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Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested or were impeded from closing. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in three of six smoke compartments at the Main Hospital.

Findings:

Main Hospital
During a tour of the facility with Maintenance Staff and the Director of Support Services, doors were inspected throughout the facility.

1. On 5/4/12, at 8:45 a.m., the corridor door to the Coffee Room did not positive latch when tested.

2. On 5/4/12, at 8:56 a.m., the corridor door to the Charge Planning Office was held open by a door wedge. Staff were not present in the room at that time.

3. On 5/4/12, at 9:35 a.m., the 20 minute fire-rated door to the Anesthesia Office was held open by a door wedge.

4. At 9:50 a.m., the fire-rated corridor door to the Laundry Room did not positive latch when tested by releasing it from its magnetic hold-open device.

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 observed unsealed penetrations. This affected two of six smoke compartments at the Main Hospital and could potentially 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 Maintenance Staff and the Director of Support Services, smoke barriers were inspected throughout the facility.

Main Hospital
On 5/4/12, at 3:29 p.m., the smoke barrier wall located near the Laboratory had unsealed penetrations as follows:
1. One penetration was caused by an approximately one and one-quarter inch metal sleeve passing through the wall that had a non fire-rated foam sealant used to seal around it.
2. One approximately one-half inch by one inch penetration was caused by blue data cables traveling through the wall.
3. One penetration was approximately one and one-half inches by three inches in size and was located below a metal sleeve.
All of the above penetrations could be seen from the west side of the cross-corridor doors above the drop down ceiling in the lower right portion of the wall.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors which were equipped with latching hardware and which failed to latch when tested. This affected all staff and residents in two of six smoke compartments at the Main Hospital building and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services, fire doors were inspected throughout the facility.

Main Hospital
1. On 5/4/12, at 10:55 a.m., the one hour fire-rated cross corridor door located near the Kitchen did not positive latch when the fire alarm system was activated. The left leaf facing west failed to close and latch completely.

Based on observation and interview, the facility failed to maintain emergency illumination in accordance with 2000 NFPA 101.
This was evidenced by a battery-powered emergency egress light that failed to stay illuminated when tested. This affected one of three Outpatient Buildings surveyed and could potentially result in injury or a delayed evacuation in the event of an emergency.

19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.

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.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services, egress lighting was inspected

Trinity Clinic
On 5/4/12, at 11:32 a.m., the battery-powered light and exit sign combination unit above the front lobby door did not stay illuminated when tested. Staff confirmed that the light did not work.

Based on observation, the facility failed to maintain all exit and directional signs in accordance with 2000 NFPA 101.
This was evidenced by exit signs which did not stay illuminated when tested. It is essential that all exit signs are properly illuminated in order to identify the location of exits in an emergency situation. This affected all staff and patients in one of six smoke compartments at the Main Hospital Building and two of three Outpatient Service Buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.

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

7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes),
display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National
Electrical Code?.

7.9.3 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

Findings:

During a tour of the facility with Maintenance Staff, exit signs were inspected throughout the facility.

Main Hospital
1. On 5/3/12, at 3:44 p.m., the exit sign near the Health Information Office did not stay illuminated when tested by pushing the battery test button.

2. On 5/3/12, at 3:45 p.m., the exit sign above the hose rack near Health Information did not stay illuminated when tested by pushing the battery test button.

Trinity Clinic
2. On 5/4/12, at 11:32 a.m., the exit sign located at the Front Lobby door did not stay illuminated when tested. This building is a business occupancy and does not have a back-up generator to supply power for egress.

3. On 5/4/12, at 11:33 a.m., the exit sign in the corridor near the lobby did not stay illuminated when tested.

Hayfork Clinic
4. On 5/4/12, at 1:53 p.m., the exit signs located at the front and back exits in the annex were not illuminated. This exit signs did not have an internal battery back-up power supply. Staff 1 was unsure why the signs were not illuminated.

Based on record review and interview, the facility failed to document that all staff are being trained in the use of, and response to, fire alarms in accordance with 2000 NFPA 101. This was evidenced by a lack of documentation for two of four required NOC shift fire drills in a twelve month period. This affected all staff and patients in six of six smoke compartments at the Main Hospital and could potentially result in some staff not being trained and familiar with emergency procedures.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

Findings:

1. During document review on 5/3/12, at 1:00 p.m., the facility failed to provide documentation for fire drills for the fourth quarter NOC shift of 2011 and the first quarter NOC shift of 2012. Staff stated that the drills had not been done during that time period.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by fire extinguishers that were mounted too high above the floor or were inaccessible. This deficient practice affected staff and patients in three of six smoke compartments at the Main Hospital building and one of three Outpatient Services buildings. This could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1 6.6.)
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services, fire extinguishers were observed in the following locations:

Main Hospital Building
1. On 5/3/12, at 3:35 p.m., the fire extinguisher located near the Business Office was mounted to the wall 72 inches from the floor to the top of the extinguisher handle.

2. On 5/3/12, at 4:15 p.m., the fire extinguisher located in the Laundry Room was mounted to the wall 81 inches from the floor to the top of the extinguisher.

3. On 5/3/12, at 4:23 p.m., there was a fire extinguisher located near the Skilled Co-ordinator's Office that was mounted to the wall 65 inches from the floor to the top of the extinguisher

4. On 5/4 12, at 9:30 a.m., the fire extinguisher located in the corridor between the Lobby and the Emergency Room was mounted in a recessed cabinet into the wall. This fire extinguisher did not have signage indicating its location.

5. On 5/4/12, at 9:35 a.m., the fire extinguisher located in the corridor across the room from the Emergency Room Office was mounted in a cabinet into the wall. This fire extinguisher did not have signage indicating its location.

6. On 5/4/12, at 9:43 a.m., the fire extinguisher located near Procedure Room 2 had two blood pressure monitors and a scale blocking access to the extinguisher.

Hayfork Clinic
7. On 5/4/12, at 1:53 p.m., the fire extinguisher located in the West corridor was mounted 72 inches from the floor to the top of the handle.

Based on record review and interview, the facility failed to maintain its cooking facilities in accordance with 1998 NFPA 96 . This was evidenced by the kitchen fire suppression system ventilation hood being equipped with mesh filters. This deficient practice affected one of six smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.

NFPA 96, 1998 edition
3-1 Listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.


Findings:

1. During a tour of the facility on 5/3/12 at 4:10 p.m. with Maintenance Staff and the Director of Support Services, the Kitchen was inspected. This surveyor observed that the Kitchen hood ventilation system had mesh-type filters.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 1999 NFPA 99. This was evidenced by unapproved portable heaters in non-sleeping staff areas. This affected all staff and patients in one of six smoke compartments at the Main Hospital and could potentially result in the ignition of fire.

NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services, electrical equipment was inspected.

Main Hospital
1. On 5/3/12, at 3:35 p.m., the Administrative Office had a portable electric heater in it.

2. At 5/3/12, at 4:23 p.m., the Human Resources Office had an unplugged portable electric heater. This heater had the coils visible.

3. On 5/3/12, at 4:28 p.m., the Office near the Gift Shop had a portable heater in it.

4. On 5/3/12, at 4:30 p.m., the Gift Shop had a heater that was plugged in that had the coils visible.

5. On 5/4/12, at 9:25 a.m., the room that stored x-ray film had a portable heater that was plugged in.

The facility was unable to provide documentation that the heaters had been tested and approved for use in the facility. These heaters also had three foot clearance warning labels on them. When asked, Maintenance Staff stated that the facility does attach inspection tags to the heaters that are acceptable.

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 a door that required special knowledge to open the door from the egress side.
*This was also evidenced by items that were stored in the path of egress. This affected three of six smoke compartments at the Main Hospital and one of three Outpatient Buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

3.3.121.1 Means of Egress, Accessible. A path of travel, usable by a person with a severe mobility impairment, that
leads to a public way or an area of refuge.

39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated
locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed
when the door is locked from the side from which egress is to be made.


7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

Main Hospital
During a tour of the facility with Maintenance Staff and the Director of Support Services, means of egress were inspected throughout the facility.

1. On 5/3/12, at 3:30 p.m., the Office Storage room in the Administration Office had a key-type door lock requiring the occupant of the room to have a key to open the door from the egress side if the door was locked.

2. On 5/4/12, at 8:58 a.m., the south exit door near the Charge Planning Office had a wheel chair placed in front of the door.

3. On 5/4/12, at 9:04 a.m., the corridor between the Emergency Room and the Admitting area had a patient scale stored in the corridor throughout the survey. The clear width of the corridor was four feet five inches from the wall to the scale.

Hayfork Clinic
4. On 5/4/12, at 1:50 p.m., the back exit door leading to the outside from the corridor had a dead bolt locking mechanism on the door requiring two distinct motions to open the door from the egress side.

5. On 5/4/12, at 1:53 p.m., the west exit door leading from the corridor to the outside of the facility had a dead bolt locking mechanism on the door requiring two distinct motions to open the door from the egress side.

6. On 5/4/12, at 2:00 p.m., the front door to the Annex had a dead bolt locking mechanism on the door requiring two distinct motions to open the door from the egress side.

Based on observation, the facility failed to regulate the placement of excessive combustible personal furnishings and/or decorations. This was evidenced by a cloth mural attached to the wall that did not have documentation of flame treatment of retardancy. This affected one of six smoke compartments at the Main Hospital building and could potentially result in the spread of smoke and/or fire.

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services on 5/3/12, at 4:03 p.m., the room identified as the Board Room had an approximately five foot by eight foot mural that was hanging loosely on the wall. The facility was unable to provide documentation of flame treatment or retardancy.

Based on observation, the facility failed to protect its medical gas storage area in accordance with 1999 NFPA 99. This was evidenced by a room that was being used for oxygen storage which did not meet the requirements of 8-3.1.11. This room was not labeled as an oxygen storage room and contained more than 300 cubic feet of oxygen. This affected one of six smoke compartments at the Main Hospital building and could potentially result in the acceleration of fire.


Oxygen Storage Requirements for inclosures storing greater than 300 cubic feet (12 E size tanks) but less than 3000 cubic feet of oxygen:

NFPA 99
8-3.1.11 Storage Requirements
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Findings:

Main Hospital
During a tour of the facility with Maintenance Staff and the Director of Support Services on 5/4/12, oxygen storage areas were inspected.

1. At 8:30 a.m., the unsprinklered room located in the second floor west wing had 12 E size oxygen cylinders and one H size cylinder stored in the room. There was no oxygen storage sign identifying this location as oxygen storage.

Based on document review and interview, the facility failed to provide continuing safety education in accordance with 1999 NFPA 99. This was evidenced by the facility's failure to provide documentation for laboratory safety education for all laboratory personnel. This affected one of six smoke compartments within the facility and could potentially result in accidents occurring in the laboratory.

10-2.1.4 Orientation and Training.
10-2.1.4.1 New laboratory personnel shall be taught general safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.

Findings:

During document review on 5/3/12, at 1:00 p.m., the facility failed to provide documentation of laboratory specific safety training. Staff 1 stated that they were unable to find records of any training.

Based on document review and staff interview, the facility failed to inspect and maintain its back-up generator in accordance with 1999 NFPA 99 and 1999 NFPA 110.
*This was evidenced by the failure to visually inspect the generator for twelve of 52 weekly inspections.
*This was also evidenced by the failure of the generator to operate under 75 percent load for the required duration during the annual load bank test.
This finding affected all staff and residents in six of six smoke compartments within the facility and could potentially result in deficiencies with the generator going unnoticed and/or the generator not functioning during a loss of normal power.

6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

Main Hospital
During a record review, generator logs and test records were reviewed.
1. On 5/3/12, at 1:00 p.m., generator logs indicated that the generator weekly inspections were missing for 12 of 52 weekly visual inspections. Months that documented fewer than one visual inspection per week were as follows: January, February, and March of 2012; and June, July, August, and September of 2011.

2. On 5/3/12, at 1:00 p.m., documentation provided for the annual load bank test indicated that the generator heated up when loaded at 75 percent (112.5 kw) of its name plate rating of 150 kw. The load bank test also indicated that the generator was loaded at 75 percent for 15 minutes total instead of the required one hour time period. It was in these fifteen minutes that the generator began heating up. The generator coolant temperature increased from 184 degrees Farenheit to 220 degrees Farenheit in the above mentioned 15 minute periods.

Documentation from the from the generator logs indicated that the normal building load each month was approximately 40 to 45 kw and did not show overheating under normal building loads.

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, and the permanent use of extension cords. This affected five of six smoke compartments at the Main Hospital 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.

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 Maintenance Staff and the Director of Support Services, electrical wiring and equipment were observed.

Main Hospital
1. On 5/3/12, at 3:33 p.m., the Business Office had a coffee pot, and a microwave oven plugged into a power strip that was suspended above the floor.

2. On 5/3/12, at 3:40 p.m., The Director of Financial Services Office had a coffee pot plugged into a power strip.

3. On 5/3/12, at 3:42 p.m., the Medical Records Office had a microwave oven plugged into a power strip.

4. On 5/3/12, at 3:44 p.m., the Ladder Storage had a junction box that was partially unattached from the wall.

5. On 5/3/12, at 3:58 p.m., the Medical Records Office had an unprotected two to six outlet adapter with an extension cord plugged into a power strip.

6. On 5/4/12, at 8:23 a.m., the outside Riser Room had a junction box with wires pulled out that did not have a cover plate covering it.

7. On 5/4/12, at 8:43 a.m., the Doctors' Lounge had a microwave oven plugged into power strip the was suspended above the floor.

8. On 5/4/12, at 8:44 a.m., the Training Room had a power strip that had the outer insulation separating from the power strip.

9. On 5/4/12, at 8:54 a.m., the Medications Room had an extension cord that traveled across the room to a Pyxis machine.

10. On 5/4/12, at 9:11 a.m., the Laboratory Director's Office had an unapproved brown extension cord with a microwave oven and power strip plugged into it.

11. On 5/4/12, at 9:15 p.m., the Laboratory had a household blow dryer that was sitting on the counter. The wattage of the dryer was 1875 watts. Laboratory Staff stated that the dryer was being used to dry pathology slides. Administrative Staff 1 stated that the dryer would be removed and a laboratory slide dryer would be used in the future.

12. On 5/4/12, at 9:25 a.m., the X-Ray Office had a power strip suspended above the floor supplying power to a copy machine.

13. On 5/4/12, at 9:30 a.m., the Ultra Sound Room had an extension cord in use.

14. On 5/4/12, /at 9:31 a.m., the Break Room had a coffee pot plugged into a power strip.

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 dispenser located above a source of ignition. This affected one of six smoke compartments at the Main Hospital and one of three Out Patient Service buildings and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with Maintenance Staff and the Director of Support Services, ABHR dispenser were observed.

Main Hospital
1. On 5/4/12, at 9:25 a.m., there was an ABHR dispenser located in the Admissions Office above a card printer.

Trinity Clinic
2. On 5/4/12, at 11:37 a.m., there was an ABHR Dispenser located above a light switch.