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Based on observations made during tour and staff interview, it was determined that the facility failed to maintain a smoke barrier with at least a one-half hour fire resistance rating in the family lounge on the fifth floor in the B Building. This could affect all individuals in either of the affected smoke compartments.

Findings include:

Tour was conducted on 12/01/10 from 9:20 AM until 4:30 PM with Staff UU, Staff HH, Staff YY, and Staff BB. On the fifth floor, in the family lounge, a pair of sliding glass windows were observed in the smoke wall that comprised one wall of the lounge. The windows were not rated or wired and were moveable when unlocked. These findings were confirmed by Staff UU and Staff HH during the tour.

Based on observations and staff interview, the facility failed to ensure one exit was arranged so the exit terminated directly at a public way. This could affect all patients eating in the cafeteria, all visitors, and staff. The total capacity is 523 and the census was 365.


Findings include:

A tour was conducted on 12/02/10 with Staff CC, KK, and LL between 10:00 AM and 2:40 PM. A concrete patio was observed outside the dining room exit side door. This exit lacked a continuous hard surface to the public way from this concrete patio. The concrete pad was located approximately 33 feet from the public way, and observations revealed the area leading to the public way was through grass. This was verified with Staff CC and KK on tour. Staff CC verified this is a designated exit. Patients were observed eating in the dining room during this visit.

Based on observations and staff interviews, the facility failed to ensure 3 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 19.2.8 and 7.8. This affected all patients, staff, and visitors. The total capacity is 523 and the census was 365.


Findings include:

A tour was conducted on 12/01/10 with Staff AA, BB, and CC between 3:00 PM and 3:30 PM revealed two exit discharges without adequate lighting. The stairwell exit BR.105. DE lacked adequate discharge lighting outside the building. Stairwell exit B.M. 05.DE was observed with a sidewalk approximately forty feet long, with four steps in the middle of this sidewalk. There was no discharge lighting from the exit discharge to the public way along this sidewalk. The exit discharge at A1-11 Stairwell 5 was observed with only a single bulb at the exit discharge. This was verified with all three staff.

Based on observations and staff interviews, the facility failed to ensure at least 9 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 19.2.8 and 7.8. This affected all patients, staff, and visitors. The total capacity is 523 and the census was 365.


Findings include:

A tour was conducted on 12/02/10 with Staff CC, KK, and LL between 10:00 AM and 2:40 PM. Tour of the courtyard revealed four exit discharges without adequate lighting.
These exits were located as follows:
a) from receiving room 1076, (one light bulb),
b) from Stairs ST61-01 (no lights at discharge),
c) from the Solarium 1063 (no discharge lighting),
d) and from Stairs ST61-04 (no lights).
e) One gymnasium exit, located by exercise room G 102, and discharged outside the courtyard, was observed without discharge lighting.
f) A second gymnasium exit, which discharged into the courtyard, was observed with only a single light bulb.
g)Two of two courtyard wall exits were observed without discharge lighting as required by the code.
h) The sidewalk from the courtyard to the public way next to the gym was observed with a sidewalk approximately 20 feet in length without discharge lighting to illuminate exiting to the public way.
i) The exit from the dining room lacked discharge lights (no lights at discharge).

These exit discharges were verified as not having adequate lighting on tour by Staff CC and KK.

Based on observations and staff interviews, the trash chute discharge in Building A was not maintained in accordance with the NFPA 101, 2000 code at 9.5 and NFPA 82, due to being held open by bags of trash during tour. This could affect all staff, patients, and visitors in the facility. The total capacity is 523 and the census was 365.


Findings include:

Tour was conducted on 12/01/10 at 11:05 AM with Staff AA, BB, and CC. The trash chute discharge room A2-221 was observed with a large container on wheels (gondola) that was observed overflowing with bags of trash. The container was tilted to one side, and 8 full bags of trash were observed on the floor near the tilted side of the container. Additional bags of trash were observed holding open the trash chute door. These staff verified the overflow of trash and the trash chute door being held open by the trash.
An interview was conducted at that time with Staff JJ (Director of Housekeeping) who verified the trash was backed up holding open the trash chute discharge door, stating the facility had two employees constantly emptying the trash gondolas.

Based on observation made during tour and staff interview, it was determined that the facility failed to have the light fixture in one of one medical gas storage rooms located as required by NFPA 99. The light fixture was located less than five feet above the floor.

The hospital has a capacity of 523 with a census of 365 at the time of survey.

Findings include:

Tour was conducted with Staff DD, Staff EE, Staff FF, and Staff GG on 12/2/10 from 9:15 AM through 12:30 PM. During the tour of the medical gas storage room on the first floor, it was observed that the medical gas room contained greater than 3000 cubic feet of medical gases. The light switch inside the room was observed to be located less than five feet above the floor. This finding was confirmed by Staff FF during the tour.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room was protected in accordance with NFPA 99, 4.3.1.1.2. This could affect all patients, staff, and visitors in the facility. The total capacity is 523 and the census was 365.


Findings include:

A tour conducted on 12/01/10 at 3:00 PM with Staff AA, BB, and CC revealed the B-R dock contained a Room R3333 with contained large cylinders of medical gases of oxygen, heliox, and nitrous oxide. An electrical light switch and an electrical receptacle were observed at approximately 4 foot above floor level. The code requires that electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage All three aforementioned staff verified the level of the electrical switch and receptacle.

Based on review of relative humidity records and staff interview, it was determined that the facility failed to maintain relative humidity equal to or greater than thirty-five per cent in eight of eight operating rooms (#'s 1, 2, 3, 4, 5, 6, 7, and 8) on all but three days during the period reviewed, 11/04/10 through 12/01/10.

The hospital has a capacity of 523 with a census of 365 at the time of survey.

Findings include:

Records of relative humidity were reviewed with Staff AA, Staff DD, and Staff FF on 12/02/10 between 1:30 PM and 2:30 PM. The relative humidity for all days between 11/04/10 and 12/01/10, except 11/16/10, 11/22/10, and 11/25/10, was not maintained equal to or greater than 35 per cent in operating rooms #1, #2, #3, #4, #5, #6, #7, and #8. The recorded relative humidity readings for these dates were all below 30 percent. These findings were confirmed by Staff AA, Staff DD, and Staff EE on 12/02/10.

Based on review of the operating room (OR) humidity logs, and staff interview, the facility failed to ensure 4 ORs maintained relative humidity equal to or greater than 35% in November and December 2010, as required by NFPA 99, 4.3.1.2.3. This could affect all patients receiving surgery, and all staff and visitors in the surgical area. The total capacity is 523 and the census was 365.


Findings include:

On 12/03/10, a review was conducted for operating room logs for Rooms 1,2,9,and 15 for the months of November and December 2010. According to an interview at 4:15 PM with Staff BB, these 4 ORs were not a part of the automated monitoring system and had to be manually recorded by staff. There
was no evidence the humidity readings had been recorded prior to November 12, 2010. The humidity readings for these four ORs were consistently below 35% humidity between 11/12/10 and 12/03/10 (as low as 15%). This was verified with Staff BB.

Based on review of the fire watch plan, and interview with staff, the facility failed to have a fire watch plan in place when the required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. This could affect all patients, staff, and visitors in the facility. The total capacity is 523 and the census was 365.


Findings include:

A review of the fire watch plan was conducted on 12/03/10 at 4:00 PM with Staff BB. It was verified by this employee the facility's fire watch plan lacked information related to the automatic sprinkler system being out of service for more than 4 hours in a 24 hour period, failed to include notification of the local authority having jurisdiction, and was silent to the person designated to conduct the fire watch and was silent to the frequency of the fire watch. This was verified with Staff BB.

Based on review of the fire watch plan, and interview with staff, the facility failed to have a fire watch plan in place when the required fire alarm system is out of service for more than 4 hours in a 24-hour period. This could affect all patients, staff, and visitors in the facility. The total capacity is 523 and the census was 365.


Findings include:

A review of the fire watch plan was conducted on 12/03/10 at 4:00 PM with Staff BB. It was verified by this employee the facility's fire watch plan lacked information related to the fire alarm system being out of service for more than 4 hours in a 24 hour period, failed to include notification of the local authority having jurisdiction, and was silent to the person designated to conduct the fire watch and was silent to the frequency of the fire watch. This was verified with Staff BB.