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Based on facility observation and staff verification, the facility failed to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating. This had to potential to affect all persons utilizing the facility. The census was 193 patients at the time of the survey.

Findings include:

Tour of the facility was conducted on 10/01/12 between 1:05 P.M. and 4:30 P.M. and 10/02/12 between 7:50 A.M. and 4:45 P.M., with Staff A5, A6 and A7. The following observations were noted in walls designated by facility life safety drawings to have a two hour fire resistance rating.

Located on the second floor;
*A penetration was noted above the ceiling tiles in a two hour fire rated wall between the pharmacy leadership meeting room (H-L-107) and a women's restroom. The unsealed area surrounded a black plastic pipe.
* A penetration was observed above the ceiling tiles surrounding a steel conduit on both sides of a two hour fire separation between the medical office building and the main hospital. This was located on the second floor.
* Penetration was observed above the ceiling tiles in a two hour fire rated wall at H4-ST-W and a store room.

Staff present on the tour observed and verified the penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barrier was constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first and second floor critical care expansion areas took place on 10/01/12 with staff members A1, A2 and A3. During tour observation was made of two areas with penetrations in the one hour smoke barrier above the ceiling tiles in the following locations:

First floor critical care:
*One open end conduit at the emergency room patient registration area.
*Above the radiology double doors observation was made of a one inch open end conduit.

This finding was verified by staff member A3 during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure the hazardous areas were protected with at least a one hour fire rated construction, specifically in regards to the medical records room. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the medical records room observation was made of an approximate four foot by two foot section of drywall missing around several insulated pipes. This was verified by all staff members during tour of the medical records room.

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first floor critical care expansion areas took place on 10/01/12 and tour of the surgical areas took place on 10/03/12 with staff members A1, A2 and A3. During tour of the hazardous rooms observation was made of several penetrations in the one hour fire rated barrier above the ceiling tiles in the following locations:

First floor critical care:
*One open end conduit with two red wires passing through within the emergency department storage room located across from the elevators.

Second floor critical care:
*From within Pod A equipment room, observation was made of a one inch open end conduit protruding down from the upper deck.
*From within the soiled utility room located in the intensive care unit, observation was made of four open end conduits on the north wall and one open end conduit on the south wall.

Second floor surgery area:
*Within room MA2-304 observation was made of an approximate one inch by two inch opening in the northeast corner of the room.
* Within room MA2-326 observation was made of an open end flex conduit located on the east wall of the room.
*Within the storage room of suite one and above the door, observation was made of an open end conduit.


These findings were verified by all staff members during tour.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. Potentially all patients, staff and visitors could be affected. The facility census was 193 patients at the time of the survey.

Findings include:

On 10/01/12 between 1:05P.M. and 4:30 P.M. tour of the Trudell building was conducted with Staff A5, A6 and A7. Observation of the paths of egress located on the first floor of the psychiatric unit revealed one exit discharge which required travel across an uneven grassy area.

The exit door was noted to open onto a concrete pad estimated to be approximately three feet long and nine feet wide From the concrete pad to the hard surface of the public way, it estimated to be approximately 20 to 30 feet, across the uneven and grassy area. Staff present on the tour verified the findings.

Based on facility observation and staff verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. The facility had a census of 193 patients at the time of the survey.

Findings include:

On 10/02/12 between the hours of 7:50 A.M. and 3:00 P.M., tour of the secured psychiatric care unit was conducted with Staff A5, A6 and A7. Staff F conducted the tour of the unit. Staff F revealed there were 13 patient bedrooms on the unit and two special care (seclusion) rooms. During tour, one patient was observed sleeping a special care room with the door to the room open. Staff F verified the patient was using the room as a sleeping room.

Tour of the unit revealed the patient room doors had locks in place which required a key. Observation from inside a patient room revealed that once the door was locked from the corridor side by the key, there was no means to open the door from the patient's side of the door. Staff F verified the locks were present on every patient sleeping room door. Staff F further stated that patient rooms were not typically locked using the key.

Staff A5, present on tour, verified the patient room doors could not be opened, once locked, from the patient room side

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building specifically in regards to location of sprinkler heads mounted at least 18 inches above any possible obstruction. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the pharmacy mixing area observation was made of a sprinkler head located ten and a half inches above a hood system which would impede the sprinkler flow pattern in the event of an emergency. This finding was verified by staff A1 during a revisit to this area on 10/03/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition in regards to cleaning dust and debris from off the sprinkler heads and ensuring the escutcheon rings were in place. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first floor critical care expansion areas and a portion of the radiology department took place on 10/01/12 with staff members A1, A2 and A3. During tour observation was made of dirty sprinkler heads or sprinkler heads missing the escutcheon rings in the following locations:

*Within the emergency department staff lounge.
*Within patient rooms 21, 25 and 27.
*Within the soiled utility room by the stairwell.
*Within the consultation room beside the stairwell.
*Within the triage area.
*Within the women ' s restrooms near the registration area.
*Within the control room located between the CT and MRI room.

These findings were verified by all staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition in regards to cleaning dust and debris from off the sprinkler heads and ensuring the escutcheon rings were in place. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour observation was made of dirty sprinkler heads or sprinkler heads missing the escutcheon rings in the following locations:

First floor:
*Room located between the large mobile bin storage room and the men ' s restroom adjacent to the pharmacy had a sprinkler head missing an escutcheon ring.
*Dirty sprinkler head in the control room of the cardiology department.
*Soiled utility room located across from the angio pre/post control room was observed to have a sprinkler head which had a piece of plastic hanging from it.
*Escutcheon ring was missing from a sprinkler head located in waiting room number 4 of the radiology department.
*Dirty sprinkler heads were observed in the radiology registration area.

These finding were verified by all staff members during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure that fire extinguishers were not obstructed from view and had monthly inspections according to the National Fire Protection Association (NFPA) 10 Chapter 1-6.6 and 4-3.4.2. This had the potential to affect all those utilizing these areas of the facility.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the east mechanical room observation was made of two fire extinguishers that were obstructed and/or had lacked the monthly inspection. One fire extinguisher had not been monthly inspected since 05/28/11 and it was also obstructed by contractor's supplies. The other fire extinguisher was obstructed by a table and contractor's supplies.
During tour of the first floor parallel switch room in one south, observation was made of one fire extinguisher obstructed by a large spool of contractor wire.
These findings were verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the large mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were located in a room protected as a hazardous area when not attended. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the surgical areas took place on 10/03/12 with staff members A1, A2, A3 and A4. During tour of the surgical processing department (SPD) observation was made of a large mobile trash container filled with cardboard located adjacent to the south exit access. Observation of this container was over a period of one and one half hour to two hours in which it had not been moved. Interview with staff member A4 on 10/03/12 at approximately 4:50 P.M. revealed he/she was not aware of how often this container was emptied. Staff A4 stated the container was not stored in this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure six cylinders of carbon dioxide was properly stored according to the National Fire Protection Association 99. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the ground floor storage area located adjacent to the medical gas storage room, observation was made of six small cylinders of carbon not secured sitting on the floor. This finding was verified by all staff during tour of this storage area.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9. with regards to periodic testing of the battery powered emergency lights.

Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of emergency battery powered lighting.

Review of facility documentation with Staff A9 revealed emergency battery lighting was tested monthly. Documentation of the testing did not reveal that testing was completed for at least 30 seconds each month. There was no documented evidence that an annual test of 90 minutes was completed for the emergency lights

Further interview of Staff A9 verified the facility documentation did not show the length of the monthly test and that no annual test for 90 minutes had been completed .in accordance with section 7.9 requirements.

**

Based on facility observation and staff interview and verification, the facility failed to ensure that oxygen storage was in accordance with NFPA 99, Chapter 4, with regards to protection and storage of oxygen cylinders from excessive heat or freezing temperatures.


Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00 A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed that oxygen for patients was provided through a manifold system and piped into the facility.

Observation of the oxygen storage area revealed the oxygen delivery system was located outside the facility in an enclosed courtyard. The manifold and oxygen cylinders were located immediately outside the door of the facility and were exposed to the weather. A piece of well-weathered plywood was placed over the top of the H size tanks to provided some protection. Two small carts capable of each holding 12 E size cylinders of oxygen were sitting next to the larger tanks of oxygen. Each smaller cart contained less than six E size oxygen tanks.

Storage of full and empty H size tanks of oxygen were noted to be chained to the fence which surrounded the courtyard area. This storage area was located behind the diesel emergency generator.

Interview of Staff A9 verified that in winter months getting to the oxygen cylinders could be somewhat difficult for staff with the presence of snow and ice.



.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9. with regards to periodic testing of the battery-powered emergency lights.

Findings include:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of emergency battery powered lighting.

Interview of staff present on the tour regarding monthly and annual testing of the emergency lighting revealed the facility was in a leased building. Any testing and maintenance of the emergency lighting was completed by the property owners. Staff A6 and A9 verified no documentation of testing or maintenance was provided to the facility.

Later in the afternoon, review of facility documentation with Staff A6 and A8 verified there was no documented evidence the battery operated emergency lighting had been tested monthly or annually in accordance with section 7.9 requirements.

**

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that automatic sprinklers systems were maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection, Chapter 2.

Findings included:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of an automatic sprinkler system. Further observation of the sprinkler heads revealed that four escutcheons were missing from around the respective sprinkler heads.

Interview of staff present on the tour regarding testing and maintenance of the sprinkler system revealed the facility was in a leased building. Any testing and maintenance of the sprinkler system was completed by the property owners. Staff A6 and A9 verified no documentation of testing or maintenance was provided to the facility.

Later in the afternoon, review of facility documentation with Staff A6 and A8 verified there was no documented evidence of quarterly or annual testing of the sprinkler system as well as any completed maintenance.

On 10/04/12 at 11:40 A.M. Staff A1 and A6 provided documentation that an annual testing of the sprinkler system had been completed in June 2012. Staff further verified there was no documentation that quarterly inspection of the sprinkler system had been conducted.

**

Based on facility observation and staff interview and verification, the facility failed to ensure the facility was protected from hazards in accordance with Chapter 38.3.2, with regards to general storage areas and protection of such areas in accordance with Section 8.4.

Findings included:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of a small storage room. Observation of the storage room revealed constructed with a partial wall and open at the ceiling. No sprinkler protection was provided within the area designated as the storage room. The door to the room was wood with no designated fire resistance rating and no closing device. Combustible materials such as cardboard boxes and paper products were stored in the room

Interview of staff present on the tour regarding the facility construction, revealed the outpatient rehabilitation therapy location was in a leased building. Staff A5 and A6 verified the storage room was not constructed in accordance with requirements addressed at 38.3.2 and Section 8.4 for hazardous areas

Based on staff interview it was determined this facility failed to ensure fire drills were conducted quarterly as required by the National Fire Protection Association (NFPA) 21.7.1.2 which states: " Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. "
Based on building tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating as required by NFPA Chapter 21 3.7.2 which states: " Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour. "
Based on observation during tour and staff verification it was determined this facility failed to ensure all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, specifically NFPA 70B 17-4.3.
Based on observation during tour and staff verification it was determined this facility failed to ensure spaces under stairs were not utilized for storage according to NFPA 101 Chapter 7.2.2.5.3 which states in part: " There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress, " and specifically as worded in the appendix A.7.2.2.5.3 which states: " An example of a use with the potential to interfere with egress is storage. "
Based on observation during tour it was determined this facility failed to ensure that storage of medical gases were in accordance with NFPA 99.
Based on emergency battery operated light documentation review it was determined this facility failed to ensure the emergency battery operated lights wre tested annually for 90 minutes according to NFPA 101 Chapter 7.9. Potentially all patients, staff and visitors could be affected. The patient census at the beginning of the survey was 20.
Findings include:

Documentation review took place on 10/02/12 and 10/03/12 with staff members A1, A2, A4 and A10. A request was made by this writer for the past four quarterly fire drills. Three of the four fire drills were presented to this writer on 10/02/12. The first quarter fire drill for 2012 was not available and additional requests were made for it on 10/02/12 and 10/03/12. This documentation was still not available by the time of the exit conference on 10/04/12.

Facility tour of the smoke barrier took place on 10/03/12 with staff members A1, A2 and A4. During tour observation was made of penetrations in the one hour fire rated smoke barrier above the ceiling tile in the following locations:
*Within pre-op bay number 5, observation was through an approximate one inch by ten inch opening under a curved duct of an undetermined amount of drywall missing on the inner side of the smoke barrier.
*Above the smoke barrier door next to pre-op bay number 1, observation was made of two unsealed flex conduits.

These findings were verified by staff A2 during tour.

Facility tour of the smoke barrier took place on 10/03/12 with staff members A1, A2 and A4. During tour within operating room number 1 observation was made of a piece of surgical equipment which was an electrical heat producing device used to cauterizes blood vessels, having a frayed cord nearest the back part of the unit. Observation was made on this unit of an inspection sticker dated for January 2012.

This finding was acknowledged by all staff members during tour of the operating room.

Tour of the facility stairwells took place on 10/03/12 with staff members A1, A2 and A4. During tour of stair number 3, which was a stair access to the upper penthouse, observation was made of a large quantity of storage located within the stairwell. These items consisted of two floor scrubbers, four stretchers and several smaller miscellaneous items.

Tour of stairwell number 2 which was a exit access to the lower level which lead directly out of the building, was observed to have two small cardboard boxes and a mop stored under and beside the stairwell.

These findings were acknowledged by all staff members during tour.

On 10/03/12 at 4:30 P.M., observation of the medical gas storage area was conducted with Staff A1 and A8. Observation of the medical gas storage room revealed presence of H size cylinders of oxygen and other medical gases which totaled greater than 3000 cubic feet.
Observation above the ceiling tiles revealed construction of walls to the roof decking above. Five penetrations were observed in the wall above the ceiling tiles of the room. The penetrations were noted to surround the area where three ducts went through the wall of the room. In addition an area approximately 1 inch wide by 12 inches long and another area three inches square were noted. The space at the ceiling and wall abutment was not sealed on the door side of the room.
Staff A1 present on tour verified the sizes and locations of the penetrations.
Documentation review for the emergency battey operated light monthly and annual testing took place on 10/02/12 and 10/03/12 with staff members A1, A2, A4 and A10. A request was made by this writer for the annual test reports and was told none were available because they had not performed them for 2011.

Based on facility observation and staff verification, the facility failed to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating. This had to potential to affect all persons utilizing the facility. The census was 193 patients at the time of the survey.

Findings include:

Tour of the facility was conducted on 10/01/12 between 1:05 P.M. and 4:30 P.M. and 10/02/12 between 7:50 A.M. and 4:45 P.M., with Staff A5, A6 and A7. The following observations were noted in walls designated by facility life safety drawings to have a two hour fire resistance rating.

Located on the second floor;
*A penetration was noted above the ceiling tiles in a two hour fire rated wall between the pharmacy leadership meeting room (H-L-107) and a women's restroom. The unsealed area surrounded a black plastic pipe.
* A penetration was observed above the ceiling tiles surrounding a steel conduit on both sides of a two hour fire separation between the medical office building and the main hospital. This was located on the second floor.
* Penetration was observed above the ceiling tiles in a two hour fire rated wall at H4-ST-W and a store room.

Staff present on the tour observed and verified the penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barrier was constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first and second floor critical care expansion areas took place on 10/01/12 with staff members A1, A2 and A3. During tour observation was made of two areas with penetrations in the one hour smoke barrier above the ceiling tiles in the following locations:

First floor critical care:
*One open end conduit at the emergency room patient registration area.
*Above the radiology double doors observation was made of a one inch open end conduit.

This finding was verified by staff member A3 during tour.

Based on facility tour and staff verification it was determined this facility failed to ensure the hazardous areas were protected with at least a one hour fire rated construction, specifically in regards to the medical records room. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the medical records room observation was made of an approximate four foot by two foot section of drywall missing around several insulated pipes. This was verified by all staff members during tour of the medical records room.

Based on observation during tour and staff verification it was determined this facility failed to ensure the hazardous areas were constructed with at least a one hour fire resistance rating. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first floor critical care expansion areas took place on 10/01/12 and tour of the surgical areas took place on 10/03/12 with staff members A1, A2 and A3. During tour of the hazardous rooms observation was made of several penetrations in the one hour fire rated barrier above the ceiling tiles in the following locations:

First floor critical care:
*One open end conduit with two red wires passing through within the emergency department storage room located across from the elevators.

Second floor critical care:
*From within Pod A equipment room, observation was made of a one inch open end conduit protruding down from the upper deck.
*From within the soiled utility room located in the intensive care unit, observation was made of four open end conduits on the north wall and one open end conduit on the south wall.

Second floor surgery area:
*Within room MA2-304 observation was made of an approximate one inch by two inch opening in the northeast corner of the room.
* Within room MA2-326 observation was made of an open end flex conduit located on the east wall of the room.
*Within the storage room of suite one and above the door, observation was made of an open end conduit.


These findings were verified by all staff members during tour.

Based on facility observation and staff interview and verification, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. Potentially all patients, staff and visitors could be affected. The facility census was 193 patients at the time of the survey.

Findings include:

On 10/01/12 between 1:05P.M. and 4:30 P.M. tour of the Trudell building was conducted with Staff A5, A6 and A7. Observation of the paths of egress located on the first floor of the psychiatric unit revealed one exit discharge which required travel across an uneven grassy area.

The exit door was noted to open onto a concrete pad estimated to be approximately three feet long and nine feet wide From the concrete pad to the hard surface of the public way, it estimated to be approximately 20 to 30 feet, across the uneven and grassy area. Staff present on the tour verified the findings.

Based on facility observation and staff verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. The facility had a census of 193 patients at the time of the survey.

Findings include:

On 10/02/12 between the hours of 7:50 A.M. and 3:00 P.M., tour of the secured psychiatric care unit was conducted with Staff A5, A6 and A7. Staff F conducted the tour of the unit. Staff F revealed there were 13 patient bedrooms on the unit and two special care (seclusion) rooms. During tour, one patient was observed sleeping a special care room with the door to the room open. Staff F verified the patient was using the room as a sleeping room.

Tour of the unit revealed the patient room doors had locks in place which required a key. Observation from inside a patient room revealed that once the door was locked from the corridor side by the key, there was no means to open the door from the patient's side of the door. Staff F verified the locks were present on every patient sleeping room door. Staff F further stated that patient rooms were not typically locked using the key.

Staff A5, present on tour, verified the patient room doors could not be opened, once locked, from the patient room side

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building specifically in regards to location of sprinkler heads mounted at least 18 inches above any possible obstruction. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the pharmacy mixing area observation was made of a sprinkler head located ten and a half inches above a hood system which would impede the sprinkler flow pattern in the event of an emergency. This finding was verified by staff A1 during a revisit to this area on 10/03/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition in regards to cleaning dust and debris from off the sprinkler heads and ensuring the escutcheon rings were in place. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the first floor critical care expansion areas and a portion of the radiology department took place on 10/01/12 with staff members A1, A2 and A3. During tour observation was made of dirty sprinkler heads or sprinkler heads missing the escutcheon rings in the following locations:

*Within the emergency department staff lounge.
*Within patient rooms 21, 25 and 27.
*Within the soiled utility room by the stairwell.
*Within the consultation room beside the stairwell.
*Within the triage area.
*Within the women ' s restrooms near the registration area.
*Within the control room located between the CT and MRI room.

These findings were verified by all staff members present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the sprinkler system was continuously maintained in reliable operating condition in regards to cleaning dust and debris from off the sprinkler heads and ensuring the escutcheon rings were in place. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour observation was made of dirty sprinkler heads or sprinkler heads missing the escutcheon rings in the following locations:

First floor:
*Room located between the large mobile bin storage room and the men ' s restroom adjacent to the pharmacy had a sprinkler head missing an escutcheon ring.
*Dirty sprinkler head in the control room of the cardiology department.
*Soiled utility room located across from the angio pre/post control room was observed to have a sprinkler head which had a piece of plastic hanging from it.
*Escutcheon ring was missing from a sprinkler head located in waiting room number 4 of the radiology department.
*Dirty sprinkler heads were observed in the radiology registration area.

These finding were verified by all staff members during tour of these areas.

Based on observation during tour and staff verification it was determined this facility failed to ensure that fire extinguishers were not obstructed from view and had monthly inspections according to the National Fire Protection Association (NFPA) 10 Chapter 1-6.6 and 4-3.4.2. This had the potential to affect all those utilizing these areas of the facility.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the east mechanical room observation was made of two fire extinguishers that were obstructed and/or had lacked the monthly inspection. One fire extinguisher had not been monthly inspected since 05/28/11 and it was also obstructed by contractor's supplies. The other fire extinguisher was obstructed by a table and contractor's supplies.
During tour of the first floor parallel switch room in one south, observation was made of one fire extinguisher obstructed by a large spool of contractor wire.
These findings were verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the large mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were located in a room protected as a hazardous area when not attended. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 193.

Findings include:

Tour of the surgical areas took place on 10/03/12 with staff members A1, A2, A3 and A4. During tour of the surgical processing department (SPD) observation was made of a large mobile trash container filled with cardboard located adjacent to the south exit access. Observation of this container was over a period of one and one half hour to two hours in which it had not been moved. Interview with staff member A4 on 10/03/12 at approximately 4:50 P.M. revealed he/she was not aware of how often this container was emptied. Staff A4 stated the container was not stored in this area.

Based on observation during tour and staff verification it was determined this facility failed to ensure six cylinders of carbon dioxide was properly stored according to the National Fire Protection Association 99. This had the potential to affect all those utilizing these areas of the facility. The facility census was 93 at the beginning of the survey.
Findings include:
Facility tour of the ground and first floor areas of the main building took place on 10/02/12 and 10/03/12 with staff members A1, A2 and A3. During tour of the ground floor storage area located adjacent to the medical gas storage room, observation was made of six small cylinders of carbon not secured sitting on the floor. This finding was verified by all staff during tour of this storage area.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9. with regards to periodic testing of the battery powered emergency lights.

Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of emergency battery powered lighting.

Review of facility documentation with Staff A9 revealed emergency battery lighting was tested monthly. Documentation of the testing did not reveal that testing was completed for at least 30 seconds each month. There was no documented evidence that an annual test of 90 minutes was completed for the emergency lights

Further interview of Staff A9 verified the facility documentation did not show the length of the monthly test and that no annual test for 90 minutes had been completed .in accordance with section 7.9 requirements.

**

Based on facility observation and staff interview and verification, the facility failed to ensure that oxygen storage was in accordance with NFPA 99, Chapter 4, with regards to protection and storage of oxygen cylinders from excessive heat or freezing temperatures.


Findings include:

On 10/03/12 between 7:30 A.M.. and 9:00 A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed that oxygen for patients was provided through a manifold system and piped into the facility.

Observation of the oxygen storage area revealed the oxygen delivery system was located outside the facility in an enclosed courtyard. The manifold and oxygen cylinders were located immediately outside the door of the facility and were exposed to the weather. A piece of well-weathered plywood was placed over the top of the H size tanks to provided some protection. Two small carts capable of each holding 12 E size cylinders of oxygen were sitting next to the larger tanks of oxygen. Each smaller cart contained less than six E size oxygen tanks.

Storage of full and empty H size tanks of oxygen were noted to be chained to the fence which surrounded the courtyard area. This storage area was located behind the diesel emergency generator.

Interview of Staff A9 verified that in winter months getting to the oxygen cylinders could be somewhat difficult for staff with the presence of snow and ice.



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Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9. with regards to periodic testing of the battery-powered emergency lights.

Findings include:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of emergency battery powered lighting.

Interview of staff present on the tour regarding monthly and annual testing of the emergency lighting revealed the facility was in a leased building. Any testing and maintenance of the emergency lighting was completed by the property owners. Staff A6 and A9 verified no documentation of testing or maintenance was provided to the facility.

Later in the afternoon, review of facility documentation with Staff A6 and A8 verified there was no documented evidence the battery operated emergency lighting had been tested monthly or annually in accordance with section 7.9 requirements.

**

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that automatic sprinklers systems were maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection, Chapter 2.

Findings included:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of an automatic sprinkler system. Further observation of the sprinkler heads revealed that four escutcheons were missing from around the respective sprinkler heads.

Interview of staff present on the tour regarding testing and maintenance of the sprinkler system revealed the facility was in a leased building. Any testing and maintenance of the sprinkler system was completed by the property owners. Staff A6 and A9 verified no documentation of testing or maintenance was provided to the facility.

Later in the afternoon, review of facility documentation with Staff A6 and A8 verified there was no documented evidence of quarterly or annual testing of the sprinkler system as well as any completed maintenance.

On 10/04/12 at 11:40 A.M. Staff A1 and A6 provided documentation that an annual testing of the sprinkler system had been completed in June 2012. Staff further verified there was no documentation that quarterly inspection of the sprinkler system had been conducted.

**

Based on facility observation and staff interview and verification, the facility failed to ensure the facility was protected from hazards in accordance with Chapter 38.3.2, with regards to general storage areas and protection of such areas in accordance with Section 8.4.

Findings included:

On 10/03/12 between 10:20 a.m. and 11:00A.M. tour of the facility was conducted with Staff A5, A6 and A9. Observation of the facility revealed the presence of a small storage room. Observation of the storage room revealed constructed with a partial wall and open at the ceiling. No sprinkler protection was provided within the area designated as the storage room. The door to the room was wood with no designated fire resistance rating and no closing device. Combustible materials such as cardboard boxes and paper products were stored in the room

Interview of staff present on the tour regarding the facility construction, revealed the outpatient rehabilitation therapy location was in a leased building. Staff A5 and A6 verified the storage room was not constructed in accordance with requirements addressed at 38.3.2 and Section 8.4 for hazardous areas

Based on staff interview it was determined this facility failed to ensure fire drills were conducted quarterly as required by the National Fire Protection Association (NFPA) 21.7.1.2 which states: " Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. "
Based on building tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating as required by NFPA Chapter 21 3.7.2 which states: " Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour. "
Based on observation during tour and staff verification it was determined this facility failed to ensure all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, specifically NFPA 70B 17-4.3.
Based on observation during tour and staff verification it was determined this facility failed to ensure spaces under stairs were not utilized for storage according to NFPA 101 Chapter 7.2.2.5.3 which states in part: " There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress, " and specifically as worded in the appendix A.7.2.2.5.3 which states: " An example of a use with the potential to interfere with egress is storage. "
Based on observation during tour it was determined this facility failed to ensure that storage of medical gases were in accordance with NFPA 99.
Based on emergency battery operated light documentation review it was determined this facility failed to ensure the emergency battery operated lights wre tested annually for 90 minutes according to NFPA 101 Chapter 7.9. Potentially all patients, staff and visitors could be affected. The patient census at the beginning of the survey was 20.
Findings include:

Documentation review took place on 10/02/12 and 10/03/12 with staff members A1, A2, A4 and A10. A request was made by this writer for the past four quarterly fire drills. Three of the four fire drills were presented to this writer on 10/02/12. The first quarter fire drill for 2012 was not available and additional requests were made for it on 10/02/12 and 10/03/12. This documentation was still not available by the time of the exit conference on 10/04/12.

Facility tour of the smoke barrier took place on 10/03/12 with staff members A1, A2 and A4. During tour observation was made of penetrations in the one hour fire rated smoke barrier above the ceiling tile in the following locations:
*Within pre-op bay number 5, observation was through an approximate one inch by ten inch opening under a curved duct of an undetermined amount of drywall missing on the inner side of the smoke barrier.
*Above the smoke barrier door next to pre-op bay number 1, observation was made of two unsealed flex conduits.

These findings were verified by staff A2 during tour.

Facility tour of the smoke barrier took place on 10/03/12 with staff members A1, A2 and A4. During tour within operating room number 1 observation was made of a piece of surgical equipment which was an electrical heat producing device used to cauterizes blood vessels, having a frayed cord nearest the back part of the unit. Observation was made on this unit of an inspection sticker dated for January 2012.

This finding was acknowledged by all staff members during tour of the operating room.

Tour of the facility stairwells took place on 10/03/12 with staff members A1, A2 and A4. During tour of stair number 3, which was a stair access to the upper penthouse, observation was made of a large quantity of storage located within the stairwell. These items consisted of two floor scrubbers, four stretchers and several smaller miscellaneous items.

Tour of stairwell number 2 which was a exit access to the lower level which lead directly out of the building, was observed to have two small cardboard boxes and a mop stored under and beside the stairwell.

These findings were acknowledged by all staff members during tour.

On 10/03/12 at 4:30 P.M., observation of the medical gas storage area was conducted with Staff A1 and A8. Observation of the medical gas storage room revealed presence of H size cylinders of oxygen and other medical gases which totaled greater than 3000 cubic feet.
Observation above the ceiling tiles revealed construction of walls to the roof decking above. Five penetrations were observed in the wall above the ceiling tiles of the room. The penetrations were noted to surround the area where three ducts went through the wall of the room. In addition an area approximately 1 inch wide by 12 inches long and another area three inches square were noted. The space at the ceiling and wall abutment was not sealed on the door side of the room.
Staff A1 present on tour verified the sizes and locations of the penetrations.
Documentation review for the emergency battey operated light monthly and annual testing took place on 10/02/12 and 10/03/12 with staff members A1, A2, A4 and A10. A request was made by this writer for the annual test reports and was told none were available because they had not performed them for 2011.