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Based on observation, and interview, it was determined the facility allowed portable heating devices as evidenced by 3 heaters discovered in patient care areas while touring the facility. Portable heating devices are a fire hazard and have the potential to effect all occupants of the facility as a result of fire caused by improper portable heater failure or improper usage. The failed practice created a fire hazard that had the potential to affect all patients admitted to the facility with an average daily census of 4.3 patients and 8 of 8 patients on the first day (09/27/10) of the survey. The findings follow:

A. On a tour of the Emergency Department with the Assistant Administrator on 09/28/10 at 1015, an electric space heater was observed in the Janitors Closet located in the Emergency Department.

B. On a tour of the facility with the Maintenance Director on 09/28/10 at 1330, one oil-filled portable heater was observed in the Outpatient Treatment Room #2 (OP-2) and one portable heater was discovered in Outpatient Treatment Room #3 (OP-3).

C. The Maintenance Director verified the observed portable heaters in the Emergency Department and Outpatient Treatment Rooms on 09/28/10 at 1400.

Based on generator log review, and interview, it could not be determined the generator had run for 30 consecutive minutes, under load, for each month from April 2009 to September 2010. Load exercising of the generator provides a method of testing the generator for reliability to ensure continuation of life support and fire safety equipment. The failed practice had the potential to affect all patients admitted to the facility with an average daily census of 4.3 patients and 8 of 8 patients on the first day (09/27/10) of the survey. The findings follow:

A. Review of the emergency generator logs on 09/27/10 at 1400 revealed on the dates of the monthly load test, a single hour meter reading was recorded. The hour meter readings were recorded from week to week. The generator run time from week to week could be determined; however the single hour reading was not sufficient to determine the length of time the generator was run on the day of the load test. There was no electrical load data recorded to document the electrical load the generator was run under.
B. In an interview on 09/27/10 at 1435, the Maintenance Director verified there was no further generator documentation available for review.

Based on observation, and interview, it was determined the facility allowed portable heating devices as evidenced by 3 heaters discovered in patient care areas while touring the facility. Portable heating devices are a fire hazard and have the potential to effect all occupants of the facility as a result of fire caused by improper portable heater failure or improper usage. The failed practice created a fire hazard that had the potential to affect all patients admitted to the facility with an average daily census of 4.3 patients and 8 of 8 patients on the first day (09/27/10) of the survey. The findings follow:

A. On a tour of the Emergency Department with the Assistant Administrator on 09/28/10 at 1015, an electric space heater was observed in the Janitors Closet located in the Emergency Department.

B. On a tour of the facility with the Maintenance Director on 09/28/10 at 1330, one oil-filled portable heater was observed in the Outpatient Treatment Room #2 (OP-2) and one portable heater was discovered in Outpatient Treatment Room #3 (OP-3).

C. The Maintenance Director verified the observed portable heaters in the Emergency Department and Outpatient Treatment Rooms on 09/28/10 at 1400.

Based on generator log review, and interview, it could not be determined the generator had run for 30 consecutive minutes, under load, for each month from April 2009 to September 2010. Load exercising of the generator provides a method of testing the generator for reliability to ensure continuation of life support and fire safety equipment. The failed practice had the potential to affect all patients admitted to the facility with an average daily census of 4.3 patients and 8 of 8 patients on the first day (09/27/10) of the survey. The findings follow:

A. Review of the emergency generator logs on 09/27/10 at 1400 revealed on the dates of the monthly load test, a single hour meter reading was recorded. The hour meter readings were recorded from week to week. The generator run time from week to week could be determined; however the single hour reading was not sufficient to determine the length of time the generator was run on the day of the load test. There was no electrical load data recorded to document the electrical load the generator was run under.
B. In an interview on 09/27/10 at 1435, the Maintenance Director verified there was no further generator documentation available for review.