HospitalInspections.org

Based on observation, the facility failed to maintain the two hour separation barrier between the old side of the hospital, wood frame construction, and the later addition which is steel frame and concrete construction. This was evidenced by a penetration in the occupancy separation wall and by a door that was not self-closing.

Findings:

During a tour of the facility on 5/8/12, the walls and doors were observed.

1. At 11:19 a.m., there was a 1/2 inch and a 3/4 inch unsealed conduits in the two hour separation wall above corridor ceiling near the male surgical locker room.

2. At 5:47 p.m., the communicating door in the equipment corridor door next to OR 5 was left in the full open position. This door was not equipped with an automatic or self closing device.

Based on observation, the facility failed to ensure the integrity of the building construction was maintained as evidenced by penetrations in walls or ceilings. This could result in the spread of smoke or fire, in the event of a fire, affecting 4 of 8 smoke compartments.

Findings:

During the facility tour on 5/8/12 the wall and ceiling construction was observed:

First Floor Hospital
1. At 10:23 a.m. there were two cables passing through an unsealed 2 1/2 inch conduit in the wall above the entrance foyer doors to the waiting area.

2. At 5:59 p.m., there was a four inch by two inch penetration in the wall behind the entry door to OR 3 where the door handle penetrated the wall.

Second Floor, Hospital
2. At 1:50 p.m., there was a quarter inch penetration around one side of a half inch plastic tube that passed through the wall of the soiled linen closet across from the nurse station.

Second Floor, 1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
3. At 3:22 p.m., there was a ceiling tile missing in the break room.

4. At 3:23 p.m., there was no sealant inside a three inch conduit that was half filled with a cable bundle in the electrical room.

5. At 4:55 p.m. there were seven penetrations in the double wall above the roll down fire curtain between the office area and the waiting room. There was a two inch, a three inch, a 1/2 inch, a 3/4 inch conduit, and a four inch angle brace, a 12 by 12 inch square cut-out, and a 6 by 12 inch area opened up with hammer.

6. At 4:58 p.m., there were two penetration in the wall between the waiting area and the pre-operative area. There was a 2 inch by 4 inch penetration and a 3 inch by four inch penetration in the wall in the area adjacent to the roll down fire curtain.

Based on observation, the facility failed to maintain corridor walls as evidenced by penetrations through walls that separating corridors and use areas. This could result in the spread of fire or smoke in a fire emergency affecting two of eight smoke compartments.

Findings:

At 10:20 a.m., there were two one inch unsealed conduits passing through the corridor wall above the ceiling into the mens surgical locker room.

At 10:35 a.m., there was a three inch sprinkler branch line that had a one inch penetration around the pipe. This was located in the wall between the conference room hallway and the equipment corridor next to OR 2.

At 10:36 a.m., there was a 1/4 inch penetration around a one inch armored cable and two 1/2 inch conduits that passed through the corridor wall at the conference room.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected three of ten smoke compartments and could result in the spread of smoke and fire, in a fire emergency.

Findings:

Hospital
During the facility tour with Maintenance Staff 2 on 5/8/12, the facility corridor doors were observed.

First Floor - old side
1. At 2:46 p.m., the X-Ray corridor door did not self close. The door was not equipped with self closing hardware.

Second Floor - old side
2. At 7:51 p.m., the separation door between the office and the exit access corridor from the exam rooms had been removed. There was open shelf storage of patient medical records filed up to the hinge side of the door frame. There was no separation between combustible storage and the exit access.

1239 McHenry, First Floor, X-Ray at Precision Imaging
3. At 1:25 p.m., the door to the break room failed to latch when closed. The strike latch on the door was taped down.

Based on observation, the facility failed to ensure the vertical openings between floors were protected with doors that close and latch. This was evidenced by four of ten doors in four stairwells that failed to latch. This could result in the spread of fire or smoke from one floor to the next and a delay in evacuation affecting two of four buildings.

Findings:

1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
During a facility tour with Maintenance Staff 1 and 2 on 5/9/12, the exit access stairwells and doors were observed.

1. At 3:20 p.m., the East Stairwell door did not latch in three of three attempts.

1501 Oakdale Road, Third Floor, Physical Therapy:
During a facility tour with Maintenance Staff 1 and 2 on 5/10/12, the exit access stairwells and doors were observed.

2. At 6:53 a.m., the front stairwell door at the first level entrance failed to close the last one inch and was not able to latch. The door strike latch hardware was missing.

3. At 7:00 a.m., the rear stairwell door at the second level failed to latch. The door strike latch hardware was missing.

4. At 7:02 a.m., the rear stairwell door at the third level failed to latch. The door strike latch hardware was missing.

Based on observation, the facility failed to ensure that doors were held open by devices in accordance with NFPA 101, 2000 edition. This was evidenced by a door in an exit passageway that was not automatic or self closing. This could result in the spread of fire or smoke, in a fire emergency, affecting one of eight smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with Facility Maintenance Staff 2 on 5/8/12 , doors in exit passage ways were observed.

At 2:33 p.m., the half door between the Pathology area and the egress corridor was found fully open. The door was not equipped with automatic or self closing hardware. There was approximately one gallon of fomalin in a box container stored on the counter next to the corridor opening.

Based on observation and interview, the facility failed to mark access to all exits. This was evidenced by one exit that was not readily apparent. This could delay evacuation during a fire emergency affecting one of eight smoke compartments.

Findings:

Hospital - First Floor
During the facility tour with Maintenance Staff 1 on 5/8/12, the corridors and exit signs were observed.

At 2:39 p.m., there was no sign marking the exit access door from the employee service hall. This door provided access to stairwell #2 and an exit door.

Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed in accordance with NFPA 101, 2000 edition. This was evidenced by smoke barrier walls that had penetrations around pipes. This could result in the spread of smoke from one compartment to another, in the event of a fire, affecting four of eight smoke compartments.

Findings:

Hospital - First Floor
During the facility tour with Staff 1 on 5/8/12, the smoke barrier walls were observed on the first floor of the hospital.

1. At 10:51 a.m., there were two approximately 3 inch by nine inch penetrations around a 9 inch diameter ventilation duct located in the wall above the corridor ceiling door next to OR 1.

2. At 5:04 p.m., there were two 2 inch conduits passing through the pan deck to the floor above the Data Room next to Elevator 1. The conduits were not sealed around the cabling passing through the sleeve.

Based on observation and interview, the facility failed to ensure hazardous areas are protected in accordance with NFPA 101, 2000 edition. This was evidenced by a hazardous storage area not protected by a self - closing door. This could result in the spread of smoke and fire into the corridors affecting three of eight smoke compartments.

Findings:

During the facility tour with Maintenance Staff 1 on 5/8/12, the hazardous areas of the facility were observed.

Hospital - First Floor
1. At 4:29 p.m., the receiving and materials storage area contained approximately 100 cases and boxes. The room was greater than 50 square feet and did not have a self closing or automatic closing door. The room is considered a hazardous storage area.

2. At 4:42 p.m., the corridor door to the mechanical equipment was not automatic or self closing. The equipment room contained gas fired water heaters and miscellaneous combustible storage.

Hospital - Second Floor
3. At 7:43 p.m., there was more than 100 cases of medical records storage in a room that was greater than 200 square feet. There was no sheet rock ceiling installed. The wood framed roof structure was exposed to the combustible storage in the room.

Based on record review, observation and interview, the facility failed to maintain their emergency lighting in the building. This was evidenced by two of eight emergency lights that were not regularly tested and failed to light affecting three of ten smoke compartments. This could result in failure of the emergency lights and cause a delay in evacuation and an increased risk of exposure to smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
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.

Finding:

During document review on 5/7/12, inspection records were requested for battery operated emergency lighting. At 5:30 p.m., there were no inspection records provided.

During the facility tour and interview with Maintenance Staff 1 on 5/8/12, the facility emergency lighting was observed.

Hospital
1. At 11:41 a.m., there was an emergency light at the 300 kW genset that was not tested monthly and annually. There was no test documentation for the 30 second monthly test and none for the ninety minute annual test. Maintenance Staff 1 stated they do not perform annual inspections of battery powered emergency lighting.

Hospital - First Floor
2. At 2:56 p.m. there was a battery back-up emergency egress light inside Endoscopy Room Two.

3. At 2:57 p.m., there was a battery back-up emergency egress light inside Endoscopy Room One.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
4. At 1:31 p.m., there were four emergency battery lights with no records of inspections.

1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
During a facility tour with Maintenance Staff 1 and 2 on 5/9/12, the emergency egress lighting was observed.

5. At 3:46 p.m., the battery back-up emergency light in the supply store room failed to operate when tested.

Outpatient Physical Therapy - Third Floor at 1501 Oakdale Road
During the facility tour and interview with Maintenance Staff 1 and 2 on 5/10/12, the emergency lighting egress lighting was observed.

6. At 7:04 a.m., an emergency egress battery powered light was observed at the first level. There was no record of monthly or annual inspections available and Maintenance Staff 2 stated they do not perform the monthly or annual inspections of the emergency lights.

7. At 7:06 a.m., an emergency egress battery powered light was observed near the back stairwell There was no record of monthly or annual inspections available.

8. At 7:08 a.m., an emergency egress battery powered light was observed in front of the women's restroom at the third floor lobby area. The battery powered light failed to operate when tested and there was no record of monthly or annual inspections available. The lobby provided access for Physical Therapy staff and patients to get to the elevator and front stairwell.

Based on interview, the facility failed to ensure that staff were prepared and knowledgeable in the use of their fire response plan. This was evidenced by no documentation of fire drills conducted at all three outpatient clinic locations. This could result in staff not able to respond quickly getting occupants out of danger and preparing the building for evacuation.
Findings:
X-Ray at Precision Imaging, 1239 McHenry Avenue
During an interview on 5/9/12 at 7:13 a.m., Maintenance Staff 1 stated that they do not conduct fire drills for Precision Imaging and there are no building owner fire drill records available.
Clinic at Coffee Road Surgery Center, 1335 Coffee Road
During an interview on 5/9/12 at 3:55 p.m., Maintenance Staff 1 stated there are no fire drills conducted at the Coffee Road Facility and there are no building owner fire drill records available.
Outpatient Physical Therapy Clinic, 1501 Oakdale Road
During an interview on 5/10/12 at 7:13 a.m., Maintenance staff 2 stated that they do not conduct fire drills for the Physical Therapy Clinic and there are no building owner fire drill records available.

Based on record review and interview, the facility failed to test the fire alarm system according to NFPA 72. This was evidenced by no record for certification or qualifications for personnel performing the annual testing. This could result in an increased risk of failure of the fire alarm system, or the failure to identify problems with the system, potentially delaying notification in the event of a fire. This affected the entire facility and maintenance of one of one fire alarm panel.

NFPA 72 National Fire Alarm Code, 1999 Edition
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:

(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems"

Findings:

During record review and interview on 5/7/12, records were requested for annual fire alarm testing.

At 2:27 p.m., the fire alarm system testing records were requested. Maintenance Staff 1 stated that they perform their testing in-house.

At 3:10 p.m., Maintenance Staff 1 provided their procedure for "Annual Fire Alarm Inspection," and report labeled "Fire Alarm Sytem Device Location." This report confirmed annual functional testing of notification and initiation devices were conducted by in-house staff. There was no indication of control panel and battery testing.

At 3:25 p.m., Maintenance Staff 1 confirmed that he and his staff were not certified or factory trained to conduct the annual fire alarm system testing. He described his reasoning for in-house testing came about because of problems with the previously established vendor.

At 3:30 p.m., the last vendor provided annual fire alarm system inspection was dated 12/13/08.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 25. This was evidenced by failure to inspect and test the sprinkler system quarterly. This affected four of ten smoke compartments and could result in the spread of smoke or fire or a delay in extinguishing a fire.

Findings:

During the facility tour with staff on 5/8/12, the complete sprinkler system was observed.
Hospital - First Floor

1. At 5:58 p.m., there was a celiing pendant spinkler in front of the entrance to OR #1 that was mounted with the deflector within 1/8 inch of being flush to the escutcheon.

Hospital - Second Floor - old side
2. At 7:49 p.m., there was an obstructed sprinkler head in exam room 3. The pendant sprinkler deflector was recessed approximately 1/4 inch inside the escutcheon.

During record review and interview on 5/9/12 the quarterly fire sprinkler system testing records were requested.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
3. At 11:18 a.m., there were no documents available for quarterly sprinkler system testing. Maintenance Staff 1 stated they do not perform quarterly testing at the off-site clinics.

Outpatient Physical Therapy - Third Floor at 1501 Oakdale Road
4. At 7:03 a.m., there were no documents available for quarterly sprinkler system testing. Maintenance Staff 1 stated they do perform quarterly testing for this clinic but they do not document this as a record.

Based on record review, observation and interview, the facility failed to ensure that "no smoking" provisions were enforced outside of exit doors. This was evidenced by cigarette butts discarded into a plastic 5 gallon bucket that was stored within three feet of an exit door and into a container mixed with combustible trash within eight feet of the exit door. This could result in the spread of smoke or fire into the hospital affecting one of nine smoke compartments.

Finding:

During a facility tour and interview with Maintenance Staff 2 on 5/8/12, the exterior exits were observed.

Hospital
At 8:36 p.m., there were 25 cigarette butts laying inside a 5 gallon bucket that was sitting on the sidewalk within three feet of the exit door next to purchasing in the hospital materials receiving area. A cigarette butt was observed inside the combustible trash container within eight feet of the exit door. There was no appropriate smoking area or disposal containers. Maintenance Staff 2 explained that there was not supposed to be any smoking on the hospital grounds.

During record review on 5/10/12 at 8:10 a.m., the hospital smoking policy was reviewed. According to the hospital policy there was no smoking allowed in the building.

Based on record review and interview, the facility failed to take action when the Operating Room (OR) relative humidity dropped below 35%. This could increase the risk of a fire resulting in injury to the patient affecting seven of eight operating rooms.

NFPA 99 (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.
Findings:
During the document review and interview with Maintenance Staff 1 on 5/7/12 the Operating Room (OR) temperature and humidity records were requested.

At 5:05 p.m., the last 6 months of temperature and humidity logs provided by the facility documented relative humidity levels in the Operating Room suites below 30 percent for the following days when surgeries were performed: 3/8/12 OR's 1, 5, 6, 7, & 8; 3/7/12 OR's 4, 5, 6, 7, & 8; 1/20/12 OR's 3, 5, 6, 7, & 8; 1/19/12 OR's 1, 3, & 5; 1/17/12 OR's 3, 5, 6, 7, & 8; 1/16/12 OR's 1, 3, 6, 7, & 8; 12/22/11 OR's 5, 6, & 7; 12/19/11 OR's 6, & 7; 12/8/11 OR's 3, 6, & 7; 12/7/11 OR's 5, 6, & 7; 12/6/11 OR's 1, 3, 5, 6, & 7; 12/5/11 OR's 1, 3, 5, 6, & 8; 12/2/11 OR's 3, 5, 7, & 8; 12/1/11 OR's 5, 6, 8. The daily OR temperature and humidity logs indicated there was no action taken in the OR suites when the humidity levels were out of range.

At 5:11 p.m., Maintenance Staff 1 stated that the facility air conditioning system is not equipped with humidifiers and that he will not increase the outside air to raise humidity in the OR suites. He explained that doing so would also raise temperatures and he cannot do this due to the low temperature requirements of surgical staff.

Based on observation, the facility failed ensure the oxygen storage areas of greater than 3000 cu feet are protected by a one hour enclosure. This was evidenced by a door on the medical gas manifold room that was not self closing. This could result in the spread of fire or smoke in a fire emergency affecting one of eight smoke compartments.

Findings:

Hospital
During the facility tour with Maintenance Staff 1 and 2 on 5/8/12, the oxygen storage locations were observed.

At 4:50 p.m., there were three 200 liter containers of liquid oxygen, three H cylinders of compressed oxygen gas, and ten E-sized cylinders of compressed oxygen gas stored in the medical gas room. The corridor door was not equipped with a self closing device.

Based on observation, interview and record review, the facility failed to document weekly generator inspections of the starting battery electrolyte level and charging rate and confirmation that the diesel powered generators were reaching the minimum load requirement. This was evidenced by no monthly record that documented testing was at least 30% of the nameplate rating or at a specified exhaust temperature, and by no record for a current annual load bank test. This could result in a greater risk of engine failure and complete loss of electrical power, in the event of a power outage, affecting 5 of 5 patients.
NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

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.
6-4.2.2 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.
6-4.3 Load tests of generator sets shall include complete cold starts.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.
Findings:
During record review, observation, and interviews with Maintenance Staff on 5/7/12, the emergency generator testing and maintenance record was reviewed.
1. At 3:25 p.m., there was no "Generator Maintenance Log" reports indicated the generator was run weekly but there was no indication that the starting battery was tested weekly. The only record of starting battery inspection occurred on the monthly load test.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment are in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of an extension cords and electrical adaptors. This affected six of eight smoke compartments and could increase the risk of electrical fire.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
Section 400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During the facility tour and interview with Maintenance Staff 1 & 2 on 5/8/12 the electrical devices and wiring connections were observed.

1. At 2:30 p.m., there was a water cooler plugged into a multi-outlet extension cord which was plugged into an orange extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet in the physicians lounge.

2. At 2:45 p.m., there was desk top equipment plugged into a multi-outlet extension cord which was plugged into a wall outlet in the X-Ray area.

3. At 2:51 p.m., there was an EKG monitor plugged into an extension cord which was plugged into a wall outlet in the GI Laser room.

4. At 3:05 p.m., there was a microwave plugged into a gray extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the preadmission's area.

5. At 3:07 p.m., there was a coffee maker and an ice maker plugged into a multi-outlet extension cord which was plugged into a wall outlet in the medical Staff office area.

6. At 3:09 p.m., there was a portable heater plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Medical Staff office area.

7. At 3:12 a.m., there was a microwave and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Director of Nursing office.

8. At 3:14 p.m., there was a micro-wave plugged into an extension cord which was plugged into a wall outlet and a refrigerator that was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Chief Executive Officer's office.

9. At 2:46 p.m., there was a red extension cord in use in the Consulting area in Admitting.

10. At 4:10 p.m., the kitchen electrical panels K1 and K2 were obstructed from use by a coffee cart and a portable deep fat fryer.

11. At 4:34 p.m., there was micro-wave and a refrigerator plugged into a three way adaptor which was plugged into an orange extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Purchasing Office.

12. At 5:18 p.m., there was a Bovie cauterizer plugged into a Tripp Lite Model PS 615- HG multi-outlet extension cord in OR 7. There was no documentation available that indicated it was approved for patient care equipment.

13. At 5:25 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 6. There was no documentation available that indicated it was approved for patient care equipment.

14. At 5:30 p.m., the OR nurse removed a four plug Tripp Lite power strip from below the the Bovie cauterizer cart in OR 5. The power strip had one plug that had been arced with a burn pattern around the receptacle. There was a similar electrical arc burn pattern on the frame of the Bovie cart. There was no power strip mounted to the Bovie cart labeled ValleyLab Force FX in OR 5. The OR nurse stated she had just removed the power strip from the cart because it was faulty.

15. At 5:50 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 2. There was no documentation available that indicated it was approved for patient care equipment.

16. At 5:58 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 3. There was no documentation available that indicated it was approved for patient care equipment.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
17. At 1:36 p.m., there was a refrigerator plugged into an extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet.

18. At 1:38 p.m., there was desk top computer equipment plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into the wall outlet.

19. At 2 p.m., there was a broken cover plate for an electrical outlet at reception desk 3.

Based on observation, the facility failed to ensure that alcohol based hand rubs were not located above an ignition source or combustible materials. This was evidenced by a dispensers located above combustible materials, light switches in operating rooms (OR's), a nurse call switch, dirty linens, and Styrofoam. This could result in the spread of fire or smoke, in the event of a fire, affecting one of four smoke compartments.

Finding:

Hospital - First Floor
During the facility tour with Maintenance Staff 1 and 2 on 5/8/12, the placement of alcohol based hand rubs dispensers were observed.

1. At 4:46 p.m., there was an alcohol based hand rub (ABHR) dispenser located above combustible materials in the Biohazard Room.

2. At 5:22 p.m., there was an ABHR dispenser located above two light switch ignition sources in OR 7.

Based on observation, the facility failed to maintain the two hour separation barrier between the old side of the hospital, wood frame construction, and the later addition which is steel frame and concrete construction. This was evidenced by a penetration in the occupancy separation wall and by a door that was not self-closing.

Findings:

During a tour of the facility on 5/8/12, the walls and doors were observed.

1. At 11:19 a.m., there was a 1/2 inch and a 3/4 inch unsealed conduits in the two hour separation wall above corridor ceiling near the male surgical locker room.

2. At 5:47 p.m., the communicating door in the equipment corridor door next to OR 5 was left in the full open position. This door was not equipped with an automatic or self closing device.

Based on observation, the facility failed to ensure the integrity of the building construction was maintained as evidenced by penetrations in walls or ceilings. This could result in the spread of smoke or fire, in the event of a fire, affecting 4 of 8 smoke compartments.

Findings:

During the facility tour on 5/8/12 the wall and ceiling construction was observed:

First Floor Hospital
1. At 10:23 a.m. there were two cables passing through an unsealed 2 1/2 inch conduit in the wall above the entrance foyer doors to the waiting area.

2. At 5:59 p.m., there was a four inch by two inch penetration in the wall behind the entry door to OR 3 where the door handle penetrated the wall.

Second Floor, Hospital
2. At 1:50 p.m., there was a quarter inch penetration around one side of a half inch plastic tube that passed through the wall of the soiled linen closet across from the nurse station.

Second Floor, 1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
3. At 3:22 p.m., there was a ceiling tile missing in the break room.

4. At 3:23 p.m., there was no sealant inside a three inch conduit that was half filled with a cable bundle in the electrical room.

5. At 4:55 p.m. there were seven penetrations in the double wall above the roll down fire curtain between the office area and the waiting room. There was a two inch, a three inch, a 1/2 inch, a 3/4 inch conduit, and a four inch angle brace, a 12 by 12 inch square cut-out, and a 6 by 12 inch area opened up with hammer.

6. At 4:58 p.m., there were two penetration in the wall between the waiting area and the pre-operative area. There was a 2 inch by 4 inch penetration and a 3 inch by four inch penetration in the wall in the area adjacent to the roll down fire curtain.

Based on observation, the facility failed to maintain corridor walls as evidenced by penetrations through walls that separating corridors and use areas. This could result in the spread of fire or smoke in a fire emergency affecting two of eight smoke compartments.

Findings:

At 10:20 a.m., there were two one inch unsealed conduits passing through the corridor wall above the ceiling into the mens surgical locker room.

At 10:35 a.m., there was a three inch sprinkler branch line that had a one inch penetration around the pipe. This was located in the wall between the conference room hallway and the equipment corridor next to OR 2.

At 10:36 a.m., there was a 1/4 inch penetration around a one inch armored cable and two 1/2 inch conduits that passed through the corridor wall at the conference room.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected three of ten smoke compartments and could result in the spread of smoke and fire, in a fire emergency.

Findings:

Hospital
During the facility tour with Maintenance Staff 2 on 5/8/12, the facility corridor doors were observed.

First Floor - old side
1. At 2:46 p.m., the X-Ray corridor door did not self close. The door was not equipped with self closing hardware.

Second Floor - old side
2. At 7:51 p.m., the separation door between the office and the exit access corridor from the exam rooms had been removed. There was open shelf storage of patient medical records filed up to the hinge side of the door frame. There was no separation between combustible storage and the exit access.

1239 McHenry, First Floor, X-Ray at Precision Imaging
3. At 1:25 p.m., the door to the break room failed to latch when closed. The strike latch on the door was taped down.

Based on observation, the facility failed to ensure the vertical openings between floors were protected with doors that close and latch. This was evidenced by four of ten doors in four stairwells that failed to latch. This could result in the spread of fire or smoke from one floor to the next and a delay in evacuation affecting two of four buildings.

Findings:

1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
During a facility tour with Maintenance Staff 1 and 2 on 5/9/12, the exit access stairwells and doors were observed.

1. At 3:20 p.m., the East Stairwell door did not latch in three of three attempts.

1501 Oakdale Road, Third Floor, Physical Therapy:
During a facility tour with Maintenance Staff 1 and 2 on 5/10/12, the exit access stairwells and doors were observed.

2. At 6:53 a.m., the front stairwell door at the first level entrance failed to close the last one inch and was not able to latch. The door strike latch hardware was missing.

3. At 7:00 a.m., the rear stairwell door at the second level failed to latch. The door strike latch hardware was missing.

4. At 7:02 a.m., the rear stairwell door at the third level failed to latch. The door strike latch hardware was missing.

Based on observation, the facility failed to ensure that doors were held open by devices in accordance with NFPA 101, 2000 edition. This was evidenced by a door in an exit passageway that was not automatic or self closing. This could result in the spread of fire or smoke, in a fire emergency, affecting one of eight smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with Facility Maintenance Staff 2 on 5/8/12 , doors in exit passage ways were observed.

At 2:33 p.m., the half door between the Pathology area and the egress corridor was found fully open. The door was not equipped with automatic or self closing hardware. There was approximately one gallon of fomalin in a box container stored on the counter next to the corridor opening.

Based on observation and interview, the facility failed to mark access to all exits. This was evidenced by one exit that was not readily apparent. This could delay evacuation during a fire emergency affecting one of eight smoke compartments.

Findings:

Hospital - First Floor
During the facility tour with Maintenance Staff 1 on 5/8/12, the corridors and exit signs were observed.

At 2:39 p.m., there was no sign marking the exit access door from the employee service hall. This door provided access to stairwell #2 and an exit door.

Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed in accordance with NFPA 101, 2000 edition. This was evidenced by smoke barrier walls that had penetrations around pipes. This could result in the spread of smoke from one compartment to another, in the event of a fire, affecting four of eight smoke compartments.

Findings:

Hospital - First Floor
During the facility tour with Staff 1 on 5/8/12, the smoke barrier walls were observed on the first floor of the hospital.

1. At 10:51 a.m., there were two approximately 3 inch by nine inch penetrations around a 9 inch diameter ventilation duct located in the wall above the corridor ceiling door next to OR 1.

2. At 5:04 p.m., there were two 2 inch conduits passing through the pan deck to the floor above the Data Room next to Elevator 1. The conduits were not sealed around the cabling passing through the sleeve.

Based on observation and interview, the facility failed to ensure hazardous areas are protected in accordance with NFPA 101, 2000 edition. This was evidenced by a hazardous storage area not protected by a self - closing door. This could result in the spread of smoke and fire into the corridors affecting three of eight smoke compartments.

Findings:

During the facility tour with Maintenance Staff 1 on 5/8/12, the hazardous areas of the facility were observed.

Hospital - First Floor
1. At 4:29 p.m., the receiving and materials storage area contained approximately 100 cases and boxes. The room was greater than 50 square feet and did not have a self closing or automatic closing door. The room is considered a hazardous storage area.

2. At 4:42 p.m., the corridor door to the mechanical equipment was not automatic or self closing. The equipment room contained gas fired water heaters and miscellaneous combustible storage.

Hospital - Second Floor
3. At 7:43 p.m., there was more than 100 cases of medical records storage in a room that was greater than 200 square feet. There was no sheet rock ceiling installed. The wood framed roof structure was exposed to the combustible storage in the room.

Based on record review, observation and interview, the facility failed to maintain their emergency lighting in the building. This was evidenced by two of eight emergency lights that were not regularly tested and failed to light affecting three of ten smoke compartments. This could result in failure of the emergency lights and cause a delay in evacuation and an increased risk of exposure to smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
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.

Finding:

During document review on 5/7/12, inspection records were requested for battery operated emergency lighting. At 5:30 p.m., there were no inspection records provided.

During the facility tour and interview with Maintenance Staff 1 on 5/8/12, the facility emergency lighting was observed.

Hospital
1. At 11:41 a.m., there was an emergency light at the 300 kW genset that was not tested monthly and annually. There was no test documentation for the 30 second monthly test and none for the ninety minute annual test. Maintenance Staff 1 stated they do not perform annual inspections of battery powered emergency lighting.

Hospital - First Floor
2. At 2:56 p.m. there was a battery back-up emergency egress light inside Endoscopy Room Two.

3. At 2:57 p.m., there was a battery back-up emergency egress light inside Endoscopy Room One.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
4. At 1:31 p.m., there were four emergency battery lights with no records of inspections.

1335 Coffee Road, Second Floor, Clinic at Coffee Road Surgery Center
During a facility tour with Maintenance Staff 1 and 2 on 5/9/12, the emergency egress lighting was observed.

5. At 3:46 p.m., the battery back-up emergency light in the supply store room failed to operate when tested.

Outpatient Physical Therapy - Third Floor at 1501 Oakdale Road
During the facility tour and interview with Maintenance Staff 1 and 2 on 5/10/12, the emergency lighting egress lighting was observed.

6. At 7:04 a.m., an emergency egress battery powered light was observed at the first level. There was no record of monthly or annual inspections available and Maintenance Staff 2 stated they do not perform the monthly or annual inspections of the emergency lights.

7. At 7:06 a.m., an emergency egress battery powered light was observed near the back stairwell There was no record of monthly or annual inspections available.

8. At 7:08 a.m., an emergency egress battery powered light was observed in front of the women's restroom at the third floor lobby area. The battery powered light failed to operate when tested and there was no record of monthly or annual inspections available. The lobby provided access for Physical Therapy staff and patients to get to the elevator and front stairwell.

Based on interview, the facility failed to ensure that staff were prepared and knowledgeable in the use of their fire response plan. This was evidenced by no documentation of fire drills conducted at all three outpatient clinic locations. This could result in staff not able to respond quickly getting occupants out of danger and preparing the building for evacuation.
Findings:
X-Ray at Precision Imaging, 1239 McHenry Avenue
During an interview on 5/9/12 at 7:13 a.m., Maintenance Staff 1 stated that they do not conduct fire drills for Precision Imaging and there are no building owner fire drill records available.
Clinic at Coffee Road Surgery Center, 1335 Coffee Road
During an interview on 5/9/12 at 3:55 p.m., Maintenance Staff 1 stated there are no fire drills conducted at the Coffee Road Facility and there are no building owner fire drill records available.
Outpatient Physical Therapy Clinic, 1501 Oakdale Road
During an interview on 5/10/12 at 7:13 a.m., Maintenance staff 2 stated that they do not conduct fire drills for the Physical Therapy Clinic and there are no building owner fire drill records available.

Based on record review and interview, the facility failed to test the fire alarm system according to NFPA 72. This was evidenced by no record for certification or qualifications for personnel performing the annual testing. This could result in an increased risk of failure of the fire alarm system, or the failure to identify problems with the system, potentially delaying notification in the event of a fire. This affected the entire facility and maintenance of one of one fire alarm panel.

NFPA 72 National Fire Alarm Code, 1999 Edition
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:

(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems"

Findings:

During record review and interview on 5/7/12, records were requested for annual fire alarm testing.

At 2:27 p.m., the fire alarm system testing records were requested. Maintenance Staff 1 stated that they perform their testing in-house.

At 3:10 p.m., Maintenance Staff 1 provided their procedure for "Annual Fire Alarm Inspection," and report labeled "Fire Alarm Sytem Device Location." This report confirmed annual functional testing of notification and initiation devices were conducted by in-house staff. There was no indication of control panel and battery testing.

At 3:25 p.m., Maintenance Staff 1 confirmed that he and his staff were not certified or factory trained to conduct the annual fire alarm system testing. He described his reasoning for in-house testing came about because of problems with the previously established vendor.

At 3:30 p.m., the last vendor provided annual fire alarm system inspection was dated 12/13/08.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 25. This was evidenced by failure to inspect and test the sprinkler system quarterly. This affected four of ten smoke compartments and could result in the spread of smoke or fire or a delay in extinguishing a fire.

Findings:

During the facility tour with staff on 5/8/12, the complete sprinkler system was observed.
Hospital - First Floor

1. At 5:58 p.m., there was a celiing pendant spinkler in front of the entrance to OR #1 that was mounted with the deflector within 1/8 inch of being flush to the escutcheon.

Hospital - Second Floor - old side
2. At 7:49 p.m., there was an obstructed sprinkler head in exam room 3. The pendant sprinkler deflector was recessed approximately 1/4 inch inside the escutcheon.

During record review and interview on 5/9/12 the quarterly fire sprinkler system testing records were requested.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
3. At 11:18 a.m., there were no documents available for quarterly sprinkler system testing. Maintenance Staff 1 stated they do not perform quarterly testing at the off-site clinics.

Outpatient Physical Therapy - Third Floor at 1501 Oakdale Road
4. At 7:03 a.m., there were no documents available for quarterly sprinkler system testing. Maintenance Staff 1 stated they do perform quarterly testing for this clinic but they do not document this as a record.

Based on record review, observation and interview, the facility failed to ensure that "no smoking" provisions were enforced outside of exit doors. This was evidenced by cigarette butts discarded into a plastic 5 gallon bucket that was stored within three feet of an exit door and into a container mixed with combustible trash within eight feet of the exit door. This could result in the spread of smoke or fire into the hospital affecting one of nine smoke compartments.

Finding:

During a facility tour and interview with Maintenance Staff 2 on 5/8/12, the exterior exits were observed.

Hospital
At 8:36 p.m., there were 25 cigarette butts laying inside a 5 gallon bucket that was sitting on the sidewalk within three feet of the exit door next to purchasing in the hospital materials receiving area. A cigarette butt was observed inside the combustible trash container within eight feet of the exit door. There was no appropriate smoking area or disposal containers. Maintenance Staff 2 explained that there was not supposed to be any smoking on the hospital grounds.

During record review on 5/10/12 at 8:10 a.m., the hospital smoking policy was reviewed. According to the hospital policy there was no smoking allowed in the building.

Based on record review and interview, the facility failed to take action when the Operating Room (OR) relative humidity dropped below 35%. This could increase the risk of a fire resulting in injury to the patient affecting seven of eight operating rooms.

NFPA 99 (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.
Findings:
During the document review and interview with Maintenance Staff 1 on 5/7/12 the Operating Room (OR) temperature and humidity records were requested.

At 5:05 p.m., the last 6 months of temperature and humidity logs provided by the facility documented relative humidity levels in the Operating Room suites below 30 percent for the following days when surgeries were performed: 3/8/12 OR's 1, 5, 6, 7, & 8; 3/7/12 OR's 4, 5, 6, 7, & 8; 1/20/12 OR's 3, 5, 6, 7, & 8; 1/19/12 OR's 1, 3, & 5; 1/17/12 OR's 3, 5, 6, 7, & 8; 1/16/12 OR's 1, 3, 6, 7, & 8; 12/22/11 OR's 5, 6, & 7; 12/19/11 OR's 6, & 7; 12/8/11 OR's 3, 6, & 7; 12/7/11 OR's 5, 6, & 7; 12/6/11 OR's 1, 3, 5, 6, & 7; 12/5/11 OR's 1, 3, 5, 6, & 8; 12/2/11 OR's 3, 5, 7, & 8; 12/1/11 OR's 5, 6, 8. The daily OR temperature and humidity logs indicated there was no action taken in the OR suites when the humidity levels were out of range.

At 5:11 p.m., Maintenance Staff 1 stated that the facility air conditioning system is not equipped with humidifiers and that he will not increase the outside air to raise humidity in the OR suites. He explained that doing so would also raise temperatures and he cannot do this due to the low temperature requirements of surgical staff.

Based on observation, the facility failed ensure the oxygen storage areas of greater than 3000 cu feet are protected by a one hour enclosure. This was evidenced by a door on the medical gas manifold room that was not self closing. This could result in the spread of fire or smoke in a fire emergency affecting one of eight smoke compartments.

Findings:

Hospital
During the facility tour with Maintenance Staff 1 and 2 on 5/8/12, the oxygen storage locations were observed.

At 4:50 p.m., there were three 200 liter containers of liquid oxygen, three H cylinders of compressed oxygen gas, and ten E-sized cylinders of compressed oxygen gas stored in the medical gas room. The corridor door was not equipped with a self closing device.

Based on observation, interview and record review, the facility failed to document weekly generator inspections of the starting battery electrolyte level and charging rate and confirmation that the diesel powered generators were reaching the minimum load requirement. This was evidenced by no monthly record that documented testing was at least 30% of the nameplate rating or at a specified exhaust temperature, and by no record for a current annual load bank test. This could result in a greater risk of engine failure and complete loss of electrical power, in the event of a power outage, affecting 5 of 5 patients.
NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

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.
6-4.2.2 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.
6-4.3 Load tests of generator sets shall include complete cold starts.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.
Findings:
During record review, observation, and interviews with Maintenance Staff on 5/7/12, the emergency generator testing and maintenance record was reviewed.
1. At 3:25 p.m., there was no "Generator Maintenance Log" reports indicated the generator was run weekly but there was no indication that the starting battery was tested weekly. The only record of starting battery inspection occurred on the monthly load test.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment are in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of an extension cords and electrical adaptors. This affected six of eight smoke compartments and could increase the risk of electrical fire.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
Section 400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During the facility tour and interview with Maintenance Staff 1 & 2 on 5/8/12 the electrical devices and wiring connections were observed.

1. At 2:30 p.m., there was a water cooler plugged into a multi-outlet extension cord which was plugged into an orange extension cord which was plugged into a second multi-outlet extension cord which was plugged into a wall outlet in the physicians lounge.

2. At 2:45 p.m., there was desk top equipment plugged into a multi-outlet extension cord which was plugged into a wall outlet in the X-Ray area.

3. At 2:51 p.m., there was an EKG monitor plugged into an extension cord which was plugged into a wall outlet in the GI Laser room.

4. At 3:05 p.m., there was a microwave plugged into a gray extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the preadmission's area.

5. At 3:07 p.m., there was a coffee maker and an ice maker plugged into a multi-outlet extension cord which was plugged into a wall outlet in the medical Staff office area.

6. At 3:09 p.m., there was a portable heater plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Medical Staff office area.

7. At 3:12 a.m., there was a microwave and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Director of Nursing office.

8. At 3:14 p.m., there was a micro-wave plugged into an extension cord which was plugged into a wall outlet and a refrigerator that was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Chief Executive Officer's office.

9. At 2:46 p.m., there was a red extension cord in use in the Consulting area in Admitting.

10. At 4:10 p.m., the kitchen electrical panels K1 and K2 were obstructed from use by a coffee cart and a portable deep fat fryer.

11. At 4:34 p.m., there was micro-wave and a refrigerator plugged into a three way adaptor which was plugged into an orange extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet in the Purchasing Office.

12. At 5:18 p.m., there was a Bovie cauterizer plugged into a Tripp Lite Model PS 615- HG multi-outlet extension cord in OR 7. There was no documentation available that indicated it was approved for patient care equipment.

13. At 5:25 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 6. There was no documentation available that indicated it was approved for patient care equipment.

14. At 5:30 p.m., the OR nurse removed a four plug Tripp Lite power strip from below the the Bovie cauterizer cart in OR 5. The power strip had one plug that had been arced with a burn pattern around the receptacle. There was a similar electrical arc burn pattern on the frame of the Bovie cart. There was no power strip mounted to the Bovie cart labeled ValleyLab Force FX in OR 5. The OR nurse stated she had just removed the power strip from the cart because it was faulty.

15. At 5:50 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 2. There was no documentation available that indicated it was approved for patient care equipment.

16. At 5:58 p.m., there was a Bovie cauterizer with a Tripp Lite PS 615- HG multi-outlet extension cord in OR 3. There was no documentation available that indicated it was approved for patient care equipment.

X-Ray at Precision Imaging, First Floor at 1239 McHenry Avenue
17. At 1:36 p.m., there was a refrigerator plugged into an extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet.

18. At 1:38 p.m., there was desk top computer equipment plugged into a multi-outlet extension cord which was plugged into a second multi-outlet extension cord which was plugged into the wall outlet.

19. At 2 p.m., there was a broken cover plate for an electrical outlet at reception desk 3.