HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke from one area to another, in the event of a fire. This affected one of three smoke compartments in the main hospital, the administration building, and the plant operations building.

Findings:

During the facility tour with facility staff on 4/23 and 4/24/13, the ceilings and walls were observed.

Administration Building - 4/23/13
1. At 11:20 a.m., there was a two inch unsealed pipe sleeve in the fire alarm panel room ceiling. There was a penetration around a bundle of wires, inside the pipe sleeve.

Main Hospital
2. At 1:50 p.m., there was an approximately one by four inch penetration in the Triage Room. The penetration was on the left wall, behind the open door.
At 1:51 p.m., during an interview, Staff 2 stated that the door knob caused the penetration when the door opened and hit the wall.

3. At 2:28 p.m., there was an approximately 2 by 13 inch penetration in the janitor's closet, across the hall from Radiology, next to the reading room. The penetration was on the left side of the wall.

4. At 3 p.m., there was an approximately 1 by 26 inch penetration in the sterilizer room. The penetration was above the sterilizer machine.

5. At 3:55 p.m., there was an approximately one inch round penetration in the Surgery Med Room. The penetration was on the left wall, around a drain pipe.

Plant Operations - 4/24/13
6. At 7:50 a.m., there were two approximately two inch unsealed conduits, around black cables, in the phone room. The conduits were in the left side of the room penetrating the ceiling.

7. At 7:52 a.m., there was a two inch unsealed conduit around a bundle of cables in the phone room. The conduit was on the right side of the room, in the upper corner, penetrating the wall.

8. At 7:55 a.m., there were two approximately 1 1/2 inch cut out penetrations in the engineering shop. The penetrations were on the wall adjacent to the phone room.

Based on observation, the facility failed to ensure corridor walls were constructed to resist the passage of smoke. This was evidenced by a penetration in one corridor wall. The penetration could allow the spread of smoke or fire in the event of a fire, and affected one of three smoke compartments in the hospital.

Findings:

During the facility tour with facility staff on 4/23 and 4/24/13, the corridor walls and ceilings were observed.

At 8:47 a.m., there was an approximately 1/2 inch penetration around two wires, inside a 1/2 inch pipe sleeve, in the corridor wall above the drop ceiling. The penetration was above the ENDO Room.

Based on observation and interview, the facility failed to ensure that corridor doors were free from obstructions, and that doors close and latch. This was evidenced by seven doors that failed to close and latch, by seven doors that were impeded from closing, and by a self closing door that was disabled. This failure could result in the spread of smoke or fire, in the event of a fire, and affected two of three smoke compartments in the main hospital and the Administration Building.

Findings:

During the facility tour with facility staff from 4/22 to 4/24/13, the corridor doors were observed.

Main Hospital - 4/23/13
1. At 9:54 a.m., the self closing corridor door to X-Ray Room 2 failed to fully close and latch after activation of the fire alarm system.

Administration Building
2. At 11:10 a.m., there was a brown, rubber door wedge holding the corridor door open in the HIM (Health Information Management) Room.

3. At 11:12 a.m., there was a brown, rubber door wedge holding the corridor door open in the Quality Management Department Room.

4. At 11:22 a.m., the self closing corridor door to the waiting room area failed to fully close and latch. The door was tested three times.

5. At 1:28 p.m., there was a brown, rubber door wedge holding the corridor door open in the Administration Conference Room.

Main Hospital
6. At 1:59 p.m., there was a soiled linen container obstructing the self closing corridor door in Exam Room 5. The door was tested after removing the obstruction. The door failed to fully close and latch. The door rubbed on the door frame and was obstructed from closing.

At 2 p.m., during an interview, Staff 1 reported that the door was split on the bottom lower right hand side.

7. At 2:21 p.m., the self closing corridor door to the Handicap Restroom, in the Emergency Department (ED), failed to close and latch. The door was tested three times.

8. At 2:41 p.m., the self closing corridor door to the Quiet Room, across from the ED, closed but failed to latch.

9. At 2:59 p.m., the self closing corridor door to the Medical Supply Room, near the OR, failed to fully close and latch. The door was tested three times.

10. At 3:13 p.m., the self closing corridor door to the OB Doctor's Lounge failed to fully close and latch. The door was tested three times.

11. At 3:20 p.m., the self closing corridor door was impeded from closing by a sofa, in the OB and Same Day Surgery Family Waiting Room.

12. At 4:01 p.m., the self closing corridor door to the Steam Room, next to LDRP 2, failed to fully close and latch.
At 4:02 p.m., during an interview, Staff 1 stated that it appeared that the door had swelled up.

13. At 4:10 p.m., the self closing corridor door to the Hospitalist Office was missing the arms that closed the door.
At 4:11 p.m., during an interview, health staff reported that the self closer had not been working since July of last year.

14. At 4:36 p.m., the corridor door to Room 104 was obstructed from closing by an isolation station that was hanging over the door.

Based on observation, the facility failed to ensure that the smoke barrier doors were capable of resisting the passage of smoke, and that the doors were self-closing. This was evidenced by one of three smoke barrier doors that failed to fully close and latch during fire alarm system testing. This affected two of three smoke compartments and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire in the main hospital.

Findings:

During alarm testing with facility staff, on 4/23/13, the smoke barrier doors were observed and tested.

At 9:03 a.m., the right side smoke barrier door by Room 118 closed after activation of the fire alarm system. The door did not fully close and latch.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resistant partitions and self closing doors. This was evidenced by hazardous storage areas without self closing doors. This could result in the spread of smoke or fire affecting one of three smoke compartments in the main hospital and the Administration Building, in the event of a fire.

Findings:

During a tour of the facility with facility staff from 4/22 to 4/24/13, the walls and doors to hazardous areas were observed. Combustible storage areas, soiled linen and trash rooms, laboratories, and fuel fire heater rooms are considered hazardous areas. The doors are required to self close and latch.

Administration Building -
1. At 11:30 a.m., on 4/23/13, there was no self closer on the corridor door to the Laboratory. The room was greater than 50 square feet in size.

Main Hospital -
2. At 4:31 p.m., there was no self closer on the door to Room 109. The room is greater than 50 square feet in size and was used as a storage room. The room contained a crib with a mattress, two sofas, one bed, a baby warmer, three wheelchairs, one e-size oxygen tank, a bassinet, a scale, three bed side commodes, lifts, three vital sign machine and other miscellaneous medical supplies.

Based on observation, the facility failed to maintain the battery operated emergency lighting within the emergency power generator area. This could result in a potential delay in repairing the emergency power generator if it had failed to operate as required during a public utility outage.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
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.

Finding:

During the facility tour with facility staff on 4/24/13, the facility emergency lighting and generator were observed.

At 8:07 a.m., on 4/24/13, the battery operated emergency lights in the emergency generator area failed to illuminate when tested.

Based on observation, the facility failed to maintain the emergency exit sign back up batteries. This was evidenced by exit signs that failed to illuminate when tested. This affected two of three smoke compartments in the Main Hospital and the Administration Building. This could result in delayed egress from the building and potential harm to the patients and staff.

NFPA 101 Life Safety Code (2000 Edition)
Maintaining Existing Equipment
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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 1/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour with facility staff, from 4/22 to 4/24/13, the facility exit signs were tested and observed.

Administration Building - 4/23/13
1. At 1:30 p.m., the exit sign, posted above the Administrator's Office hallway exit door, did not work. When the test button was activated the exit light did not illuminate.

Main Building - 4/23/13
2. At 9:31 a.m., the exit sign failed to illuminate when the test button was activated, on the sign above the hallway exit door by LDRP 2.

3. At 9:34 a.m., the exit sign above the hallway exit door by Room 120 was not working. When the test button was activated, the exit light did not illuminate.

4. At 9:52 a.m., the exit sign at the exit door by Mammography failed to illuminate when the test button was activated.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 13 and NFPA 25. This was evidenced by and escutcheon ring that was not flush with the ceiling, and by storage within 18 inches of a sprinkler deflector. Escutcheon rings are used to cover the penetrations around sprinkler pipes. A sprinkler deflector is used to divert the water to create the spray pattern when a sprinkler is activated. This affected two of three smoke compartments in the main hospital and could result in the spread of smoke or fire, or a delay in extinguishing a fire.

NFPA 13 Installation of Sprinkler Systems 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1999 Edition
2-2 Inspection.
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 the facility tour with facility staff, from 4/22 to 4/23/13, the complete sprinkler system was observed.

Main Hospital - 4/23/13
1. At 2:20 p.m., there was an approximately 3/4 inch gap between the escutcheon ring and the ceiling in the handicap restroom of the Emergency Department. This exposed an approximately 3/4 inch penetration around the sprinkler pipe.

2. At 4:58 p.m., there was a cardboard box stored within approximately 16 inches of the sprinkler deflector, in the office supply storage closet across from Room 114.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles is not exceeded within any 64 square foot area. This was evidenced by multiple 32 gallon receptacles placed in three areas in the facility. The facility also failed to ensure that these receptacles when not attended are located in a room protected as a hazardous area. This failure could result in fire in an unprotected area, and affected two of three smoke compartments of the main hospital.

Findings:

During the facility tour with facility staff, on 4/22 and 4/23/13, soiled linen and trash receptacles (carts) were observed in the facility.

Main Hospital - 4/23/13
1. At 2:05 p.m., there was a soiled linen cart and a trash cart lined up, side by side, in Exam Room 4. The soiled linen cart was approximately 23 gallons and the trash cart was approximately 32 gallons in size.

2. At 2:07 p.m., there was a soiled linen cart and a trash container lined up, side by side, in Exam Room 3. The soiled linen cart was approximately 23 gallons and the trash cart was approximately 32 gallons in size. There was a red biohazard container within the 64 square foot area. The biohazard container was approximately eight gallons in size.

3. At 3:15 p.m., there was a trash container and a red biohazard container, side by side in the LDR1. The containers were both approximately 23 gallons in size.

4. At 3:24 p.m., there was a soiled linen cart and a trash cart lined up, side by side in the Nursery. The containers were approximately 23 gallons in size.

5. At 4:02 p.m., there was a soiled linen cart and a trash container, side by side, in LDR2. The containers were approximately 23 gallons in size.

Based on record review and interview, the facility failed to maintain and test the generator in accordance with NFPA 99 and NFPA 110. This was evidenced by incomplete records for weekly visual inspections for 23 of 52 weeks. This could result in the failure of the emergency generator in the event of a power outage affecting the entire facility.

Findings:

During record review with facility staff, on 4/24/13, the generator weekly inspection records were requested and reviewed.

At 9:08 a.m., the facility provided 29 of 52 weekly inspection records titled, "Engineering Dept. Emergency Generator." There were 23 weekly inspections records missing.

During an interview, Staff 1 stated he was testing the generator under load every other week and he began the weekly inspections a few months ago. He reported that he did not conduct the weekly visual inspections during 2012.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by an electrical panel that was not maintained with 36 inch clearance, by the use of extension cords and surge protectors instead of permanent wiring, and by surge protectors connected to other surge protectors. This affected two of three smoke compartments in the main hospital and the Administration Building, and could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

400.8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords 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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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.

NFPA 99 Health Care Facilities 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with facility staff, from 4/22 to 4/24/13, the electrical equipment and wiring were observed.

Administration Building - 4/23/13
1. At 11:05 a.m., there was a six plug surge protector connected to another six plug surge protector in the HIM Coder Office. One surge protector was used to connect a printer to the wall outlet. The other surge protector connected computer equipment to the wall outlet.

2. At 11:09 a.m., there was a six plug surge protector connecting a refrigerator and computer equipment to the wall outlet in the HIM Manager's Office.

3. At 11:19 a.m., there was a six plug surge protector connected to a six plug UPS (Uninterrupted Power Source). The UPS was connected to a three plug adapter that was connected to the wall outlet in the Lab Manager's Office, underneath the desk. A pencil sharpener was plugged into the six plug surge protector. Computer equipment was plugged into the UPS.

4. At 11:24 a.m., there was a six plug surge protector connecting a microwave to the wall outlet in the Lab.

Main Hospital
5. At 2:17 p.m., there was a large refrigerator plugged into a six plug surge protector in the Emergency Department Break Room.

6. At 3:22 p.m., there was a green, heavy duty extension cord connecting a water cooler to the wall outlet in the OB Nurses' Station.

7. At 3:25 p.m., there was a white six plug surge protector connected to a black six plug surge protector, in the OB Nurses' Station, underneath the desk. The surge protectors were connecting computer equipment to the wall outlet.

8. At 4 p.m., there was a six plug surge protector connected to another six plug surge protector in the OB Education Office. The surge protectors were connecting computer equipment to the wall outlet.

9. At 4:05 p.m., there was a six plug surge protector connecting a battery charger and a mid size refrigerator to the wall outlet in the Soiled Utility Room.

10. At 4:15 p.m., there was a six plug surge protector connected to another six plug surge protector that was connected to the wall outlet in the ICU Nursing Station. A telephone and a printer were connected to one surge protector. The other was connecting computer equipment to the wall outlet.

11. At 4:27 p.m., there was a microwave and a mid size refrigerator connected to a UPS that was connected to a six plug surge protector. The surge protector was connected to the wall outlet in the Respirator Therapy Room. The surge protector was used to connect computer equipment to the wall outlet.

12. At 4:27 p.m., there was a six plug surge protector connected to another six plug surge protector, connected to the wall outlet in the Respiratory Therapy Office. Computer equipment was connected to one surge protector and the other was connecting a paper shredder and a printer to the wall outlet.

13. At 4:40 p.m., there was a microwave connected to a six plug surge protector in the Nurses' Lounge. Computer equipment was plugged into the surge protector.

14. At 4:47 p.m., there was a trash cart directly in front of the electrical panel B1A in the Biohazard Room.

15. At 4:52 p.m., there was a broken ground port on the electrical wall outlet in the mechanical room HP 20, across from Room 107.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."

Based on observation, the facility failed to comply with the installation requirements for Alcohol Based Hand Rub (ABHR) dispensers, as evidenced by mounting two ABHR dispensers above and adjacent to an ignition source. Staff could potentially be harmed from a static discharge and a fire. This affected one of three smoke compartments in the main hospital.

Findings:

During the facility tour with facility staff from 4/22 to 4/24/13, the ABHR dispensers were observed.

At 5:07 p.m., on 4/23/13, the Lab Stat Room had an ABHR dispenser mounted four inches adjacent to and above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

Based on observation and interview, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke from one area to another, in the event of a fire. This affected one of three smoke compartments in the main hospital, the administration building, and the plant operations building.

Findings:

During the facility tour with facility staff on 4/23 and 4/24/13, the ceilings and walls were observed.

Administration Building - 4/23/13
1. At 11:20 a.m., there was a two inch unsealed pipe sleeve in the fire alarm panel room ceiling. There was a penetration around a bundle of wires, inside the pipe sleeve.

Main Hospital
2. At 1:50 p.m., there was an approximately one by four inch penetration in the Triage Room. The penetration was on the left wall, behind the open door.
At 1:51 p.m., during an interview, Staff 2 stated that the door knob caused the penetration when the door opened and hit the wall.

3. At 2:28 p.m., there was an approximately 2 by 13 inch penetration in the janitor's closet, across the hall from Radiology, next to the reading room. The penetration was on the left side of the wall.

4. At 3 p.m., there was an approximately 1 by 26 inch penetration in the sterilizer room. The penetration was above the sterilizer machine.

5. At 3:55 p.m., there was an approximately one inch round penetration in the Surgery Med Room. The penetration was on the left wall, around a drain pipe.

Plant Operations - 4/24/13
6. At 7:50 a.m., there were two approximately two inch unsealed conduits, around black cables, in the phone room. The conduits were in the left side of the room penetrating the ceiling.

7. At 7:52 a.m., there was a two inch unsealed conduit around a bundle of cables in the phone room. The conduit was on the right side of the room, in the upper corner, penetrating the wall.

8. At 7:55 a.m., there were two approximately 1 1/2 inch cut out penetrations in the engineering shop. The penetrations were on the wall adjacent to the phone room.

Based on observation, the facility failed to ensure corridor walls were constructed to resist the passage of smoke. This was evidenced by a penetration in one corridor wall. The penetration could allow the spread of smoke or fire in the event of a fire, and affected one of three smoke compartments in the hospital.

Findings:

During the facility tour with facility staff on 4/23 and 4/24/13, the corridor walls and ceilings were observed.

At 8:47 a.m., there was an approximately 1/2 inch penetration around two wires, inside a 1/2 inch pipe sleeve, in the corridor wall above the drop ceiling. The penetration was above the ENDO Room.

Based on observation and interview, the facility failed to ensure that corridor doors were free from obstructions, and that doors close and latch. This was evidenced by seven doors that failed to close and latch, by seven doors that were impeded from closing, and by a self closing door that was disabled. This failure could result in the spread of smoke or fire, in the event of a fire, and affected two of three smoke compartments in the main hospital and the Administration Building.

Findings:

During the facility tour with facility staff from 4/22 to 4/24/13, the corridor doors were observed.

Main Hospital - 4/23/13
1. At 9:54 a.m., the self closing corridor door to X-Ray Room 2 failed to fully close and latch after activation of the fire alarm system.

Administration Building
2. At 11:10 a.m., there was a brown, rubber door wedge holding the corridor door open in the HIM (Health Information Management) Room.

3. At 11:12 a.m., there was a brown, rubber door wedge holding the corridor door open in the Quality Management Department Room.

4. At 11:22 a.m., the self closing corridor door to the waiting room area failed to fully close and latch. The door was tested three times.

5. At 1:28 p.m., there was a brown, rubber door wedge holding the corridor door open in the Administration Conference Room.

Main Hospital
6. At 1:59 p.m., there was a soiled linen container obstructing the self closing corridor door in Exam Room 5. The door was tested after removing the obstruction. The door failed to fully close and latch. The door rubbed on the door frame and was obstructed from closing.

At 2 p.m., during an interview, Staff 1 reported that the door was split on the bottom lower right hand side.

7. At 2:21 p.m., the self closing corridor door to the Handicap Restroom, in the Emergency Department (ED), failed to close and latch. The door was tested three times.

8. At 2:41 p.m., the self closing corridor door to the Quiet Room, across from the ED, closed but failed to latch.

9. At 2:59 p.m., the self closing corridor door to the Medical Supply Room, near the OR, failed to fully close and latch. The door was tested three times.

10. At 3:13 p.m., the self closing corridor door to the OB Doctor's Lounge failed to fully close and latch. The door was tested three times.

11. At 3:20 p.m., the self closing corridor door was impeded from closing by a sofa, in the OB and Same Day Surgery Family Waiting Room.

12. At 4:01 p.m., the self closing corridor door to the Steam Room, next to LDRP 2, failed to fully close and latch.
At 4:02 p.m., during an interview, Staff 1 stated that it appeared that the door had swelled up.

13. At 4:10 p.m., the self closing corridor door to the Hospitalist Office was missing the arms that closed the door.
At 4:11 p.m., during an interview, health staff reported that the self closer had not been working since July of last year.

14. At 4:36 p.m., the corridor door to Room 104 was obstructed from closing by an isolation station that was hanging over the door.

Based on observation, the facility failed to ensure that the smoke barrier doors were capable of resisting the passage of smoke, and that the doors were self-closing. This was evidenced by one of three smoke barrier doors that failed to fully close and latch during fire alarm system testing. This affected two of three smoke compartments and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire in the main hospital.

Findings:

During alarm testing with facility staff, on 4/23/13, the smoke barrier doors were observed and tested.

At 9:03 a.m., the right side smoke barrier door by Room 118 closed after activation of the fire alarm system. The door did not fully close and latch.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resistant partitions and self closing doors. This was evidenced by hazardous storage areas without self closing doors. This could result in the spread of smoke or fire affecting one of three smoke compartments in the main hospital and the Administration Building, in the event of a fire.

Findings:

During a tour of the facility with facility staff from 4/22 to 4/24/13, the walls and doors to hazardous areas were observed. Combustible storage areas, soiled linen and trash rooms, laboratories, and fuel fire heater rooms are considered hazardous areas. The doors are required to self close and latch.

Administration Building -
1. At 11:30 a.m., on 4/23/13, there was no self closer on the corridor door to the Laboratory. The room was greater than 50 square feet in size.

Main Hospital -
2. At 4:31 p.m., there was no self closer on the door to Room 109. The room is greater than 50 square feet in size and was used as a storage room. The room contained a crib with a mattress, two sofas, one bed, a baby warmer, three wheelchairs, one e-size oxygen tank, a bassinet, a scale, three bed side commodes, lifts, three vital sign machine and other miscellaneous medical supplies.

Based on observation, the facility failed to maintain the battery operated emergency lighting within the emergency power generator area. This could result in a potential delay in repairing the emergency power generator if it had failed to operate as required during a public utility outage.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
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.

Finding:

During the facility tour with facility staff on 4/24/13, the facility emergency lighting and generator were observed.

At 8:07 a.m., on 4/24/13, the battery operated emergency lights in the emergency generator area failed to illuminate when tested.

Based on observation, the facility failed to maintain the emergency exit sign back up batteries. This was evidenced by exit signs that failed to illuminate when tested. This affected two of three smoke compartments in the Main Hospital and the Administration Building. This could result in delayed egress from the building and potential harm to the patients and staff.

NFPA 101 Life Safety Code (2000 Edition)
Maintaining Existing Equipment
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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 1/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour with facility staff, from 4/22 to 4/24/13, the facility exit signs were tested and observed.

Administration Building - 4/23/13
1. At 1:30 p.m., the exit sign, posted above the Administrator's Office hallway exit door, did not work. When the test button was activated the exit light did not illuminate.

Main Building - 4/23/13
2. At 9:31 a.m., the exit sign failed to illuminate when the test button was activated, on the sign above the hallway exit door by LDRP 2.

3. At 9:34 a.m., the exit sign above the hallway exit door by Room 120 was not working. When the test button was activated, the exit light did not illuminate.

4. At 9:52 a.m., the exit sign at the exit door by Mammography failed to illuminate when the test button was activated.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 13 and NFPA 25. This was evidenced by and escutcheon ring that was not flush with the ceiling, and by storage within 18 inches of a sprinkler deflector. Escutcheon rings are used to cover the penetrations around sprinkler pipes. A sprinkler deflector is used to divert the water to create the spray pattern when a sprinkler is activated. This affected two of three smoke compartments in the main hospital and could result in the spread of smoke or fire, or a delay in extinguishing a fire.

NFPA 13 Installation of Sprinkler Systems 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1999 Edition
2-2 Inspection.
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 the facility tour with facility staff, from 4/22 to 4/23/13, the complete sprinkler system was observed.

Main Hospital - 4/23/13
1. At 2:20 p.m., there was an approximately 3/4 inch gap between the escutcheon ring and the ceiling in the handicap restroom of the Emergency Department. This exposed an approximately 3/4 inch penetration around the sprinkler pipe.

2. At 4:58 p.m., there was a cardboard box stored within approximately 16 inches of the sprinkler deflector, in the office supply storage closet across from Room 114.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles is not exceeded within any 64 square foot area. This was evidenced by multiple 32 gallon receptacles placed in three areas in the facility. The facility also failed to ensure that these receptacles when not attended are located in a room protected as a hazardous area. This failure could result in fire in an unprotected area, and affected two of three smoke compartments of the main hospital.

Findings:

During the facility tour with facility staff, on 4/22 and 4/23/13, soiled linen and trash receptacles (carts) were observed in the facility.

Main Hospital - 4/23/13
1. At 2:05 p.m., there was a soiled linen cart and a trash cart lined up, side by side, in Exam Room 4. The soiled linen cart was approximately 23 gallons and the trash cart was approximately 32 gallons in size.

2. At 2:07 p.m., there was a soiled linen cart and a trash container lined up, side by side, in Exam Room 3. The soiled linen cart was approximately 23 gallons and the trash cart was approximately 32 gallons in size. There was a red biohazard container within the 64 square foot area. The biohazard container was approximately eight gallons in size.

3. At 3:15 p.m., there was a trash container and a red biohazard container, side by side in the LDR1. The containers were both approximately 23 gallons in size.

4. At 3:24 p.m., there was a soiled linen cart and a trash cart lined up, side by side in the Nursery. The containers were approximately 23 gallons in size.

5. At 4:02 p.m., there was a soiled linen cart and a trash container, side by side, in LDR2. The containers were approximately 23 gallons in size.

Based on record review and interview, the facility failed to maintain and test the generator in accordance with NFPA 99 and NFPA 110. This was evidenced by incomplete records for weekly visual inspections for 23 of 52 weeks. This could result in the failure of the emergency generator in the event of a power outage affecting the entire facility.

Findings:

During record review with facility staff, on 4/24/13, the generator weekly inspection records were requested and reviewed.

At 9:08 a.m., the facility provided 29 of 52 weekly inspection records titled, "Engineering Dept. Emergency Generator." There were 23 weekly inspections records missing.

During an interview, Staff 1 stated he was testing the generator under load every other week and he began the weekly inspections a few months ago. He reported that he did not conduct the weekly visual inspections during 2012.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by an electrical panel that was not maintained with 36 inch clearance, by the use of extension cords and surge protectors instead of permanent wiring, and by surge protectors connected to other surge protectors. This affected two of three smoke compartments in the main hospital and the Administration Building, and could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

400.8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords 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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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.

NFPA 99 Health Care Facilities 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with facility staff, from 4/22 to 4/24/13, the electrical equipment and wiring were observed.

Administration Building - 4/23/13
1. At 11:05 a.m., there was a six plug surge protector connected to another six plug surge protector in the HIM Coder Office. One surge protector was used to connect a printer to the wall outlet. The other surge protector connected computer equipment to the wall outlet.

2. At 11:09 a.m., there was a six plug surge protector connecting a refrigerator and computer equipment to the wall outlet in the HIM Manager's Office.

3. At 11:19 a.m., there was a six plug surge protector connected to a six plug UPS (Uninterrupted Power Source). The UPS was connected to a three plug adapter that was connected to the wall outlet in the Lab Manager's Office, underneath the desk. A pencil sharpener was plugged into the six plug surge protector. Computer equipment was plugged into the UPS.

4. At 11:24 a.m., there was a six plug surge protector connecting a microwave to the wall outlet in the Lab.

Main Hospital
5. At 2:17 p.m., there was a large refrigerator plugged into a six plug surge protector in the Emergency Department Break Room.

6. At 3:22 p.m., there was a green, heavy duty extension cord connecting a water cooler to the wall outlet in the OB Nurses' Station.

7. At 3:25 p.m., there was a white six plug surge protector connected to a black six plug surge protector, in the OB Nurses' Station, underneath the desk. The surge protectors were connecting computer equipment to the wall outlet.

8. At 4 p.m., there was a six plug surge protector connected to another six plug surge protector in the OB Education Office. The surge protectors were connecting computer equipment to the wall outlet.

9. At 4:05 p.m., there was a six plug surge protector connecting a battery charger and a mid size refrigerator to the wall outlet in the Soiled Utility Room.

10. At 4:15 p.m., there was a six plug surge protector connected to another six plug surge protector that was connected to the wall outlet in the ICU Nursing Station. A telephone and a printer were connected to one surge protector. The other was connecting computer equipment to the wall outlet.

11. At 4:27 p.m., there was a microwave and a mid size refrigerator connected to a UPS that was connected to a six plug surge protector. The surge protector was connected to the wall outlet in the Respirator Therapy Room. The surge protector was used to connect computer equipment to the wall outlet.

12. At 4:27 p.m., there was a six plug surge protector connected to another six plug surge protector, connected to the wall outlet in the Respiratory Therapy Office. Computer equipment was connected to one surge protector and the other was connecting a paper shredder and a printer to the wall outlet.

13. At 4:40 p.m., there was a microwave connected to a six plug surge protector in the Nurses' Lounge. Computer equipment was plugged into the surge protector.

14. At 4:47 p.m., there was a trash cart directly in front of the electrical panel B1A in the Biohazard Room.

15. At 4:52 p.m., there was a broken ground port on the electrical wall outlet in the mechanical room HP 20, across from Room 107.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."