HospitalInspections.org

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to provide a readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the back exit door of the acute dialysis unit as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

There is the need of an illuminated exit sign near the water treatment room at the back of the Acute Dialysis Unit as observed on 6/24/10 at 9:50 am with the facility's Engineer (employee #65). An illuminated exit sign in this area will help to safely guide patients and staff out of this area in the event of an emergency.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that smoke barriers near patient's rooms #301, #317, near the medical record department and near the waiting area for the operating room do not close flush to their frames and the gap between door leafs are greater than 1/8 of an inch when released from their hold open devices which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.3 and 19.3.7.5.

Findings include:

1. The smoke barrier doors located near patient's room #301 did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 9:25 am, this can permit smoke, fire and noxious gases to enter the smoke barriers in the event of a fire.

2. The smoke barrier doors located near patient's room #317 did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 9:40 am, this can permit smoke, fire and noxious gases to enter the smoke barriers in the event of a fire.

3. The smoke barrier doors located near the medical record department did not close flush to within 1/8 of an inch to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 1:00 pm, this can permit smoke, fire and noxious gases to enter the smoke barrier in the event of a fire.

4. The smoke barrier doors located near the waiting area of the operating rooms did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 1:05 pm, this can permit smoke, fire and noxious gases to enter the smoke barrier in the event of a fire.

Based on tests and observations made during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in some exit routes in the operating room department, the Laboratory department and the Catherization department and no evidence was found of the 30 minute monthly and 90 minute annual tests for all emergency lamps as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm in the following areas:
a. Some exit routes in the operating room department.
b. The Laboratory department.
c. In the Catherization department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. Documentation about tests to emergency lighting reviewed on 6/25/10 at 9:50 am from the hospital provided evidence that the facility is not performing monthly 30 second and annual 90 minute tests to all of the emergency lights at the facility.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that a written plan was found at the nursing station for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 6/23/10 at 10:30 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient's room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity, smoke generation and failed to ensure that sufficient fire drills are conducted (the facility performed only two fire drills during the 11:00 pm till 7:00 am shifts) as required by LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the facility's Engineer (employee #65) and Safety Officer (employee #67) on 6/25/10 at 11:00 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written documents about conducted fire drills for the hospital were reviewed on 6/25/10 at 10:25 am and it was found that the facility failed to perform at least four fire drills annually for each shift. The facility has three shifts and provided evidence that only two fire drills were performed during the past twelve months for the 11:00 pm till 7:00 am shifts. The facility failed to comply with this regulation due to the lack of at least four fire drills during the 11:00 pm till 7:00 am shifts.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that smoke detectors are available in the pantry in the operating suite department, Hematology Coagulation room, biohazardous trash closets and regular trash closets on the third and fourth floors, Acute Dialysis Unit, the physical therapy room located at the hospital, the Respiratory therapy department, the dirty linen closet located on the first floor, lack of fire alarm system documentation, smoke detectors are to close to air conditioner vents and returns and strobe lights are needed in public bathrooms in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm:
a. The pantry in the operating suite department.
b. The Hematology Coagulation room.
c. The biohazardous trash closet and regular trash closet on the fourth floor.
d. The biohazardous trash closet and regular trash closet on the third floor.
e. The Acute Dialysis Unit.
f. In the physical therapy room located at the hospital.
g. In the Respiratory therapy department.
h. In the dirty linen closet located on the first floor.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 6/25/10 at 10:00 am with the facility's Engineer (employee #65), however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests .
c. Installation documentation.

3. The smoke detector located on the ceiling over the medication storage area of the emergency room, laboratory department and the Catherization department were found on 6/23/10 from 10:25 am till 4:00 pm with the facility's Engineer (employee #65) located within one foot from the ceiling air conditioner vent and return; due to the air flow from these vents at least three feet is needed.

4. Patient's and visitor's public bathrooms (both male and female) were visited on 6/23/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #65) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that portable fire extinguisher are available and in sufficient numbers in required areas as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm, the following was determined related to fire extinguishers:
a. A fire extinguisher is needed near the admission department; the back office area has a microwave and coffee machine and the next closest fire extinguisher to this area is farther than 80 feet.
b. A fire extinguisher is needed in or near the waiting area of the emergency room; the next closest fire extinguisher to this area is farther than 80 feet.
c. A fire extinguisher is needed in or near the CT Scan department; the next closest fire extinguisher to this area is farther than 80 feet.
d. A fire extinguisher is needed in or near the X-ray department; the next closest fire extinguisher to this area is farther than 80 feet.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #65), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to smoke barrier door held open with a piece of wood, oxygen cylinders were found in areas that do not comply with NFPA 99, inappropriate oxygen cylinder transporting, ground fault receptacles are needed, operating suites with radios on the floor, main propane gas cut off control was found obstructed by a metal rack in the kitchen, nuclear medicine department with latch on back door and medical record room is open at the top, a receptacle connected to the generator for the defibrillator is needed in the Molecular Medicine department, the fire alarm panel at the medical office building was found unlocked, no evidence was found that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in and no evidence was found that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released.

Findings include:

1. A smoke barrier door that separates the waiting area and an entrance hallway of the emergency room was found with a piece of wood placed under a door leaf to maintain it in the open position as observed on 6/23/10 at 9:00 am with the facility's Engineer (employee
#65).

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the facility with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm, type E and type H oxygen cylinders were found in areas that do not meet minimum requirements:
a. A type H oxygen cylinder was found in the waiting area near the minor surgery room of the emergency room.
b. A type H oxygen cylinder was found near the nursing station of the emergency room.
c. A type H oxygen cylinder was found in the pediatric treatment room of the emergency room.
d. Three type E oxygen cylinders were found near the crash cart of the nursing station of the emergency room.
e. A type E oxygen cylinder was found in operating suite #4 and it was not in a safety base.
f. Twelve type E oxygen cylinders were found at the nursing station of the Intensive Care Unit.
g. Four type E oxygen cylinders were found in the dirty utility room of the delivery room.
h. Four type E oxygen cylinders were found in front of patient's room #418.
i. Three type E oxygen cylinders were found in front of patient's room #426.
j. Two type E oxygen cylinders were found at the neuro surgery ward on the third floor.
k. Three type E oxygen cylinders were found in front of patient's room #314.
l. Three type E oxygen cylinders were found in front of patient's room #322.
m. A type H oxygen cylinder was found in the Nuclear Medicine Department.
n. A type H oxygen cylinder was found in the CT Scan Department.

3. During the observational tour on the emergency room with the facility's Engineer (employee #65) on 6/23/10 at 10:45 am, a facility employee (employee #64) was observed carrying a type E oxygen cylinder from the flow meter of the cylinder.

4. A regular receptacle was found near the sink in the pantry of the emergency room on 6/23/10 at 10:40 am with the facility's Engineer (employee #65). A ground fault receptacle is needed due to its close proximity to a water source.

5. Operating suites #2 and #4 were found with radio placed directly on the floor as observed on 6/23/10 from 1:30 pm till 3:00 pm with the facility's Engineer (employee #65).

6. The smoke barrier doors located near patient's room #422 was observed on 6/24/10 at 9:15 am with the facility's Engineer (employee #65) with a maintenance cart placed in front of an open door leaf. If the fire alarm is activated and the doors are released from their hold open devices they will not close completely and protect the smoke compartments.

7. The kitchen was visited on 6/24/10 at 10:00 am with the facility's Engineer (employee
#65) and provided evidence of the following:
a. Two regular receptacles were observed behind the pots and pans drying rack.
b. The main propane gas cut off control was found obstructed by a metal rack.

8. The Nuclear Medicine department was visited on 6/24/10 at 10:30 am with the facility's Engineer (employee #65) and provided evidence that a latch was placed on the back exit door which could impeded the use of this door in the event of an emergency.

9. The Nuclear Medicine department was visited on 6/24/10 at 10:30 am with the facility's Engineer (employee #65) and provided evidence that the room used to store records was opened at the top.

10. The Rehabilitation department located at the medical office building was visited on 6/24/10 at 11:20 am with the facility's Engineer (employee #65) and provided evidence that the back exit door had a set of weights causing an obstacle to the exit door.

11. The Molecular Medicine department located at the medical office building was visited on 6/24/10 at 11:35 am with the facility's Engineer (employee #65) and provided evidence that the defibrillator is not plugged into a receptacle that is supplied by the Essential Electrical System (generator).

12. The fire alarm panel located at the medical office building was visited on 6/24/10 at 11:50 am with the facility's Engineer (employee #65) and provided evidence that it was left unlocked and accessible to non-authorized persons.

13. No evidence was found on 6/25/10 at 11:00 am that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in.

14. No evidence was found on 6/25/10 at 9:00 am that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks written evidence of the weekly inspections of the generator as reviewed with the facility's Engineer (employee #65) on 6/25/10 at 11:15 am. The facility did not have a check list which includes batteries condition, coolant level, belts, oil pressure and oil change, battery contacts, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter and other checks from NFPA-99. During the past year of 2009 and the months of 2010 the facility could not provide evidence of weekly tests.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence reviewed on 6/25/10 at 11:05 am with the facility's Engineer (employee #65) related to preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances. The six month and annual tests must be performed by a qualified electrician and the varied tests that are performed must be documented and handed to the facility.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to provide a readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the back exit door of the acute dialysis unit as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

There is the need of an illuminated exit sign near the water treatment room at the back of the Acute Dialysis Unit as observed on 6/24/10 at 9:50 am with the facility's Engineer (employee #65). An illuminated exit sign in this area will help to safely guide patients and staff out of this area in the event of an emergency.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that smoke barriers near patient's rooms #301, #317, near the medical record department and near the waiting area for the operating room do not close flush to their frames and the gap between door leafs are greater than 1/8 of an inch when released from their hold open devices which is not in accordance with the requirements of the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.3 and 19.3.7.5.

Findings include:

1. The smoke barrier doors located near patient's room #301 did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 9:25 am, this can permit smoke, fire and noxious gases to enter the smoke barriers in the event of a fire.

2. The smoke barrier doors located near patient's room #317 did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 9:40 am, this can permit smoke, fire and noxious gases to enter the smoke barriers in the event of a fire.

3. The smoke barrier doors located near the medical record department did not close flush to within 1/8 of an inch to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 1:00 pm, this can permit smoke, fire and noxious gases to enter the smoke barrier in the event of a fire.

4. The smoke barrier doors located near the waiting area of the operating rooms did not close flush to its frame when released from its hold open device with the facility's Engineer (employee #65) on 6/24/10 at 1:05 pm, this can permit smoke, fire and noxious gases to enter the smoke barrier in the event of a fire.

Based on tests and observations made during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in some exit routes in the operating room department, the Laboratory department and the Catherization department and no evidence was found of the 30 minute monthly and 90 minute annual tests for all emergency lamps as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm in the following areas:
a. Some exit routes in the operating room department.
b. The Laboratory department.
c. In the Catherization department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. Documentation about tests to emergency lighting reviewed on 6/25/10 at 9:50 am from the hospital provided evidence that the facility is not performing monthly 30 second and annual 90 minute tests to all of the emergency lights at the facility.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that a written plan was found at the nursing station for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 6/23/10 at 10:30 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient's room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Engineer (employee #65) and Safety Officer (employee #67), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity, smoke generation and failed to ensure that sufficient fire drills are conducted (the facility performed only two fire drills during the 11:00 pm till 7:00 am shifts) as required by LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the facility's Engineer (employee #65) and Safety Officer (employee #67) on 6/25/10 at 11:00 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written documents about conducted fire drills for the hospital were reviewed on 6/25/10 at 10:25 am and it was found that the facility failed to perform at least four fire drills annually for each shift. The facility has three shifts and provided evidence that only two fire drills were performed during the past twelve months for the 11:00 pm till 7:00 am shifts. The facility failed to comply with this regulation due to the lack of at least four fire drills during the 11:00 pm till 7:00 am shifts.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that smoke detectors are available in the pantry in the operating suite department, Hematology Coagulation room, biohazardous trash closets and regular trash closets on the third and fourth floors, Acute Dialysis Unit, the physical therapy room located at the hospital, the Respiratory therapy department, the dirty linen closet located on the first floor, lack of fire alarm system documentation, smoke detectors are to close to air conditioner vents and returns and strobe lights are needed in public bathrooms in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm:
a. The pantry in the operating suite department.
b. The Hematology Coagulation room.
c. The biohazardous trash closet and regular trash closet on the fourth floor.
d. The biohazardous trash closet and regular trash closet on the third floor.
e. The Acute Dialysis Unit.
f. In the physical therapy room located at the hospital.
g. In the Respiratory therapy department.
h. In the dirty linen closet located on the first floor.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 6/25/10 at 10:00 am with the facility's Engineer (employee #65), however no evidence was found of the following:
a. A detailed description of tests performed and readings.
b. Smoke detector sensitivity tests .
c. Installation documentation.

3. The smoke detector located on the ceiling over the medication storage area of the emergency room, laboratory department and the Catherization department were found on 6/23/10 from 10:25 am till 4:00 pm with the facility's Engineer (employee #65) located within one foot from the ceiling air conditioner vent and return; due to the air flow from these vents at least three feet is needed.

4. Patient's and visitor's public bathrooms (both male and female) were visited on 6/23/10 from 9:00 am till 4:00 pm with the facility's Engineer (employee #65) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that portable fire extinguisher are available and in sufficient numbers in required areas as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm, the following was determined related to fire extinguishers:
a. A fire extinguisher is needed near the admission department; the back office area has a microwave and coffee machine and the next closest fire extinguisher to this area is farther than 80 feet.
b. A fire extinguisher is needed in or near the waiting area of the emergency room; the next closest fire extinguisher to this area is farther than 80 feet.
c. A fire extinguisher is needed in or near the CT Scan department; the next closest fire extinguisher to this area is farther than 80 feet.
d. A fire extinguisher is needed in or near the X-ray department; the next closest fire extinguisher to this area is farther than 80 feet.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #65), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to smoke barrier door held open with a piece of wood, oxygen cylinders were found in areas that do not comply with NFPA 99, inappropriate oxygen cylinder transporting, ground fault receptacles are needed, operating suites with radios on the floor, main propane gas cut off control was found obstructed by a metal rack in the kitchen, nuclear medicine department with latch on back door and medical record room is open at the top, a receptacle connected to the generator for the defibrillator is needed in the Molecular Medicine department, the fire alarm panel at the medical office building was found unlocked, no evidence was found that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in and no evidence was found that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released.

Findings include:

1. A smoke barrier door that separates the waiting area and an entrance hallway of the emergency room was found with a piece of wood placed under a door leaf to maintain it in the open position as observed on 6/23/10 at 9:00 am with the facility's Engineer (employee
#65).

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the facility with the facility's Engineer (employee #65) from 6/23/10 through 6/25/10 from 8:30 am till 4:00 pm, type E and type H oxygen cylinders were found in areas that do not meet minimum requirements:
a. A type H oxygen cylinder was found in the waiting area near the minor surgery room of the emergency room.
b. A type H oxygen cylinder was found near the nursing station of the emergency room.
c. A type H oxygen cylinder was found in the pediatric treatment room of the emergency room.
d. Three type E oxygen cylinders were found near the crash cart of the nursing station of the emergency room.
e. A type E oxygen cylinder was found in operating suite #4 and it was not in a safety base.
f. Twelve type E oxygen cylinders were found at the nursing station of the Intensive Care Unit.
g. Four type E oxygen cylinders were found in the dirty utility room of the delivery room.
h. Four type E oxygen cylinders were found in front of patient's room #418.
i. Three type E oxygen cylinders were found in front of patient's room #426.
j. Two type E oxygen cylinders were found at the neuro surgery ward on the third floor.
k. Three type E oxygen cylinders were found in front of patient's room #314.
l. Three type E oxygen cylinders were found in front of patient's room #322.
m. A type H oxygen cylinder was found in the Nuclear Medicine Department.
n. A type H oxygen cylinder was found in the CT Scan Department.

3. During the observational tour on the emergency room with the facility's Engineer (employee #65) on 6/23/10 at 10:45 am, a facility employee (employee #64) was observed carrying a type E oxygen cylinder from the flow meter of the cylinder.

4. A regular receptacle was found near the sink in the pantry of the emergency room on 6/23/10 at 10:40 am with the facility's Engineer (employee #65). A ground fault receptacle is needed due to its close proximity to a water source.

5. Operating suites #2 and #4 were found with radio placed directly on the floor as observed on 6/23/10 from 1:30 pm till 3:00 pm with the facility's Engineer (employee #65).

6. The smoke barrier doors located near patient's room #422 was observed on 6/24/10 at 9:15 am with the facility's Engineer (employee #65) with a maintenance cart placed in front of an open door leaf. If the fire alarm is activated and the doors are released from their hold open devices they will not close completely and protect the smoke compartments.

7. The kitchen was visited on 6/24/10 at 10:00 am with the facility's Engineer (employee
#65) and provided evidence of the following:
a. Two regular receptacles were observed behind the pots and pans drying rack.
b. The main propane gas cut off control was found obstructed by a metal rack.

8. The Nuclear Medicine department was visited on 6/24/10 at 10:30 am with the facility's Engineer (employee #65) and provided evidence that a latch was placed on the back exit door which could impeded the use of this door in the event of an emergency.

9. The Nuclear Medicine department was visited on 6/24/10 at 10:30 am with the facility's Engineer (employee #65) and provided evidence that the room used to store records was opened at the top.

10. The Rehabilitation department located at the medical office building was visited on 6/24/10 at 11:20 am with the facility's Engineer (employee #65) and provided evidence that the back exit door had a set of weights causing an obstacle to the exit door.

11. The Molecular Medicine department located at the medical office building was visited on 6/24/10 at 11:35 am with the facility's Engineer (employee #65) and provided evidence that the defibrillator is not plugged into a receptacle that is supplied by the Essential Electrical System (generator).

12. The fire alarm panel located at the medical office building was visited on 6/24/10 at 11:50 am with the facility's Engineer (employee #65) and provided evidence that it was left unlocked and accessible to non-authorized persons.

13. No evidence was found on 6/25/10 at 11:00 am that the facility has spare sprinklers (at least six), a sprinkler wrench or a cabinet to place them in.

14. No evidence was found on 6/25/10 at 9:00 am that the facility is periodically testing the smoke barrier doors held open by hold open devices to ensure that they close properly when released.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to ensure that personnel perform weekly inspections of the electrical generator as required by the NFPA 99, section 3.4.4.1.

Findings include:

The facility lacks written evidence of the weekly inspections of the generator as reviewed with the facility's Engineer (employee #65) on 6/25/10 at 11:15 am. The facility did not have a check list which includes batteries condition, coolant level, belts, oil pressure and oil change, battery contacts, hoses and pipes, main fuel tank level, leaks if any, oil filter, air filter and other checks from NFPA-99. During the past year of 2009 and the months of 2010 the facility could not provide evidence of weekly tests.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Engineer (employee #65), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence reviewed on 6/25/10 at 11:05 am with the facility's Engineer (employee #65) related to preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances. The six month and annual tests must be performed by a qualified electrician and the varied tests that are performed must be documented and handed to the facility.