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Based on observation, the facility failed to maintain their corridor doors. This was evidenced by three corridor doors that were obstructed from latching. This affected two of seven floors, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

1. On 7/13/11 at 2:24 p.m., the corridor door to the Fifth Floor Staff Locker Room 5221 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 7/13/11 at 2:31 p.m., the corridor door to the Fifth Floor Pediatric Medication Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch.

3. On 7/13/11 at 2:42 p.m., the corridor door to the Fourth Floor Case Management/Social Worker's Office Room 4113 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area door that was obstructed from latching. This affected one of seven floors, and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, on 7/13/11 at 2:58 p.m., the corridor door to the Fourth Floor Soiled Utility Room 4109 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source. This affected seven of seven floors, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
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 1.5 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.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with staff on 7/13/11 at 1:14 p.m., the facility was observed to have exit signs equipped with an internal emergency power supply source throughout the building, and on seven of seven floors. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the signs are not tested monthly for thirty seconds. Facilities Staff 1 indicated that the signs are not tested annually for ninety minutes. Facilities Staff 1 indicated that they were unaware of those requirements.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the accumulation of dust and debris on two sprinklers heads in the facility. This affected one of seven floors, and could result in a delayed response of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a facility tour with staff on 7/13/11 at 4:51 p.m., two of three sprinkler heads in Room 3134 were observed to have a thick accumulation of dust and debris.

Based on observation, the facility failed to maintain their designated smoking areas. This was evidenced by one designated smoking area that was not equipped with a metal self-closing container to empty ashtrays into. This affected one of seven floors, and could result in an increased risk of fire.

Findings:

During a facility tour with staff on 7/14/11 at 8:46 a.m., the designated smoking area located outside near the Shipping and Receiving Area was observed. The smoking area was equipped with three open top ashtray receptacles. The smoking area was not equipped with a metal self-closing container to empty ashtray contents into.

Based on observation, the facility failed to maintain the use of portable space heaters. This was evidenced by portable space heaters that were plugged into extension cords, portable space heaters that were within three feet of furnishings or combustibles, and portable space heaters that were not unplugged when not in use. This affected one of seven floors, and could result in an increased risk of fire.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

1. On 7/14/11 at 9:15 a.m., a portable space heater was located in Staffing Office Room 2217. The portable space heater was located under and within three feet of a desk. The portable space heater was not in use, and was plugged into a surge protected multi-outlet extension cord.

2. On 7/14/11 at 10:08 a.m., a portable space heater was located in a Staff Office Room 2362. The portable space heater was located under and within three feet of a desk. The portable space heater was not in use, and was plugged into a surge protected multi-outlet extension cord.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by one oxygen E cylinder that was stored free standing and unsecured. This affected one of seven floors, and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff on 7/14/11 at 8:39 a.m., there was one oxygen E cylinder located in a closet at the Behavioral Health Nurse Station that was stored free standing and unsecured.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or greater for eight of twelve months, and by two anesthetizing locations that were not being monitored for humidity levels. This affected twelve of twelve Operating Rooms, and two of two Endoscopy Procedure Rooms, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

NFPA 99, 1999 edition
Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.
Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Findings:

During record review and facility tour with staff, the facility's anesthetizing locations were observed.

1. On 7/13/11 at 8:39 a.m., the relative humidity logs for the facility's anesthetizing locations were reviewed. The facility's policy was to maintain humidity levels in their operating rooms between twenty percent and sixty percent. The facility has eight Main Operating Rooms, three Outpatient Operating Rooms, and one C-Section Room. Twelve of twelve operating rooms had recorded relative humidity levels below thirty-five percent during approximately eight of the past twelve months.

2. On 7/13/11 at 4:18 p.m., the Endoscopy Department was observed. The Endoscopy Department had two Procedure Rooms. Endoscopy Staff 1 was interviewed at that time. Endoscopy Staff 1 indicated that conscious sedation is utilized in the Endoscopy Procedure Rooms. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the relative humidity levels in two of two Procedure Rooms are not monitored.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into extension cords, and by one area where an extension cord was plugged into another extension cord. This affected three of seven floors, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
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
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring was observed.

1. On 7/13/11 at 3:13 p.m., a miniature refrigerator in the Lactation Room 4350 was plugged into a surge protected multi-outlet extension cord.

2. On 7/14/11 at 8:37 a.m., a microwave oven and a miniature refrigerator in the Behavioral Health Staff Lounge were plugged into a surge protected multi-outlet extension cord.

3. On 7/14/11 at 10:01 a.m., two of two miniature refrigerators in the Case Management Room 2325 were plugged into one surge protected multi-outlet extension cord.

4. On 7/14/11 at 11:40 a.m., computer equipment in the Volunteers Office Room L119 was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord. The computer equipment was located near the window side workspace.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of seven alcohol based hand rub dispensers over or adjacent to ignition sources. This affected three of seven floors, and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

1. On 7/13/11 at 2:54 p.m., an alcohol based hand rub dispenser in Room 4129 was mounted on the wall approximately two feet above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 7/13/11 at 3:19 p.m., an alcohol based hand rub dispenser in Meeting Room 4364 was mounted on the wall approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 7/13/11 at 4:24 p.m., an alcohol based hand rub dispenser in Electrophysiology Lab Office Room 3212 was mounted on the wall approximately six inches to the left of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

4. On 7/14/11 at 8:58 a.m., an alcohol based hand rub dispenser in the Second Floor Intensive Care Unit Soiled Linen Room was mounted on the wall approximately five inches to the right of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

5. On 7/14/11 at 9:12 a.m., two of two alcohol based hand rub dispensers in Room 2218 were mounted on the wall approximately four inches above a light switch. The hand rubs were sixty-two percent ethyl alcohol by volume.

6. On 7/14/11 at 9:38 a.m., an alcohol based hand rub dispenser in the Second Floor Lab Reception Office was mounted on the wall approximately three feet above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by three corridor doors that were obstructed from latching. This affected two of seven floors, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

1. On 7/13/11 at 2:24 p.m., the corridor door to the Fifth Floor Staff Locker Room 5221 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 7/13/11 at 2:31 p.m., the corridor door to the Fifth Floor Pediatric Medication Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch.

3. On 7/13/11 at 2:42 p.m., the corridor door to the Fourth Floor Case Management/Social Worker's Office Room 4113 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area door that was obstructed from latching. This affected one of seven floors, and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, on 7/13/11 at 2:58 p.m., the corridor door to the Fourth Floor Soiled Utility Room 4109 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source. This affected seven of seven floors, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
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 1.5 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.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with staff on 7/13/11 at 1:14 p.m., the facility was observed to have exit signs equipped with an internal emergency power supply source throughout the building, and on seven of seven floors. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the signs are not tested monthly for thirty seconds. Facilities Staff 1 indicated that the signs are not tested annually for ninety minutes. Facilities Staff 1 indicated that they were unaware of those requirements.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the accumulation of dust and debris on two sprinklers heads in the facility. This affected one of seven floors, and could result in a delayed response of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a facility tour with staff on 7/13/11 at 4:51 p.m., two of three sprinkler heads in Room 3134 were observed to have a thick accumulation of dust and debris.

Based on observation, the facility failed to maintain their designated smoking areas. This was evidenced by one designated smoking area that was not equipped with a metal self-closing container to empty ashtrays into. This affected one of seven floors, and could result in an increased risk of fire.

Findings:

During a facility tour with staff on 7/14/11 at 8:46 a.m., the designated smoking area located outside near the Shipping and Receiving Area was observed. The smoking area was equipped with three open top ashtray receptacles. The smoking area was not equipped with a metal self-closing container to empty ashtray contents into.

Based on observation, the facility failed to maintain the use of portable space heaters. This was evidenced by portable space heaters that were plugged into extension cords, portable space heaters that were within three feet of furnishings or combustibles, and portable space heaters that were not unplugged when not in use. This affected one of seven floors, and could result in an increased risk of fire.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

1. On 7/14/11 at 9:15 a.m., a portable space heater was located in Staffing Office Room 2217. The portable space heater was located under and within three feet of a desk. The portable space heater was not in use, and was plugged into a surge protected multi-outlet extension cord.

2. On 7/14/11 at 10:08 a.m., a portable space heater was located in a Staff Office Room 2362. The portable space heater was located under and within three feet of a desk. The portable space heater was not in use, and was plugged into a surge protected multi-outlet extension cord.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by one oxygen E cylinder that was stored free standing and unsecured. This affected one of seven floors, and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff on 7/14/11 at 8:39 a.m., there was one oxygen E cylinder located in a closet at the Behavioral Health Nurse Station that was stored free standing and unsecured.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or greater for eight of twelve months, and by two anesthetizing locations that were not being monitored for humidity levels. This affected twelve of twelve Operating Rooms, and two of two Endoscopy Procedure Rooms, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

NFPA 99, 1999 edition
Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.
Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Findings:

During record review and facility tour with staff, the facility's anesthetizing locations were observed.

1. On 7/13/11 at 8:39 a.m., the relative humidity logs for the facility's anesthetizing locations were reviewed. The facility's policy was to maintain humidity levels in their operating rooms between twenty percent and sixty percent. The facility has eight Main Operating Rooms, three Outpatient Operating Rooms, and one C-Section Room. Twelve of twelve operating rooms had recorded relative humidity levels below thirty-five percent during approximately eight of the past twelve months.

2. On 7/13/11 at 4:18 p.m., the Endoscopy Department was observed. The Endoscopy Department had two Procedure Rooms. Endoscopy Staff 1 was interviewed at that time. Endoscopy Staff 1 indicated that conscious sedation is utilized in the Endoscopy Procedure Rooms. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the relative humidity levels in two of two Procedure Rooms are not monitored.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into extension cords, and by one area where an extension cord was plugged into another extension cord. This affected three of seven floors, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
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
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring was observed.

1. On 7/13/11 at 3:13 p.m., a miniature refrigerator in the Lactation Room 4350 was plugged into a surge protected multi-outlet extension cord.

2. On 7/14/11 at 8:37 a.m., a microwave oven and a miniature refrigerator in the Behavioral Health Staff Lounge were plugged into a surge protected multi-outlet extension cord.

3. On 7/14/11 at 10:01 a.m., two of two miniature refrigerators in the Case Management Room 2325 were plugged into one surge protected multi-outlet extension cord.

4. On 7/14/11 at 11:40 a.m., computer equipment in the Volunteers Office Room L119 was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord. The computer equipment was located near the window side workspace.