator plugged into a power strip.
7. At 2:00 p.m., the Third Floor Occupational Therapy Office had an extension cord plugged into a one to three outlet plug adapter, which was supplying power to a wall mounted plug strip with approximately 15 plug receptacles, without over current protection.
8. At 2:50 p.m., the Second Floor Intensive Care Unit (ICU) Break Room had a microwave oven, a toaster, and a coffee maker plugged into a power strip.
9. At 2:55 p.m., the Second Floor ICU Medications Room had a double gain outlet that was missing a cover.
10. At 3:55 p.m., the Second Floor Laboratory had an extension cord supplying power to a Beckman Cotter Machine.
11. At 4:16 the Laboratory Break Room had a microwave oven and coffee maker plugged into a power strip.
12. At 4:36 p.m., Operating Room 5 had a power strip lying on the bottom shelf of a PYXIS mobile cart. This power strip was not cart mounted.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11 electrical wiring and equipment were observed in the following locations:

13. At 9:08 a.m.., the Basement Level Health Data Analysis Room had a microwave oven and coffee maker plugged into a power strip.
14. At 9:15 a.m., the Basement Medical Staff Lounge had an extension cord taped to the floor, which traveled under a wicker basket.
15. At 9:30 a.m., the Medical Staff Services Room had an extension cord plugged into a light duty, unapproved extension cord.
16. At 9:45 a.m., the Materials Management Room had a power strip plugged into another power strip under a desk.
17. At 9:55 a.m. the Materials Management Ladies Lounge had an extension cord in the Dressing Room.

General Hospital
During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, electrical wiring and equipment were observed in the following locations:

18. At 11:45 p.m., the room identified as the Paso Room had a power strip suspended, with the cord partially pulled out.
19. At 12:44 p.m., the Foundation Data Analysis Office had a power strip suspended above the floor.
20. At 1:38 p.m., the Occupational Health Office Adjacent to Room 3 had an extension cord traveling through a cabinet to office equipment.
21. At 1:42 p.m., the Patient Account Office three extension cords. One was supplying power to a coffee pot, and two extension cords supplying power to office equipment.
22. At 1:46 p.m., the Cafe Storage Room had an extension cord supplying power to a refrigerator.
23. At 2:10 p.m., the Patient Accounts Room had an extension cord under a rug, supplying power to a power strip.

North Coast Surgery Center
24. At 10:10 a.m. the Nurses Station had a power strip that was plugged into another power strip.
25. At 10:32 a.m., the facility's main electrical panel had two carts, two heaters, and a vacuum stored in front of it.

Sleep Center
26. At 11:55 a.m., the Manager's Office had a power strip suspended above the floor.
27. At 11:59 a.m., the Scheduling Office had two power strips plugged into each other.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition, as evidenced by an ABHR dispensers located above light switches. This finding affected one of eight smoke compartments on the Second Floor at St. Joseph's Hospital, one of two smoke compartments at the North Coast Surgery Center, and one smoke compartment at the Home Infusion Center, and could result in the ignition of fire.

Where Alcohol Based Hand Rub (ABHR) dispensers are installed:
The corridor is at least 6 feet wide
The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
The dispensers shall have a minimum spacing of 4 ft from each other
Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
Dispensers are not installed over or adjacent to an ignition source.
If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director between 1/25/11 and 1/27/11, Alcohol-Based Hand Rub Dispensers were observed in the following locations:

St. Joseph's Hospital
1. At 4:12 p.m., an ABHR dispenser was located approximately four inches above a light switch in Trauma Room 1.

Home Infusion Center
2. At 9:08 a.m., the Office area had an ABHR dispenser located above a light switch.

North Coast Surgery Center
3. At 10:20 a.m., the Patient Examination Room had an ABHR dispenser located above a light switch.

Based on observation, the facility failed to maintain the corridor construction with a one- half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This deficient practice affected one of six smoke compartments on the Third Floor, and one of eight smoke compartments on the Second Floor of the Main Hospital. At the General Hospital this deficiency affected one of eight smoke compartments on the First Floor, and one of eight smoke compartments on the Second Floor. This could potentially result in the spread of smoke and or fire

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, corridor walls were observed in the following locations:

St Joseph's Hospital
1. At 2:00 p.m., the ceiling in the room next to the Third Floor Occupational Therapy Office had an approximately four inch unsealed penetration in it.
2. At 2:15 p.m., the Second Floor Short Stay Nurses Station had eight 3/4 inch unsealed penetrations in the wall, where a television bracket had been removed.
3. At 2:45 p.m., the Second Floor Break Room had two 3/4 inch penetrations in the wall.
4. At 2:46 p.m., the Second Floor Dressing Room had four 3/4 inch penetrations in the ceiling.

General Hospital5. At 11:46 a.m., the Functional Capacity Testing Room had an approximately 12 inch by 12 inch unsealed penetration in the ceiling.
6. At 2:45 p.m., the Server Administrator ' s Office had a three inch unsealed penetration in the wall behind the door.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested, and by a corridor door that failed to resist the passage of smoke. This deficient practice affected staff and patients in one of eight smoke compartments on the Second Floor, and one of eight smoke compartments on the First Floor of St. Joseph's Hospital. At the General Hospital these findings affected four of eight smoke compartments on the First Floor. At the Outpatient North Coast Surgery Center these findings affected two of two smoke compartments. This could result in the spread of smoke and/or fire into other areas of the facility.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, doors were tested in the following locations:

St. Joseph's Main Campus
1. At 2:20 p.m., the Second Floor corridor door identified as number 1262 had three 1/2 to 3/4 inch penetrations in it, near the door knob.
2. At 2:25 p.m. the Pantry door in the Second Floor Short Stay Post Anesthesia Care Unit did not positive latch when released from an open position.
3. At 2:35 p.m., the Post Anesthesia Care Unit Nurses ' Station door was approximately 80 percent covered with loose papers. Staff removed the papers at that time.
4. At 3:00 p.m., the corridor door between Surgery and Short Stay did not positive latch when tested.
5. At 3:42 p.m., the corridor door to Prenatal did not positive latch when released from an open position.
6. At 4:15 p.m., the south facing leaf of the corridor door to the Second Floor Emergency Room did not positive latch when tested.


During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, doors were tested in the following locations:

7. At 8:58 a.m., the door between the kitchen and serving area had a cart holding the door open which impeded it from closing.

General Hospital Campus
8. At 11:50 a.m., the door to the room identified as the First Floor Phlebotomy Supervisor's Office did not positive latch when released from an open position.
9. At 12:15 p.m., the door to the First Floor Regional Foundation Manager's Office did not positive latch when released from an open position.
10. At 1:58 p.m., the door to the Patient Accounts South Office did not positive latch when released from an open position.
11. At 2:19 p.m., the door to Second Floor Rehabilitation did not positive latch when released from its magnetic hold-open device.
12. At 2:45 p.m., the door to the Second Floor IPAW Office did not positive latch when released from an open position.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, doors were tested in the following locations:

North Coast Surgery Center
13. At 10:02 a.m., the door to the Family Waiting Room had a kick type door stop attached to the bottom of the door.
14. At 10:03 a.m., the door to the Doctor ' s Office had a kick-type door stop attached to the bottom of the door.
15. At 10:05 a.m., the door to the Pathology Laboratory had a door wedge holding the door open.
16. At 10:08 a.m., the door to the Anesthesia Room did not positive latch when released from an open position.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls, in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the smoke/fire barrier walls. This deficient practice affected two of eight smoke compartments on the Second Floor, and two of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the General Hospital, these findings affected two of seven smoke compartments on the Basement Level, and two of eight smoke compartments on the First Floor. This could result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, smoke/fire barrier walls were observed in the following locations:

St. Joseph's Hospital
1. At 1:55 p.m., the two-hour fire barrier wall located on the Second Floor above the drop down ceiling between the Intensive Care Unit and the 1954 portion of the building had a two inch unsealed penetration caused by a metal sleeve. This sleeve was also not sealed around the outside.
2. At 2:45 p.m., the two hour fire-rated wall located in the Basement above the drop down ceiling between Nuclear Medicine and the 1954 portion of the building had a six inch galvanized sprinkler pipe that was cut in half, and was penetrating the fire barrier on one side. Inspection of the opposite side of the fire barrier did not show the galvanized pipe; it did, however, have a two inch metal sleeve with blue data cable traveling through it that was unsealed on the end.

General Hospital
3. At 3:05 p.m., the smoke barrier wall in the Basement above the drop down ceiling between the Storage and the Linen areas had an approximately 12 inch by 12 inch unsealed penetration above in the space between the floor above and the ceiling.
4. At 3:25 p.m., the smoke barrier wall located above the drop down ceiling between Occupational Health and the corridor had a two inch sleeve penetrating the barrier. The fire caulking was displaced in the sleeve, causing a one and one-half inch opening through the barrier.

Based on observation, the facility failed to maintain cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire as evidenced by cross-corridor doors that failed to close and latch when tested. This deficient practice affected all staff and patients in four of eight smoke compartments on the Second Floor of St. Joseph's Hospital, and two of eight smoke compartments on the Second Floor of the General Hospital. At the North Coast Surgery Center these findings affected two of two smoke compartments. This could result in the spread of smoke and/or fire from one compartment to another.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, cross corridor doors were observed at the following locations:

St. Joseph's Hospital
1. At 3:44 p.m., the cross corridor doors near Echo Interpretation did not positive latch when tested.
2. At 4:45 p.m., the cross corridor door left leaf facing Surgery Scheduling did not positive latch when tested.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, cross corridor doors were observed in the following locations:

General Hospital
3. At 2:30 p.m., the right door leaf facing south of the cross corridor doors between the Second Floor Rehabilitation and the General Acute Care portion of the building did not positive latch when tested.

North Coast Surgery Center
4. At 10:15 a.m., the cross corridor doors near the Staff Break Room and the Sterile Core did not positive latch when tested during fire alarm testing.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by corridor doors to storage rooms and hazardous areas which did not have self-closing devices on them, and doors protecting hazardous area that failed to release during alarm testing. This deficient practice affected one of eight smoke compartments on the First Floor, and one of four smoke compartments on the Basement Level of St. Joseph's Hospital. This could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director between 1/25/11 and 1/26/11, hazardous area enclosures were observed in the following locations:

1. On 1/25/11, at 5:30 p.m., the corridor doors protecting the Dining/Kitchen area did not release from their magnetic hold-open devices during activation of the fire alarm by a manual pull station.
2. At 2:50 p.m., the Intensive Care Unit Break Room had a microwave oven, a toaster, and a coffee pot plugged into a power strip. This room did not have a self-closing device on the door.
3. On 1/26/11, at 9:40 a.m., the Basement Level Medical Records Room was not equipped with a self-closing device on the corridor door. This room measured approximately 15 by 30 feet in size.

Based on observation, the facility failed to protect all of its hazardous areas in accordance with 2000 NFPA 101. This was evidenced by a gift shop which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, was not equipped with a self-closing mechanism on the door, and was in a non-sprinklered portion of the building. This deficient practice affected one of eight smoke compartments at the General Hospital, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the General Hospital with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, at 2:12 p.m., the Gift Shop located in the First Floor Lobby did not have a self-closing mechanism on the corridor door, and was in a non-sprinklered portion of the building. This Gift Shop had a large amount of combustible gifts and merchandise in it.

Based on observation and interview, the facility failed to provide emergency illumination in accordance with 1999 NFPA 99 and 2000 NFPA 101. This was evidenced by a lack of battery-powered emergency lighting units in anesthetizing locations, a lack emergency egress lights in unlit areas, and egress/exit lights which did not function when tested. This deficient practice affected five of five operating rooms at St. Joseph's Hospital, one of one smoke compartment at the Sleep Center, and one of two smoke compartments at the Outpatient Imaging Center. This could result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages. At the Outpatient Services these findings could potentially result in injury and/or a delay in evacuation in the event of an emergency.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.


7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.2.2* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

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.

7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, Operating Rooms were observed without battery back-up emergency lighting units in the following locations:

St. Joseph's Hospital
1. At 3:36 p.m., the Second Floor Delivery Operating Room did not have battery- operated emergency lighting units mounted on the walls or in the ceiling light fixtures
2. At 4:30 p.m., the Second Floor Operating Rooms 1 and 5 were observed. These Operating Rooms did not have battery back-up emergency lighting units mounted on the walls or ceiling light fixtures. When asked, Staff AS 3 stated that they did not know if there were battery back-up lights in the ceiling light fixture.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, battery-powered emergency lighting was observed at the following locations:

Sleep Center
3. At 11:26, the Sleep Center did not have emergency battery-powered lighting units installed in the facility. This Sleep Center provides care of patients during the night between 7:00 p.m. and 7:00 a.m. This facility does not have a back-up power supply; therefore, if the normal power were interrupted, the building would be dark inside.

Out Patient Imaging Center
4. At 12:16 p.m., the emergency egress/exit light at the bottom of the stairs near the exit did not function when tested.
5. At 12:17 p.m., the emergency egress/exit light leading to Ultra Sound did not function when tested.
Staff AS1 stated that the lighting units are not tested routinely, but rather that the batteries are changed annually.
This facility does not have a back-up power supply; therefore, if the normal power were interrupted, the building would be dark inside. The hours of operation for the Imaging Center were from 7:00 p.m., to 7:00 a.m.

Based on observation and interview, the facility failed to maintain its fire alarm system, in accordance with 1999 NFPA 72, as evidenced by fire alarm initiating devices failing to activate the fire alarm control panel or produce an audible alarm. This deficient practice affected staff and patients in one of eight smoke compartments on the First Floor, and one of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the North Coast Surgery Center, these findings affected two of two smoke compartments. This could potentially result in a delay in response from firefighters and/or staff in the event of a fire or other emergency if no early warning is received.

Findings:

During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, the following devices did not function when tested:

1. At 5:26 p.m., smoke detector number 19-2 in the Basement Cath Laboratory did not activate the Fire Alarm Control Panel (FACP) when tested. Staff sprayed another detector in same smoke compartment, and it did activate the FACP.

During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/26/11 the following devices did not function properly when tested:

2. At 10:40 a.m., the smoke detector located near the First Floor two hour fire wall between the Urgent Care/Business Office and the East Wing failed to produce an audible alarm when activated.

North Coast Surgery Center
During fire alarm testing with the facility's Director/Safety Officer and Maintenance Director on 1/27/11, the Inspectors Test Valve water flow failed to activate the FACP within the required 90 seconds. Staff stated that they would notify the vendor to make the repairs. Later during record review at 3:00 p.m., Administrative Staff provided documentation that the flow alarm had been repaired, tested, and met the 90 second requirement.

Based on record review, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors, in accordance with 2000 NFPA 72, 7-3.2.1., as evidenced by incomplete documentation for smoke-sensitivity testing. This deficient practice affected all staff and residents at St. Joseph ' s Hospital and the General Hospital, and could potentially result in deficiencies with the smoke detectors going unnoticed.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review on 1/24/2011 at 2:30 p.m., the facility failed to provide complete documentation indicating that the smoke detectors had been tested for sensitivity. Documentation titled "Fire Alarm Inspection Testing for 2010", stated that testing was conducted on 11/23/2010. The documentation provided stated that the "sensitivity testing was next due in 2012, and meets standard 2010". Documentation provided for the testing failed to include results for each detector tested, and sensitivity range information.

Based on observation, the facility failed to protect its smoking areas in accordance with 2000 NFPA 101 19.7.4. This was evidenced by failing to provide safety-type ash trays and proper containers to dispose of cigarette butts where smoking is allowed. This deficient practice affected one of two smoking areas outside of the facility, and could result in the ignition of fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer on 1/25/11, at 11:25 a.m., the designated Staff Smoking Area located on the southwest side of the facility did not have a safety-type ash tray available. The ash tray that was provided was an open top container built into the top of a trash can. Staff removed the container at that time.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A, as evidenced by dampers that were not inspected within a six year period. This deficient practice affected 17 of 164 dampers inspected at St. Joseph's Hospital, and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 6 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.


Findings:

During a review of the facility's documentation on 1/26/11, at 8:00 a.m., documentation provided for damper inspections dated October of 2010 indicated that of the 164 dampers inspected, 17 dampers could not be inspected due to a lack of access to the dampers. Staff AS1 stated that a company was contracted to finish inspecting the dampers. Documentation was provided indicating that a company was being contracted to complete the work.

Based on record review and interview, the facility failed to maintain its cooking facilities, in accordance with 1998 NFPA 96, as evidenced by a deficiency noted on the annual kitchen hood suppression report that had not been corrected. This deficient practice affected one of seven smoke compartments on the first floor of St. Joseph's Hospital, and could result in the spread of smoke and/or fire.

3-2.3 Grease filter shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filter shall be tight fitting and firmly held in place.

Findings:

During record review on 1/24/2011 at 2:30 p.m., documentation provided for the annual kitchen hood suppression system inspection and service stated in the deficiencies that the 16 inch grill filter did not fit and could allow flame to spread. When asked, Staff AS1 stated that a new grill filter was being constructed to replace the old one.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This deficient practice affected all staff and patients in one of eight smoke compartments on the Second Floor, and one of four smoke compartments on the Basement Level at St. Joseph's Hospital. At the General Hospital, these findings affected all staff and patients in one of eight smoke compartments on the first floor, and could result in the ignition of fire.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, portable electric heaters were observed in the following locations:

1. At 3:50 p.m., a portable electric heater was observed in the Second Floor Registration Office. This heater had the coils visible, and a high temperature warning on top.
2. At 1:55 p.m., the First Floor Accounts Office had a portable electric heater that was 1500 watts, and had a three foot clearance high temperature warning.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress in an exit corridor. This deficient practice had the potential to affect all staff and patients in one of eight smoke compartments on the Third Floor at St. Joseph's Hospital, and one of eight smoke compartment on the Second Floor at the General Hospital, and could result in injury or a delay in evacuation in the event of an emergency.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, exit corridors were observed in the following locations:

St. Joseph's Hospital
1. At 2:10 p.m., the exit corridor located near the Third Floor South Exit had two cribs and two beds stored in the corridor against the wall. At 2:45 p.m., these items were still stored in the same location.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, exit corridors were observed in the following locations:

General Hospital
2. At 3:00 p.m., the corridor in Two West had approximately nine boxes, two pallets, and computer equipment stored near the cross-corridor doors. During an inspection of the smoke barrier walls on 1/27/11, at 1:55 p.m., the items in the corridor were had been moved to allow a greater egress width, but were still in the same location.

Based on observation, the facility failed to protect its medical compressed gas storage area, in accordance with 1999 NFPA 99, as evidenced by cylinders which were stored secured together instead of individually, and cylinders more than 300 cubic feet of oxygen stored outside of an enclosure, that was open to the room. This deficient practice affected one of eight smoke compartments on the Second Floor, and one of eight smoke compartments on the First Floor of the General Hospital. This could result in damage to the cylinders if they were to fall, and the spread of smoke and/or fire.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, compressed gas storage was observed in the following locations:

General Hospital
1. At 11:05 a.m., the Maintenance Shop located on the first floor had six H size compressed gas tanks chained together on one side of the room.
2. At 2:22 p.m., the Second Floor Rehabilitation Room had 16 E size oxygen tanks stored in a rack, and four E size tanks stored in individual tank stands near the rack.

Based on document review and interview, the facility failed to maintain the relative humidity in its anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by documented humidity levels lower than the required minimum 35 percent, and by a failure to correct and record actions taken. This deficient practice had the potential to affect staff and patients in two of five operating rooms at St. Joseph's Hospital by increasing the risk of fire.

Findings:

During record review on 1/27/11 at 3:00 p.m., documentation provided titled "O.R. Environmental Check" showed that one humidity point each day was recorded. These data points (noted below), indicated that the humidity levels that were recorded were below the required minimum 35 percent humidity for the following number of days each month in 2010:

Operating Room 1
January: four days below 35 percent
February: one day below 35 percent
March: 13 days below 35 percent
April: ten days below 35 percent
May: five days below 35 percent
November: one day below 35 percent
December: two days below 35 percent

OB Operating Room
January: eight days below 35 percent
February: nine day below 35 percent
March: 14 days below 35 percent
April: 12 days below 35 percent
May: seven days below 35 percent
June: one day below 35 percent
September: three days below 35 percent
October: one day below 35 percent
November: seven days below 35 percent
December: 17 days below 35 percent

The Humidity Log showed one humidity reading for each day of the month. They did not show any actions taken or note if the humidity was adjusted back into the 35 percent or higher range. When asked, Staff AS1 stated that the Maintenance was not notified of the humidity levels when they were out of range.

Based on document review and staff interview, the facility failed to provide a remote annunciator, complete documentation of generator inspections, and emergency task lighting in accordance with 1999 NFPA 110. This was evidenced by the failure to provide a generator annunciator in a readily observed location, failure to document weekly generator inspections, and provide battery back-up emergency task lighting at generator locations. This finding affected all staff and residents at St. Joseph's Hospital, the General Hospital, and the North Coast Surgery Center. This could result in deficiencies with the generator going unnoticed, and the generator not functioning properly during a loss of normal power.

3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency
or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less
than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

NFPA 110, 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.
Exception: This requirement shall not apply to units housed outdoors.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, generator set locations were observed in the following locations:

St. Joseph's Hospital
1. At 11:15 a.m., Generator 2 (1312E) was inside of an enclosure which did not have a battery back-up task light installed.
2. At 11:35 a.m., Generator 4 (1310E) was inside of an enclosure which did not have a battery back-up task light installed.
When asked about the remote generator annunciator, AS2 stated that if the power went out, Maintenance Staff would make rounds to the different annunciators which were located as follows:
For Generator 1310 E, the annunciator is located at the PBX which is staffed from 5:00 a.m. to 10:00 p.m.
For Generators 1312E and 1313, the annunciator is located in the Boiler Rooms.
For Generator 1311E, the annunciator is located in the Basement in the Fire alarm Panel Room.

3. During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, at 11:05 a.m., the generator set location was observed at the General Hospital. This generator was located in an enclosure which did not have a battery back-up task light installed.
When asked about the location of the Generator annunciator at the General Hospital, Staff AS2 stated that it was in the Maintenance Shop. This location is a periodically unattended location. Staff AS1 stated that they may be able to monitor the annunciator using the fire alarm monitoring company.

North Coast Surgery Center
During document review at the Surgery Center facility with the facility's Director/Safety Officer and Maintenance Director on 1/27/11 at 10:36 a.m., the generator log indicated that the generator was tested under load for 30 minutes each month. The log did not, however, document any of the weekly visual inspections. Staff AS2 stated that the generators are inspected weekly, but not documented in the generator log book for the Surgery Center.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, and failure to maintain clearance in front of electrical panels. This deficient practice affected four of four floors at St. Joseph's Hospital, one of three floors at the General Hospital, the North Coast Surgery Center, and the Sleep Center, and could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/25/11, electrical wiring and equipment were observed in the following locations:

St. Joseph's Hospital
1. At 11:45 a.m., the Fourth Floor Outside Storage Room had traction equipment lying on the floor, in front of an electrical panel.
2. At 12:04 p.m., the Pediatrics Nurses Station had a power strip suspended above the floor, with an extension cord plugged into it.
3. At 12:10 p.m., the Fourth Floor Nurses Station had a power strip suspended above the floor, with a cord partially unplugged from it
4. At 1:20 p.m., the Third Floor Outcome Manager's Office had a coffee pot plugged into a power strip, which was being used as an extension cord.
5. At 1:30 p.m., the Third Floor Break Room had a microwave oven plugged into a power strip.
6. At 1:59 p.m., the Third Floor Doctors Sleep Room had a microwave oven and a refrigerator plugged into a power strip.
7. At 2:00 p.m., the Third Floor Occupational Therapy Office had an extension cord plugged into a one to three outlet plug adapter, which was supplying power to a wall mounted plug strip with approximately 15 plug receptacles, without over current protection.
8. At 2:50 p.m., the Second Floor Intensive Care Unit (ICU) Break Room had a microwave oven, a toaster, and a coffee maker plugged into a power strip.
9. At 2:55 p.m., the Second Floor ICU Medications Room had a double gain outlet that was missing a cover.
10. At 3:55 p.m., the Second Floor Laboratory had an extension cord supplying power to a Beckman Cotter Machine.
11. At 4:16 the Laboratory Break Room had a microwave oven and coffee maker plugged into a power strip.
12. At 4:36 p.m., Operating Room 5 had a power strip lying on the bottom shelf of a PYXIS mobile cart. This power strip was not cart mounted.

During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11 electrical wiring and equipment were observed in the following locations:

13. At 9:08 a.m.., the Basement Level Health Data Analysis Room had a microwave oven and coffee maker plugged into a power strip.
14. At 9:15 a.m., the Basement Medical Staff Lounge had an extension cord taped to the floor, which traveled under a wicker basket.
15. At 9:30 a.m., the Medical Staff Services Room had an extension cord plugged into a light duty, unapproved extension cord.
16. At 9:45 a.m., the Materials Management Room had a power strip plugged into another power strip under a desk.
17. At 9:55 a.m. the Materials Management Ladies Lounge had an extension cord in the Dressing Room.

General Hospital
During a tour of the facility with the facility's Director/Safety Officer and Maintenance Director on 1/26/11, electrical wiring and equipment were observed in the following locations:

18. At 11:45 p.m., the room identified as the Paso Room had a power strip suspended, with the cord partially pulled out.
19. At 12:44 p.m., the Foundation Data Analysis Office had a power strip suspended above the floor.
20. At 1:38 p.m., the Occupational Health Office Adjacent to Room 3 had an extension cord traveling through a cabinet to office equipment.
21. At 1:42 p.m., the Patient Account Office three extension cords. One was supplying power to a coffee pot, and two extension cords supplying power to office equipment.
22. At 1:46 p.m., the Cafe Storage Room had an extension cord supplying power to a refrigerator.
23. At 2:10 p.m., the Patient Accounts Room had an extension cord under a rug, supplying power to a power strip.

North Coast Surgery Center
24. At 10:10 a.m. the Nurses Station had a power strip that was plugged into another power strip.
25. At 10:32 a.m., the facility's main electrical panel had two carts, two heaters, and a vacuum stored in front of it.

Sleep Center
26. At 11:55 a.m., the Manager's Office had a power strip suspended above the floor.
27. At 11:59 a.m., the Scheduling Office had two power strips plugged into each other.