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Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that corridors were separated from use areas by walls constructed with at least a one-half hour fire resistance rating in one waiting area outside cardiac rehabilitation. This could affect all individuals utilizing the services of the smoke compartment.

Findings include:

Tour was conducted on 7/7/10 from 1:50 PM until 3:40 PM with staff R and staff T. The waiting area located outside cardiac rehabilitation was noted to be open to the corridor and lacked smoke detection. The area was less than 600 square feet and did not obstruct access to exits. Staff T confirmed during the tour that the area lacked a smoke detector.

Based on review of inspection records and staff interview, it was determined that the facility failed to have evidence that the fire alarm system was inspected and tested within the past year as required. This could affect all individuals in the facility.

Findings include:

Records of inspections of the fire alarm system were requested on 7/7/10 and again on 7/8/10. There was no inspection of the fire alarm system available for review by 7/8/10. It was confirmed by staff T on 7/9/10 at 2:50 PM that there was no fire alarm inspection record available.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that electrical fixtures in one of one medical gas storage rooms on the obstetrics unit were located equal to or greater than five feet above the floor.

Findings include:

Tour was conducted on 7/7/10 from 9:30 AM until 11:45 AM with staff R and staff T. It was observed that the medical gas storage room on the obstetrics unit, which contained two piped-in H tanks of nitrous oxide, had one wall switch and one electrical outlet that were located less than five feet above the floor. This finding was confirmed by staff R during the tour.

Based on review of relative humidity (RH) records and staff interview, it was determined that the facility failed to maintain RH equal to or greater than 35 per cent in one of one delivery rooms during the months of January through April, 2010, and in five of five active operating rooms (OR's) during the months of January through May, 2010.

Findings include:

Records for RH for the delivery room were reviewed on 7/8/10 for January through June, 2010. In January, there were nine days when the RH was below 35 per cent. In February, there were three days when the RH was below 35 per cent. In March, there were 16 days when the RH was below 35 per cent; on one of these days the RH was below 30 per cent, and a work order was sent for correction of the RH. In April, there were 23 days when the RH was below 35 per cent; on 13 of these days the RH was below 30 per cent, and work orders were sent for correction of the RH.

Records for RH for the five OR's that were in use were reviewed on 7/8/10 for January through June, 2010.

For OR #1:

In January, there were five days when the RH was below 35 per cent. In February, there were 13 days when the RH was below 35 per cent. In March, there were 14 days when the RH was below 35 per cent. In April, there were 15 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #2:

In January, there were 18 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 16 days when the RH was below 35 per cent. In April, there were 14 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #3:

In January, there were 18 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 17 days when the RH was below 35 per cent. In April, there were 17 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #4:

In January, there were 17 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 19 days when the RH was below 35 per cent. In April, there were 17 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #5:

In January, there were 16 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 19 days when the RH was below 35 per cent. In April, there were 15 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

These findings were discussed with staff R at 11:15 AM on 7/8/10. No further information was provided prior to exit.

In spaces served by air handling systems, smoke detectors shall not be located where air flow prevents operation of the detectors. NFPA 72, chapter 2-3.5.1.

This requirement was NOT MET as evidenced by:

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that smoke detectors in various locations in the building were located where air flow would not prevent operation of the detectors. This could affect all individuals utilizing the affected areas of the facility.

Findings include:

Tour of the East Wing was conducted on 7/6/10 from 2:30 PM until 4:00 PM and on 7/7/10 from 9:30 AM until 11:45 AM with staff R and staff T. Smoke detectors were observed located where air flow could affect the operation of the detectors in the following locations: in the soiled room on the second floor; in the emergency department near the stairway, by E246B; in storage room EB11; in the fifth floor lobby, by the smoke doors and in front of the elevator; in supply room E544; on the fourth floor, in front of the service elevator; on the third floor, in room 320, in the pathology room, and in the sterile special order cupboard room 310. These findings were confirmed by staff R during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that corridors were separated from use areas by walls constructed with at least a one-half hour fire resistance rating in one waiting area outside cardiac rehabilitation. This could affect all individuals utilizing the services of the smoke compartment.

Findings include:

Tour was conducted on 7/7/10 from 1:50 PM until 3:40 PM with staff R and staff T. The waiting area located outside cardiac rehabilitation was noted to be open to the corridor and lacked smoke detection. The area was less than 600 square feet and did not obstruct access to exits. Staff T confirmed during the tour that the area lacked a smoke detector.

Based on review of inspection records and staff interview, it was determined that the facility failed to have evidence that the fire alarm system was inspected and tested within the past year as required. This could affect all individuals in the facility.

Findings include:

Records of inspections of the fire alarm system were requested on 7/7/10 and again on 7/8/10. There was no inspection of the fire alarm system available for review by 7/8/10. It was confirmed by staff T on 7/9/10 at 2:50 PM that there was no fire alarm inspection record available.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that electrical fixtures in one of one medical gas storage rooms on the obstetrics unit were located equal to or greater than five feet above the floor.

Findings include:

Tour was conducted on 7/7/10 from 9:30 AM until 11:45 AM with staff R and staff T. It was observed that the medical gas storage room on the obstetrics unit, which contained two piped-in H tanks of nitrous oxide, had one wall switch and one electrical outlet that were located less than five feet above the floor. This finding was confirmed by staff R during the tour.

Based on review of relative humidity (RH) records and staff interview, it was determined that the facility failed to maintain RH equal to or greater than 35 per cent in one of one delivery rooms during the months of January through April, 2010, and in five of five active operating rooms (OR's) during the months of January through May, 2010.

Findings include:

Records for RH for the delivery room were reviewed on 7/8/10 for January through June, 2010. In January, there were nine days when the RH was below 35 per cent. In February, there were three days when the RH was below 35 per cent. In March, there were 16 days when the RH was below 35 per cent; on one of these days the RH was below 30 per cent, and a work order was sent for correction of the RH. In April, there were 23 days when the RH was below 35 per cent; on 13 of these days the RH was below 30 per cent, and work orders were sent for correction of the RH.

Records for RH for the five OR's that were in use were reviewed on 7/8/10 for January through June, 2010.

For OR #1:

In January, there were five days when the RH was below 35 per cent. In February, there were 13 days when the RH was below 35 per cent. In March, there were 14 days when the RH was below 35 per cent. In April, there were 15 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #2:

In January, there were 18 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 16 days when the RH was below 35 per cent. In April, there were 14 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #3:

In January, there were 18 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 17 days when the RH was below 35 per cent. In April, there were 17 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #4:

In January, there were 17 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 19 days when the RH was below 35 per cent. In April, there were 17 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

For OR #5:

In January, there were 16 days when the RH was below 35 per cent. In February, there were 19 days when the RH was below 35 per cent. In March, there were 19 days when the RH was below 35 per cent. In April, there were 15 days when the RH was below 35 per cent. In May, there were two days when the RH was below 35 per cent.

These findings were discussed with staff R at 11:15 AM on 7/8/10. No further information was provided prior to exit.

In spaces served by air handling systems, smoke detectors shall not be located where air flow prevents operation of the detectors. NFPA 72, chapter 2-3.5.1.

This requirement was NOT MET as evidenced by:

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that smoke detectors in various locations in the building were located where air flow would not prevent operation of the detectors. This could affect all individuals utilizing the affected areas of the facility.

Findings include:

Tour of the East Wing was conducted on 7/6/10 from 2:30 PM until 4:00 PM and on 7/7/10 from 9:30 AM until 11:45 AM with staff R and staff T. Smoke detectors were observed located where air flow could affect the operation of the detectors in the following locations: in the soiled room on the second floor; in the emergency department near the stairway, by E246B; in storage room EB11; in the fifth floor lobby, by the smoke doors and in front of the elevator; in supply room E544; on the fourth floor, in front of the service elevator; on the third floor, in room 320, in the pathology room, and in the sterile special order cupboard room 310. These findings were confirmed by staff R during the tour.