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Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire, as evidenced by an unsealed penetration observed in the fire rated sheeting. This deficient practice affected staff and residents in one of ten smoke compartments within the facility, and could result in the spread of smoke and/or fire from one area to another.

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, a penetration was observed in the gypsum wallboard. This penetration was approximately 1 1/2 inch in size and was in the ceiling near the left corner facing the washer and dryer in Utility Room 119. This room had a non commercial washer and dryer in it. Both staff confirmed the penetration.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. This deficient practice affected staff and patients in four of ten smoke compartments, and could result in the spread of smoke or fire into other areas of the facility.

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/7/10, corridor doors were observed in the following locations:
1. At 3:38 p.m., the door to Staff Breakroom 157 did not positive latch when tested by releasing the door from an open position.
2. At 3:55 p.m., the door to Storage Room 150 did not positive latch when tested by releasing the door from an open position.

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, corridor doors were observed in the following locations:
3. At 8:40 a.m., the door from the Emergency Room to the Lobby did not positive latch when tested.
4. At 8:45 a.m., the door to Soiled Utility/Oxygen Storage Room G 28 did not positive latch when tested.
5. At 8:51 a.m., the door to the Emergency Room Clerks/Record Room did not positive latch when tested.
6. At 8:55 a.m., the door to Emergency Room Office G69 did not positive latch when tested.
7. Between 9:37 and 10:00 a.m., the door to the laboratory was impeded from closing by equipment stored in the swing area of the door. Staff stated that the items were from a recent supply shipment that had been placed in that location.

Based on observation, the facility failed to maintain the one-half hour fire-rated construction of its smoke barrier walls in accordance with 2000 NFPA 101 as evidenced by one unsealed penetration observed in the smoke barrier wall above the corridor ceiling. This deficient practice affected two of ten smoke compartments within the facility, and could result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

Main Hospital Building
During an inspection of the facility's smoke barriers with the Director of Plant Operations and the Safety Security Officer on 12/7/10, a four inch unsealed penetration was observed in the smoke barrier wall above the cross corridor doors near the Front Entrance of the facility. This penetration was the result of data cables traveling through the wall which had pulled the fire rated caulking out, creating a four inch penetration on one side of the smoke barrier. Staff confirmed the penetration.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by a corridor door and an exit door that were equipped with double-action latching devices. This deficient practice affected all patients and could potentially result in a delayed egress in the event of an emergency.

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

Outpatient Services Draw Station
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, at 11:30 a.m., the door to the Patient Bathroom was equipped with a double-action latching mechanism requiring two distinct motions to open the door from the egress side.
At 11:35 a.m., the door identified as an exit in the office area was equipped with a double- action locking mechanism and deadbolt, requiring two distinct motions to open the door from the egress side. This door exited to the outside did not have a sign posted stating:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

Based on observation, the facility failed to provide emergency illumination in accordance with NFPA 99. This was evidenced by a battery-powered emergency lighting unit in an anesthetizing location which did not function when tested. This deficient practice affected one of four operating rooms, and could result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

Findings:.

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, at 2:55 p.m., the battery back-up lighting unit in Operating Room 2 also identified as Room 427 did not function when tested. Staff tested the light by disconnecting the power cord, and confirmed that it did not work.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by an extinguisher that was obstructed and not located in a conspicuous place. This deficient practice affected one of ten smoke compartments within the facility, and could result in a delay in extinguishing a fire.

1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10 at 12:06 p.m., the fire extinguisher located in the X-Ray Technician Room was mounted to the wall beside a cabinet, and had boxes stored in front of it. Staff confirmed the location of the extinguisher and the items that were stored in front of it.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This finding affected three of ten smoke compartments within the facility, and could result in the ignition of fire.

Findings:

Main Hospital Building
During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, portable electric heaters were observed in the following locations:

1. At 9:30 a.m., there was a portable heater in the Kitchen. This heater was 1500 watts with "three foot clearance" and "high temperature" warnings printed on the side of heater.
2. At 9:33 a.m., there was a portable heater in the Dietician Office120. This heater was 1500 watts with "three foot clearance" and "high temperature" warnings printed on the side of heater.
3. At 9:37 a.m., there was a portable heater in the PAC Administrator's Office.
4. At 10:00 a.m., the Nuclear Medicine Office had a portable electric heater under a desk.
5. At 10:52 a.m., the Admitting Medical Coordinator's Office had a portable electric heater under a desk.
6. At 10:53 a.m., the Admissions Director's Office had a portable electric heater under a desk.

These portable heaters were unapproved, and did not have facility acceptance inspection tags on them.
Two of the heaters that were tested during the survey exceeded the 212 degree maximum temperature rating. These heaters did not have facility acceptance stickers indicating that they had been tested and were within the allowed 212 degree maximum temperature rating.

Based on observation, the facility failed to protect its medical compressed gas storage room, in accordance with 1999 NFPA 99, as evidenced by cylinders which were stored secured together, instead of individually. This deficient practice affected one of ten smoke compartments within the facility, and could result in damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/7/10, at 3:02 p.m., the Oxygen Storage Room which could be accessed on the north side of the facility, had 22 H size compressed gas cylinders which were chained together, and not individually secured.

Based on document review and interview, the facility failed to maintain and document the relative humidity in its anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by a lack of documentation provided for humidity levels, and by documented humidity levels which were lower than the required minimum 35 percent. This deficient practice had the potential to affect staff and patients in four of four operating rooms by increasing the risk of fire.

Findings:

During record review on 12/9/10, at 9:10 a.m., documentation titled Surgical Temperature Log was provided for the months of April, 2010, through November, 2010. No documentation was provided for humidity prior to April, 2010. When asked, Staff AS3 stated that they were not recording the humidity levels prior to April, 2010.

Documentation titled Surgical Temperature Log, indicated that the humidity levels that were recorded for November 23, 2010, and November 24, 2010, were below required minimum 35 percent humidity.

Based on observation and interview, the facility failed to maintain its emergency generator, in accordance with NFPA 110 and 99, as evidenced by the lack of a battery-powered task light at a generator location, and by failing to provide a remote annunciator for its Emergency Power Supply (EPS) which could not be readily observed in the event of an interruption of the normal power. This finding affected seven of ten smoke compartments within the facility, and could result in th generator enclosure being in darkness if the generator failed to start during a power outage, and in facility staff failing to be readily alerted to problems with the generator in the event of a power outage

NFPA 110, 5-3 Lighting.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.
Findings:

3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency
or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less
than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations (AS1) and the Safety Security Officer (AS2) on 12/7/10, at 2:40 p.m., Generator 2 did not have a battery-powered emergency back-up light located in the generator enclosure.

During an inspection of the Maintenance Shop at 2:55 p.m., a generator annunciator was observed on the wall. When asked, AS1 stated that the annunciator was for Generator 2 which supplies power to the main hospital building. During a interview with staff on 12/8/10, between 8:30 and 8:45 a.m., when asked, AS2 stated that the location of the annunciator for generator 2 was not at constantly attended location when the power first goes out.

Surveyor: Compton, Robert S
Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, by the permanent use of extension cords, and by high wattage electrical appliances which were not plugged directly into fixed electrical outlets. This deficient practice affected all staff and patients in four of ten smoke compartments at the Main Hospital Building, and one of one smoke compartments at the Outpatient Draw Station, could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

Findings:

Main Hospital Building
During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/7/10, electrical wiring and equipment were observed in the following locations:

1. At 3:12 p.m., the Gift Shop Storage Room had an unapproved extension cord.
2. At 3:40 p.m., the OCS Nurses' Station had a power strip with a microwave oven plugged into it, suspended above the floor .


During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, electrical wiring and equipment were observed in the following locations:

3. At 9:07 a.m., the Anesthesia Break Room 483 had a power strip suspended, with a refrigerator plugged into it.
4. Between 9:07 and 9:20 a.m., the Post Recovery Desk near the OPAD Nurses' Station had a power strip suspended above the floor.

Outpatient Services Draw Station
5. During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, at 11:35 a.m., an extenion cord was observed plugged into an electrical outlet. This extension cord traveled approximately eight feet along a wall, through a hole drilled into a cement block of the wall, and then supplied power to office electrical equipment in a closet.

Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire, as evidenced by an unsealed penetration observed in the fire rated sheeting. This deficient practice affected staff and residents in one of ten smoke compartments within the facility, and could result in the spread of smoke and/or fire from one area to another.

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, a penetration was observed in the gypsum wallboard. This penetration was approximately 1 1/2 inch in size and was in the ceiling near the left corner facing the washer and dryer in Utility Room 119. This room had a non commercial washer and dryer in it. Both staff confirmed the penetration.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. This deficient practice affected staff and patients in four of ten smoke compartments, and could result in the spread of smoke or fire into other areas of the facility.

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/7/10, corridor doors were observed in the following locations:
1. At 3:38 p.m., the door to Staff Breakroom 157 did not positive latch when tested by releasing the door from an open position.
2. At 3:55 p.m., the door to Storage Room 150 did not positive latch when tested by releasing the door from an open position.

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, corridor doors were observed in the following locations:
3. At 8:40 a.m., the door from the Emergency Room to the Lobby did not positive latch when tested.
4. At 8:45 a.m., the door to Soiled Utility/Oxygen Storage Room G 28 did not positive latch when tested.
5. At 8:51 a.m., the door to the Emergency Room Clerks/Record Room did not positive latch when tested.
6. At 8:55 a.m., the door to Emergency Room Office G69 did not positive latch when tested.
7. Between 9:37 and 10:00 a.m., the door to the laboratory was impeded from closing by equipment stored in the swing area of the door. Staff stated that the items were from a recent supply shipment that had been placed in that location.

Based on observation, the facility failed to maintain the one-half hour fire-rated construction of its smoke barrier walls in accordance with 2000 NFPA 101 as evidenced by one unsealed penetration observed in the smoke barrier wall above the corridor ceiling. This deficient practice affected two of ten smoke compartments within the facility, and could result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

Main Hospital Building
During an inspection of the facility's smoke barriers with the Director of Plant Operations and the Safety Security Officer on 12/7/10, a four inch unsealed penetration was observed in the smoke barrier wall above the cross corridor doors near the Front Entrance of the facility. This penetration was the result of data cables traveling through the wall which had pulled the fire rated caulking out, creating a four inch penetration on one side of the smoke barrier. Staff confirmed the penetration.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by a corridor door and an exit door that were equipped with double-action latching devices. This deficient practice affected all patients and could potentially result in a delayed egress in the event of an emergency.

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

Outpatient Services Draw Station
During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, at 11:30 a.m., the door to the Patient Bathroom was equipped with a double-action latching mechanism requiring two distinct motions to open the door from the egress side.
At 11:35 a.m., the door identified as an exit in the office area was equipped with a double- action locking mechanism and deadbolt, requiring two distinct motions to open the door from the egress side. This door exited to the outside did not have a sign posted stating:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

Based on observation, the facility failed to provide emergency illumination in accordance with NFPA 99. This was evidenced by a battery-powered emergency lighting unit in an anesthetizing location which did not function when tested. This deficient practice affected one of four operating rooms, and could result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

Findings:.

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10, at 2:55 p.m., the battery back-up lighting unit in Operating Room 2 also identified as Room 427 did not function when tested. Staff tested the light by disconnecting the power cord, and confirmed that it did not work.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by an extinguisher that was obstructed and not located in a conspicuous place. This deficient practice affected one of ten smoke compartments within the facility, and could result in a delay in extinguishing a fire.

1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/8/10 at 12:06 p.m., the fire extinguisher located in the X-Ray Technician Room was mounted to the wall beside a cabinet, and had boxes stored in front of it. Staff confirmed the location of the extinguisher and the items that were stored in front of it.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This finding affected three of ten smoke compartments within the facility, and could result in the ignition of fire.

Findings:

Main Hospital Building
During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, portable electric heaters were observed in the following locations:

1. At 9:30 a.m., there was a portable heater in the Kitchen. This heater was 1500 watts with "three foot clearance" and "high temperature" warnings printed on the side of heater.
2. At 9:33 a.m., there was a portable heater in the Dietician Office120. This heater was 1500 watts with "three foot clearance" and "high temperature" warnings printed on the side of heater.
3. At 9:37 a.m., there was a portable heater in the PAC Administrator's Office.
4. At 10:00 a.m., the Nuclear Medicine Office had a portable electric heater under a desk.
5. At 10:52 a.m., the Admitting Medical Coordinator's Office had a portable electric heater under a desk.
6. At 10:53 a.m., the Admissions Director's Office had a portable electric heater under a desk.

These portable heaters were unapproved, and did not have facility acceptance inspection tags on them.
Two of the heaters that were tested during the survey exceeded the 212 degree maximum temperature rating. These heaters did not have facility acceptance stickers indicating that they had been tested and were within the allowed 212 degree maximum temperature rating.

Based on observation, the facility failed to protect its medical compressed gas storage room, in accordance with 1999 NFPA 99, as evidenced by cylinders which were stored secured together, instead of individually. This deficient practice affected one of ten smoke compartments within the facility, and could result in damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

During a tour of the facility with the Director of Plant Operations and the Safety Security Officer on 12/7/10, at 3:02 p.m., the Oxygen Storage Room which could be accessed on the north side of the facility, had 22 H size compressed gas cylinders which were chained together, and not individually secured.

Based on document review and interview, the facility failed to maintain and document the relative humidity in its anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by a lack of documentation provided for humidity levels, and by documented humidity levels which were lower than the required minimum 35 percent. This deficient practice had the potential to affect staff and patients in four of four operating rooms by increasing the risk of fire.

Findings:

During record review on 12/9/10, at 9:10 a.m., documentation titled Surgical Temperature Log was provided for the months of April, 2010, through November, 2010. No documentation was provided for humidity prior to April, 2010. When asked, Staff AS3 stated that they were not recording the humidity levels prior to April, 2010.

Documentation titled Surgical Temperature Log, indicated that the humidity levels that were recorded for November 23, 2010, and November 24, 2010, were below required minimum 35 percent humidity.

Based on observation and interview, the facility failed to maintain its emergency generator, in accordance with NFPA 110 and 99, as evidenced by the lack of a battery-powered task light at a generator location, and by failing to provide a remote annunciator for its Emergency Power Supply (EPS) which could not be readily observed in the event of an interruption of the normal power. This finding affected seven of ten smoke compartments within the facility, and could result in th generator enclosure being in darkness if the generator failed to start during a power outage, and in facility staff failing to be readily alerted to problems with the generator in the event of a power outage

NFPA 110, 5-3 Lighting.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.
Findings:

3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency
or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less
than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Findings:

Main Hospital Building
During a tour of the facility with the Director of Plant Operations (AS1) and the Safety Security Officer (AS2) on 12/7/10, at 2:40 p.m., Generator 2 did not have a battery-powered emergency back-up light located in the generator enclosure.

During an inspection of the Maintenance Shop at 2:55 p.m., a generator annunciator was observed on the wall. When asked, AS1 stated that the annunciator was for Generator 2 which supplies power to the main hospital building. During a interview with staff on 12/8/10, between 8:30 and 8:45 a.m., when asked, AS2 stated that the location of the annunciator for generator 2 was not at constantly attended location when the power first goes out.

Surveyor: Compton, Robert S
Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, by the permanent use of extension cords, and by high wattage electrical appliances which were not plugged directly into fixed electrical outlets. This deficient practice affected all staff and patients in four of ten smoke compartments at the Main Hospital Building, and one of one smoke compartments at the Outpatient Draw Station, could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

Findings:

Main Hospital Building
During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/7/10, electrical wiring and equipment were observed in the following locations:

1. At 3:12 p.m., the Gift Shop Storage Room had an unapproved extension cord.
2. At 3:40 p.m., the OCS Nurses' Station had a power strip with a microwave oven plugged into it, suspended above the floor .


During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, electrical wiring and equipment were observed in the following locations:

3. At 9:07 a.m., the Anesthesia Break Room 483 had a power strip suspended, with a refrigerator plugged into it.
4. Between 9:07 and 9:20 a.m., the Post Recovery Desk near the OPAD Nurses' Station had a power strip suspended above the floor.

Outpatient Services Draw Station
5. During a tour of the facility with Director of Plant Operations and the Safety Security Officer on 12/8/10, at 11:35 a.m., an extenion cord was observed plugged into an electrical outlet. This extension cord traveled approximately eight feet along a wall, through a hole drilled into a cement block of the wall, and then supplied power to office electrical equipment in a closet.