HospitalInspections.org

Based on observation the facility failed to maintain the building construction, as evidenced by failure to seal penetrations through out the facility, which may result in the passage of smoke and flames in the event of a fire. This affected 4 of 6 smoke compartments.

Findings:
On April 26, 2010 through April 28, 2010, on a tour of the facility from 8:30 a.m. to 4:00 p.m., with staff 4 the walls were observed.
April 27, 2010
1. At 10:23 a.m. in the emergency waiting room on the east wall there was an unsealed penetration approximately 2 inches with cable wire running through it.
2. At 10:30 a.m. in the emergency waiting room on the north wall near registration the cover plate to the reset for the roll up door was missing, leaving an unsealed penetration approximately 14 inches in diameter.
3. At 10:54 a.m., in the Electrical Room outside the emergency room there were 2 unsealed penetrations on the back wall approximately 2 inches each and near the ceiling and on the back wall an approximately 14 inch unsealed pipe.
4. At 11:15 a.m., in the housekeeping room by room 309, there were 6 unsealed penetrations on the back wall approximately 1/4 inch to 1/2 inch each.
5. At 1:55 p.m. in the report room of the nurse station 100 wing there were 3 unsealed penetrations on the west wall 1/2 inch to 1 inch each.
6. At 2:00 p.m. in the Pharmacy Office north wall there were 5 unsealed penetrations approximately 1/2 inch each.

Based on observation the facility failed to maintain the doors to shut and latch upon closure and to maintain the doors to prevent the passage of smoke. This was evidenced by doors that failed to shut completely or latch upon closure and doors with holes in the doors. This may result in the passage of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments.

Findings:
On a tour of the facility on April 26, 2010 through April 28, 2010 with staff 4, the doors were observed.
April 27, 2010;
1. At 11:20 a.m. room 307 the door failed to shut and latch. There was a loose door hinge that prevented the door from closing.
2. At 11:25 a.m. in the obstetrics department (300 wing), the convenience doors leading into the wing, the left leaf failed to latch upon closure.
3. At 11:30 a.m., labor room 2 door had 4 unsealed penetrations in the door approximately 1/8 inch to 1/4 inch.
4. At 1:57 p.m., room 205 had 3 unsealed penetrations in the door, approximately 1/2 inch each.
5. At 1:58 p.m., room 207 had 4 unsealed penetrations in the door approximately 1/2 inch each.

Based on observation the facility failed to maintain the exit and directional signs in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code. This was evidenced by exit signs that have expired expiration dates. This may result in confusion and delayed egress in the event of fire or other emergency. This affected 2 of 6 smoke compartments.

Findings:
On a tour of the facility from April 26, 2010 through April 28, 2010, with staff 4 the exit signs were observed.
April 27, 2010;
1. At 11:23 a.m. the exit sign at the doors entering the obstetrics wing was to be replaced by January 2009
2. At 11:24 a.m. the exit sign by the nurses station in obstetrics wing was to be replaced by January 2009.

Based on document review and interview the facility failed to conduct fire drills one per shift per quarter for all staff. This is evidenced by not all staff being trained quarterly during fire drills. This may result in staff being confused about duties and assignments in the event of a fire. This affects 6 of 6 smoke compartments.

19.7.1.2* Fire Drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:
On April 26, 2010 through April 28, 2010, the fire drill records were reviewed from 8:30 a.m. to 4:00 p.m.
1. No documentation was provided for fire drills being conducted for the night shift staff (7:00 p.m. to 7:00 a.m. and 11:00 p.m. to 7:00 a.m.) from April 2009 through March 2010.
2. No fire drills were conducted after 4:00 p.m. from April 2009 through March 2010.
3. No fire drills were conducted prior to 7:15 a.m. from April 2009 through March 2010.
On April 27, 2010 at 3:30 p.m. when asked staff 4 stated that nursing staff work 12 hour shifts from
7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m.. When asked if there were other employees that worked different hours staff 4 stated yes. Records for those departments were requested.
On April 28, 2010, at 1:30 p.m. during an interview with staff 4 the following departments and shifts were provided.
1. Housekeeping
11:00 p.m. to 7:30 a.m.
7:00 a.m. to 3:30 p.m.
3:00 p.m. to 11:00 p.m.
2. Security
Monday through Friday
11:00 p.m. to 7:30 a.m.
3:00 p.m. to 11:00 p.m.
Saturday and Sunday
7:00 a.m. to 3:30 p.m. .
3:00 p.m. to 11 p.m.
11:00 p.m. to 7:30 a.m.
3. Laboratory
7:00 a.m. to 5:30 p.m.
10:00 a.m. to 7:00 p.m.
7:00 p.m. to 6:30 a.m.
Saturday and Sunday
7:00 p.m. to 7:00 a.m.
7:00 a.m. to 7:00 p.m.
4. Certified Nursing Assistants (CNA'S)
6:00 a.m. to 2:00 p.m.
2:00 p.m. to 10: 00 p.m.
5. Dietary Staff
Saturday and Sunday
6:00 a.m. to 5:00 p.m.
2:30 p.m. to 6:30 p.m.
Monday through Friday
6:00 a.m. to 5:00 p.m.
6:30 a.m. to 1:00 p.m.
10:30 a.m. to 12:30 p.m. then 3:30 p.m. to 6:30 p.m.
Staff 4 confirmed that fire drills were not conducted as required to provide training to all staff on all shifts.

Based on document review, interview and observation the facility failed to maintain the fire alarm system as evidenced by, failure to provide a complete list of all components such as smoke detectors, pull stations, chimes, bells and audio visual devices, failure of devices during testing and an annual certification of the fire alarm system. This could result in the fire alarm system not functioning properly in the event of a fire. This affects 6 of 6 smoke compartments.


NFPA 72
7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
#15 f, Fire Alarm Boxes (pull stations) tested annually
# 15 h, All Smoke Detectors - Functional tested annually
#19 a, Audible Devices, tested annually
# 19 c. Visible Devices , tested annually

In accordance with NFPA 72, National Fire Alarm Code, Table 7-3.2 # 23 supervising station fire alarm systems - receivers shall be tested monthly.
NFPA 72
7-5.2.2
A permanent record of all inspections, testing and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
1. Date
2. Test frequency
3. Name of property
4. Address
5. Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
6. Name, address and representative of approving agency (ies)
7. Designation of the detector (s) tested, for example, "Tests performed in accordance with Section _____".
8. Functional test of detectors
9. *Functional test of required sequence of operations
10. Check of all smoke detectors
11. Loop resistance of all fixed-temperature, line-type heat detectors
12. Other tests required by equipment manufactures
13. Other tests as required by the authority having jurisdiction
14. Signatures of tester and approved authority representative
15. Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place.

Findings:
On April 26, 2010 through April 28, 2010 the Fire Alarm Inspection Reports were reviewed.
April 26, 2010;
1. At 11:21 a.m. the Fire Alarm Inspection Report dated March 29, 2010 was reviewed. The report indicated 2 of 32 smoke detectors were not tested, 3 of 15 pull stations were not tested.
2. At 12:25 p.m. the Fire Alarm Inspection Report dated November 5, 2009 was reviewed. indicated 1 bell, 1 chime, 1 visual signal only, Smoke Detectors 79, 11 Pull Stations, 1 Waterflow.
3. At 1:00 p.m. the Fire Alarm Inspection Report dated June 1, 2009 was reviewed. The report indicated 32 Smoke Detectors, 14 Pull Stations, no audio visual devices listed, chimes, or bells. There was no signature of the tester on the report. During an interview at this time with staff 4 a list of the number of all devices was requested. Staff 4 stated that he is in the process of compiling a list of all devices.
April 28, 2010:
1. At 9:25 a.m. the facility did not provide a complete list of all devices such as Smoke Detectors, Pull Stations, and Audio/Visual devices, Bells, Chimes.
2. At 9:35 a.m. a review of the Fire Alarm Inspection Report dated April 2, 2010 indicated 8 of 97 smoke detectors were not tested the report did not indicate any Pull Stations, Bells, Chimes, Strobes or Audio/Visual Devices. There was no signature of the tester on the report.
3. At 9:50 a.m. during an interview with staff 4 and staff 6 it was confirmed that the Fire Alarm System Reports did not give an accurate account of the fire alarm devices in the facility. Staff 4 stated that he was in the process of compiling a report with a list of all devices.
4. At 11:28 a.m. during testing of the fire alarm system the Audio Visual device located by room 303 failed to emit an audible alarm on activation of the fire alarm system.
5. At 11:33 a.m. the Audio/Visual Device located in the Intensive Care Unit hallway failed to emit an audible alarm or strobe upon activation of the fire alarm system.
6. After review of the Fire Alarm Inspection Reports dated April 2, 2010, March 29, 2010, November 5, 2009 and June 1, 2009, and interviews with staff 4 and staff 6 the surveyor was unable to confirm that all devices have been tested during the past year and there is no annual certification of the fire alarm system.

Based on document review and interview the facility failed to maintain the smoke detectors as evidenced by failure to provide evidence that smoke detectors that failed smoke detector sensitivity testing had been repaired or replaced. This affected 6 of 6 smoke compartments and may result in the smoke detectors not functioning properly in the event of a fire.

NFPA 72
7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In the zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or aerosol into the detector.

Findings:
On April 26, 2010 through April 28, 2010 the Fire Alarm Inspection Report dated April 2, 2010 was reviewed.
April 28, 2010
1. At 9:35 a.m. the Fire Alarm Inspection Report dated April 2, 2010 was reviewed for sensitivity testing.
The report indicated a total of 97 smoke detectors and 89smoke detectors were tested. and 16 devices failed.
During review of the report, 8 of the 97 smoke detectors could not be tested due to their age, and 16 of 89 smoke detectors tested failed sensitivity testing. The following smoke detectors failed sensitivity testing:
a. The smoke detector in the Emergency Room (ER) corridor by ER 1.
b. The smoke detector in the Emergency Room corridor by the restroom.
c. The smoke detector in the Emergency Room corridor by treatment room 1.
d. The smoke detector in the Emergency Room corridor by the Private Office.
e. The smoke detector in the Emergency Room lobby by the men' s restroom.
f. The smoke detector by the Emergency Room Nurse Station Window.
g. The smoke detector in the Elevator Lobby (1st floor).
h. The smoke detector in the Elevator Rear.
i. The smoke detector in the Gift Shop.
j. The smoke detector in the Main Lobby.
k. The smoke detector outside the gift shop.
l. The smoke detector by the Radiology Double Door.
m. The smoke detector by the Radiology Double Door.
n. The smoke detector in the Radiology Reception Corridor.
o. The smoke detector in the Radiology Reception Outside Window.
p. The smoke detector in X ray Room 2.

Based on observation the facility failed to maintain the automatic sprinkler system in accordance with National Fire Alarm Code (NFPA) 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 edition. This was evidenced by sprinkler contaminated with dust and lint, missing escutcheon ring and failure of one of two inspectors test valves to activate the fire alarm system. This affects 6 of 6 smoke compartments, and may result in the delayed activation of the automatic sprinkler system.

NFPA 72
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.
NFPA 25
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, corroded, damaged, or loaded; or in the improper orientation.


Findings:
On April 26, 2010 through April 28, 2010, during a tour of the facility from 8:30 a.m. to 4:00 p.m. with staff 4 the automatic sprinkler system was observed.
April 27, 2010
a. At 10:41 a.m. in the restroom by the ambulance entrance in the emergency room the sprinkler was contaminated with dust/lint.
April 28, 2010
a. At 10:56 a.m. the sprinkler in the 100 hall by the nurse's station was missing the escutcheon ring.
b. At 2:13 p.m. the Inspectors Test Valve #1 located in the 200 hall, failed to activate an alarm at 90 seconds and at 2 minutes.

Based on observation the facility failed to prevent the use of portable space heating devices in patient care areas. This may cause a fire or injury to patients or staff. This affects 1 of 6 smoke compartments.

Findings:
On April 27, 2010 during a tour of the facility with staff 4 at 10:39 a.m., in the emergency room a portable space heater was observed in the emergency room nurse reporting station.

Based on observation the facility failed to maintain the oxygen storage areas, as evidenced by empty and full cylinders being stored together in the same racks. This may cause confusion when oxygen tanks are needed and staff pick an empty tank in a emergency as opposed to a full tank. This could delay care or treatment to patients in the event of an emergency due to staff taking a empty cylinder hurriedly. This has the potential to affect 6 of 6 smoke compartments.

NFPA 99 4-3.5.2.2
(b) Nonflammable Gases
#2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:
On April 27, 2010 during a tour of the facility with staff 4 from 8:30 a.m. to 4:00 p.m. the oxygen storage was observed.
At 10:48 a.m. the oxygen storage outside the emergency room at the ambulance entrance was observed. In the room labeled as empty 9 of 52 E size cylinders stored in this room were empty. The cylinders contained different types of air, such as compressed air, lung diffusion mixture, carbon dioxide, and oxygen, and the empty were stored in the same racks as the full tanks.

Based on document review and interview the facility failed to maintain the operating rooms (OR)and the endoscopy procedure room, humidity levels at 35% or greater in accordance with National Fire Protection Association 99 (NFPA),1998 edition, Health Care Facilities, and to follow the written policy and procedure when humidity levels were outside the permissible range. This may cause an increased risk of fire and injury to patients. This affected 2 of operating rooms, the endoscopy procedure room in 1 of 6 smoke compartments.

5-4.1.1*The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:
On April 26, 2010 through April 28, 2010 from 8:30 a.m. to 4:00 p.m., during document review the Policy and Procedure for Maintaining a Safe, Functional Environment # EC.02.06.01 dated January 2, 2010 was reviewed. The policy states in Table 1.1 the Relative Humidity Levels for the Operating/Surgical, Recovery Rooms, Endoscopy Procedure Rooms, will be at 30% to 60%.
At 12:09 p.m., humidity logs dated June 2009 through April 2010 were provided. During an interview with staff 4 at this time it was stated that prior to June 2009 no humidity logs were kept for the operating rooms. During an interview with staff 2 and staff 4 at this time staff 2 stated that once the problem with humidity was identified that they brought in portable humidifiers. These humidifiers are turned on at the end of the day and run during the night and turned off in the morning at approximately 5:00 a.m. The facility began using the portable space heating devices on April 16, 2010.
At 2:07 p.m. during an interview with staff 2 and staff 4 regarding the humidity levels, staff 2 stated that new gauges were ordered for each OR and the Endoscopy Procedure Room on April 21, 2010, with a projected date of arrival of April 30, 2010. During an interview with staff 2 at this time when the humidity logs for the Endoscopy Procedure Room were requested staff 2 stated that there were no logs and that there was not even a gauge in the room. During an interview with staff 2 regarding the documentation of the humidity levels staff 2 stated that the facility is in the process of updating the policy and procedure manual. The old policy states that on weekends and holidays the humidity levels will be recorded prior to the start of procedures, per staff 2 the new policy will be humidity levels will be monitored daily. When staff 2 was asked if the hospital continues with surgeries with humidity levels below the permissible range, staff 2 stated yes.
At 2:15 p.m. documentation of facilities findings and verification that the humidity levels were adjusted in range when reported was requested from staff 4. Staff 4 stated that he did not have any work orders or records. Staff 4 stated that the facility is in the process of replacing the HVAC (Heating, Ventilating and Air Conditioning) system above to operating rooms to help control the humidity levels.
1. Humidity Levels:
June 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd - humidity level 22%
d. 9th - humidity level 33%
e. 11th - no humidity level recorded
f. 15th - humidity level 29%
g. 16th - humidity level 31%
h. 17th - humidity level 33%
i. 18th - humidity level 32%
j. 19th - no humidity level recorded
k. 22nd - humidity level 33%
m. 24th - humidity level 29%
n. 25th - humidity level 27%
o. 26th - humidity level 21%
p. 29th - humidity level 24%
q. 30th - humidity level 21%

July 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - no humidity level recorded
c. 6th - humidity level 28%
d. 7th - humidity level 28 %
e. 8th - humidity level 21%
f. 9th - humidity level 26 %
g. 10th - humidity level 21%
h. 16th - humidity level 31%
i. 17th - humidity level 30%
j. 23rd - no humidity level recorded
k. 24th - humidity level 21%
l. 31st - no humidity level recorded

August 2009: Operating Room 1
a. 3rd - humidity level 32%
b. 4th - humidity level 21%
c. 5th - humidity level 33%
d. 6th - humidity level 26%
e. 7th - humidity level 29%
f. 10th - humidity level 26%
g. 11th - humidity level 28%
h. 13th - humidity level 21%
j. 18th - humidity level 24%
k. 19th - humidity level 34%
l. 20th - humidity level 26%
m. 21st - humidity level 28%
n. 26th - humidity level 28%
o. 27th - humidity level 21%
p. 28th - humidity level 24%
q. 31st - humidity level 33%

September 2009: Operating Room 1
a.1st - no humidity level recorded
b. 2nd - humidity level 29%
c. 3rd - humidity level 31%
d. 8th - humidity level 26%
e. 9th - humidity level 26%
f. 21st - no humidity level recorded
g. 22nd - humidity level 21%
h. 23rd - humidity level 21%
i. 24th - humidity level 21%
j. 25th - no humidity level recorded'
k. 28th - humidity level 29%
l. 29th - humidity level 21%
m. 30th humidity level 21%

October 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 5th - humidity level 23%
d. 6th - humidity level 25%
e. 7th - humidity level 21%
f. 8th - humidity level 24 %
g. 9th - humidity level 24 %
h. 20th - humidity level 31%
i. 21st - humidity level 24%
j. 22nd - humidity level 24%
k. 23rd - humidity level 21%
l. 26th - humidity level 21%
m. 28th - humidity level 21%
n. 29th - humidity level 21%
o. 30th - humidity level 21%

November 2009: Operating Room 1
a. 2nd - humidity level 21%
b. 3rd - humidity level 21%
c. 4th - humidity level 21%
d. 5th - humidity level 21%
e. 6th - no humidity level recorded
f. 9th - humidity level 25%
g. 10th - humidity level 21%
h. 11th - humidity level 21%
i. 12th - humidity level 21%
j. 13th - no humidity level recorded
k. 16th - humidity level 21%
l. 17th - humidity level 21%
m. 18th - humidity level 21%
n. 19th - humidity level 21%
o. 20th - humidity level 21%
p. 23rd - humidity level 21%
q. 24th - humidity level 21%
r. 25th - humidity level 21%
s. 27th - no humidity level recorded
t. 30th - humidity level 21%

December 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd - humidity level 21%
d. 4th - humidity level 21%
e. 7th - humidity level 28%
f. 8th - humidity level 21%
g. 9th - humidity level 21%
h. 10th - humidity level 21%
j. 11th - humidity level 24 %
k. 15th - humidity level 24%
l. 16th - humidity level 23%
m. 17th - humidity level 23%
n. 18th - humidity level 21%
o. 21st - humidity level 23%
p. 22nd - humidity level 21%
q. 23 rd - humidity level 21%
r. 24th - no humidity level recorded
s. 25th - no humidity level recorded
t. 28th - no humidity level recorded
u. 29th - humidity level 21%
v. 30th - humidity level 21%
w. 31st - humidity level 21%

January 2010: Operating Room 1



February 2010: Operating Room 1
a. 1st - humidity level 23%
b. 2nd - humidity level 25%
c. 3rd - humidity level 26%
d. 4th - humidity level 24%
e. 5th - humidity level 30%
f. 8th - humidity level 26%
g. 9th - humidity level 29%
h. 10th - humidity level 31%
i. 11th - humidity level 24%
j. 12th - humidity level 24%
k. 15th - humidity level 26%
l. 16th - humidity level 26%
m. 17th - humidity level 33%
n. 18th - humidity level 26%
o. 19th - humidity level 28%
p. 22nd - humidity level 29%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 31%
t. 26th - humidity level 21%

March 2010: Operating Room 1
a. 1st - humidity level 32%
b. 2nd - humidity level 27%
c. 3rd - humidity level 31%
d. 4th - humidity level 25%
e. 5th - humidity level 21%
f. 8th - humidity level 31%
g. 9th - humidity level 21%
h. 10th - no humidity levels recorded
i. 11th - humidity level 21%
j. 12th - humidity level 21%
k. 15th - humidity level 21%
l. 16th - humidity level 23%
m. 17th - humidity level 23%
n. 18th - humidity level 25%
o. 19th - humidity level 21%
p. 22nd - humidity level 25%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 31%
t. 26th - humidity level 28%
u. 29th - humidity level 21%
v. 30th - humidity level 21%
w. 31st - humidity level 31%

April 2010: Operating Room 1
a.1st - humidity level 31%
b. 2nd - humidity level 27%
c. 5th - humidity level 26%
d. 6th - humidity level 23%
e. 7th - humidity level 21%
f. 8th - humidity level 21%
g. 9th - humidity level 31%
h. 13th - humidity level 31%
i. 14th - humidity level 31%
j. 15th - humidity level 29%
k. 16th - humidity level 33%
l. 19th - no humidity level recorded
m. 20th - humidity level 32%
n. 21st - humidity level 21%
o. 22nd - humidity level 27%
p. 23rd - humidity level 30%
q. 24th - humidity level 31%


June 2009: Operating Room 2
a. 1st - humidity level 25%
b. 2nd - humidity level 23%
c. 3rd - humidity level 23%
d. 4th - humidity level 24%
e. 19th - humidity level 33%
f. 22nd - humidity level 32%
g. 24th - humidity level 26%
h. 25th - humidity level 24%
i. 26th - humidity level 22%
j. 29th - humidity level 34%
k. 30th - humidity level 29%

July 2009: Operating Room 2
a. 1st - humidity level 24%
b. 6th - humidity level 21%
c. 7th - humidity level 23%
d. 8th - humidity level 22%
e. 9th - humidity level 28%
f. 10th - humidity level 23%
g. 23rd - no humidity levels recorded
h. 24th - no humidity levels recorded

August 2009: Operating Room 2
a. 3rd - humidity level 25%
b. 4th - humidity level 27%
c. 6th - humidity level 30%
d. 10th - humidity level 29%
e. 13th - humidity level 22%
f. 18th - humidity level 33%
g. 21st - humidity level 30%
h. 24th - humidity level 27%
i. 26th - humidity level 24%
j. 27th - humidity level 24%
k. 28th - humidity level 26%

September 2009: Operating Room 2
a. 18th - humidity level 33%
b. 21st - humidity level 22%
c. 22nd - humidity level 22%
d. 23rd - humidity level 23%
e. 24th - humidity level 24%
f. 25th - humidity level 24%
g. 28th - humidity level 28%
h. 29th - humidity level 25%
i. 30th - humidity level 26%

October 2009: Operating Room 2
a. 1st - humidity level 23%
b. 2nd - humidity level 21%
c. 5th - humidity level 21%
d. 6th - humidity level 21%
e. 7th - humidity level 22%
f. 8th - humidity level 21%
g. 9th - humidity level 22%
h. 21st - humidity level 33%
i. 22nd - humidity level 26%
j. 23rd - no humidity level recorded
k. 26th - humidity level 23%
l. 27th - humidity level 28%
m. 28th - humidity level 19%
n. 29th - humidity level 21%
o. 30th - humidity level 21%


November 2009: Operating Room 2
a. 2nd - humidity level 21%
b. 3rd - humidity level 22%
c. 4th - humidity level 23%
d. 5th - humidity level 24%
e. 9th - humidity level 30%
f. 10th - humidity level 20%
g. 11th - humidity level 19%
h. 12th - humidity level 21%
i. 13th - humidity level 27%
j. 16th - humidity level 22%
k. 17th - humidity level 22%
l. 18th - humidity level 22%
m. 19th - humidity level 23%
n. 20th - humidity level 22%
o. 23rd - humidity level 21%
p. 24th - humidity level 21%
q. 25th - no humidity level recorded
r. 27th - no humidity level recorded
s. 30th - no humidity level recorded


December 2009: Operating Room 2
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd. - humidity level 21%
d. 4th - humidity level 21%
e. 7th - humidity level 25%
f. 8th - humidity level 22%
g. 9th - humidity level 21%
h. 10th - humidity level 22%
i. 11th - humidity level 22%
j. 14th - humidity level 23%
k. 15th - humidity level 22%
l. 16th - humidity level 22%
m. 17th - humidity level 22%
n. 18th - humidity level 22%
o. 21st - humidity level 22%
p. 22nd - humidity level 22%
q. 23rd - humidity level 21%
r. 24th - humidity level 20%
s. 28th - no humidity level recorded
t. 29th - humidity level 21%
u. 30th - humidity level 22%
v. 31st - humidity level 22%

January 2010: Operating Room 2
a. 4th - humidity level 21%
b. 5th - humidity level 20%
c. 6th - humidity level 21%
d. 7th - humidity level 20%
e. 8th - humidity level 21%
f. 11th - humidity level 20%
g. 12th - humidity level 21%
h. 13th - humidity level 24%
i. 14th - humidity level 21%
j. 15th - no humidity level recorded
k. 19th - humidity level 25%
l. 20th - humidity level 25 %
m. 21st - humidity level 30%
n. 22nd - humidity level 26%
o. 25th - humidity level 23%
p. 26th - humidity level 23%
q. 27th - humidity level 32%
r. 28th - no humidity level recorded
s. 29th - humidity level 23%

February 2010: Operating Room 2
a. 1st - humidity level 23%
b. 2nd - humidity level 23%
c. 3rd - humidity level 23%
d. 4th - humidity level 22%
e. 5th - humidity level 25%
f. 8th - humidity level 24 %
g. 9th - humidity level 23%
h. 10th - humidity level 21%
i. 11th - no humidity levels recorded
j.12th - humidity level 23%
k. 15th - humidity level 22%
l. 16th - humidity level 23%
m. 17th - humidity level 30%
n. 18th - humidity level 24%
o. 19th - humidity level 23%
p. 22nd - humidity level 23%
q. 23rd - humidity level 22%
r. 24th - humidity level 20%
s. 25th - humidity level 27%
t. 26th - humidity leve 22%


March 2010: Operating Room 2
a. 1st - humidity level 25%
b. 2nd - humidity level 23%
c. 3rd - humidity level 21%
d. 4th - humidity level 23%
e. 5th - humidity level 22%
f. 8th - no humidity level recorded
g. 9th - humidity level 22%
h. 10th - no humidity level recorded
i. 11th - humidity level 21%
j. 12th - humidity level 21%
k. 15th - humidity level 21%
l. 16th - humidity level 22 %
m. 17th - humidity level 22%
n. 18th - humidity level 22%
o. 19th - humidity level 21%
p. 22nd - humidity level 21%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 30%
t. 26th - humidity level 29%
u. 29th - humidity level 23%
v. 30th - humidity level 23%
w. 31st - humidity level 23%


April 2010: Operating Room 2
a. 1st - humidity level 31%
b. 2nd - humidity level 21%
c. 5th - humidity level 24%
d. 6th - humidity level 23%
e. 7th - humidity level 22%
f. 8th - humidity level 30%
g. 9th - humidity level 22%
h. 12th - humidity level 30%
i. 13th - humidity level 30%
j. 14th - humidity level 22%
k. 15th - humidity level 26%
l. 16th - humidity level 31%
m. 19th - humidity level 22%
n. 20th - humidity level 30%
o. 21st - humidity level 34%
p. 22nd - humidity level 27%
q. 23rd - no humidity level recorded
r. 24th - humidity level 31%

2. The humidity logs for 2 of 2 operating rooms were reviewed from June, 2009 through April 26, 2010. The humidity level for Operating Room 1 was below 35% on 175 days out of 299 days, and for Operating Room 2 175 days out of 299 days.
June 2009: Operating Room 1
a. 16 of 30 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action being taken.

July 2009: Operating Room 1
a. 14 of 31 days the humidity level was below 35%, with engineering being notified 2 of 14 days, but no notation of what corrective action was taken.

August 2009: Operating Room 1
a. 16 of 31 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action being taken.

September 2009: Operating Room 1
a. 13 of 30 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action taken.

October 2009: Operating Room 1
a. 15 of 31 days the humidity level was below 35%, with indication of the engineering department being notified 8 time but not notation of what corrective action was taken.

November 2009: Operating Room 1
a. 19 of 30 days the humidity level was below 35%, with indicationof engineering department being notified 8 times but no notation of what corrective action was taken.

December 2009: Operating Room 1
a. 22 of 31 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of correction action taken.

January 2010: Operating Room 1
a. 31 of 31 days no humidity levels documented.

February 2010: Operating Room 1
a. 20 of 28 days the humidity level was below 35%, with 6 days the engineering department was notified but no notation of correction action taken.

March 2010: Operating Room 1
a. 23 of 31 days the humidity level was below 35%, with 18 days the engineering department was notified but no notation of correction action taken.

April 2010: Operating Room 1
a. 17 of 26 days the humidity level was below 35%, with 9 days the engineering department was notified but no notation of correction action taken.


June 2009: Operating Room 2
a. 12 of 30 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

July 2009: Operating Room 2
a. 8 of 31 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

August 2009: Operating Room 2
a. 11 of 31 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

September 2009: Operating Room 2
a. 8 of 30 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

October 2009: Operating Room 2
a. 15 of 30 days the humidity level was below 35%, with notation of engineering department being notified, but no notation of corrective action taken.

November 2009: Operating Room 2
a. 19 of 30 days the humidity level was below 35%, with 11 days the engineering department was notified but no notation of corrective action taken.

December 2009: Operating Room 2
a. 22 of 31 days the humidity level was below 35%, with 17 days the engineering department was notified but no notation of corrective action taken.

January 2010: Operating Room 2
a. 19 of 31 days the humidity level was below 35%, with 14 days the engineering department was notified but no notation of corrective action taken.

February 2010: Operating Room 2
a. 20 of 28 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of corrective action taken.

March 2010: Operating Room 2
a. 23 of 31 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of corrective action taken.

April 2010: Operating Room 2
a. 18 of 26 days the humidity level was below 35%, with 13 days the engineering department was notified but no notation of corrective action taken.

3. No records of humidity levels were provided for the endoscopy procedure room. According to staff 2 there is no gauge in that room and they have not been monitoring the levels. Staff 2 stated that as gauge will be put in that room when the new ones arrive.

4. No humidity levels were recorded for the following:
Operating Room 1:
a. June 11th, 19th, 2009
b. July 2nd, 31st, 2009
c. September 25th, 2009
d. November 6th, 13th, 27th, 2009
e. December 14th, 24th, 2009
f. January 1-31st, 2010
g. March 10, 2010
h. April 19, 2010

Operating Room 2:
a. June 18, 2009
b. July 23rd, 24th, 2009
c. October 23rd, 2009
d. November 24th, 25th, 30th, 2009
e. December 28th, 2009
f. January 15th, 28th, 2010
g. March 8th , 2010
h. April 23rd, 2010

5. Humidity levels using portable humidifiers.
April 2010: Operating Room 1
a. 16th - humidity level 28%
b. 19th - humidity level 26%
c. 20th - humidity level 39%
d. 21st - humidity level 24 %
e. 22nd - humidity level 27%
f. 23rd - humidity level 36%
g. 24th - humidity level 38%
h. 25th - humidity level 27%
i. 26th - humidity level 37 %

April 2010: Operating Room 2
a. 22nd - humidity level 28%
b. 23rd - humidity level a.m. 29%, p.m 28%
c. 24th - humidity level a.m. 31%, p.m. 32%
d. 25th - humidity level a.m.32%, p.m. 25%
e. 26th - humidity level a.m. 40%, p.m. 23%

Based on document review and interview the facility failed to maintain and provide complete documentation for 2 of 2 emergency generators, as evidenced by failure to provide testing records with identification of personnel performing testing, and having an portable generator. This may result in the emergency generator not functioning properly in the event of a power outage. This affects 6 of 6 smoke compartments.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
6-3.4 A written record of the EPSS inspection, tests, exercising, operation, and repairs shall be maintained on the
premises. The written record shall include the following:
(a.) The date of the maintenance report.
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

Findings:
1. On April 26, 2010, at 3:34 p.m. during review of the emergency generator logs the logs provided identified 1 of 2 emergency generators as being a portable generator. During an interview with staff 4 at this time staff stated that the portable generator had been in place for a couple of years. When asked if facility was in the process of replacing the generator staff stated no.
2. On April 27, 2010 at 8:51 a.m. the generator logs were reviewed.
Generator 1: Weekly Visual Inspections no initials or signature to identify the personnel testing.
a. August 7, 2009
b. July 31st , 2009
c. July 24th, 2009
d. July 17, 2009
e. July 3, 2009
f. June 26, 2009
g. June 13, 2009
h. June 5, 2009
i. May 26, 2009
j. May 11, 2009
k. May 1, 2009
l. April 24, 2009
m. April 17, 2009
n. April 10, 2009
Generator 2 (portable)
a. August 21, 2009
b. August 14, 2009
c. August 7, 2009
d. July 31, 2009
e. July 24, 2009
f. July 17, 2009
g. July 10, 2009
h. July 3, 2009
i. June 26, 2009
j. June 13, 2009
k. June 5, 2009
l. May 26, 2009
m. May 15, 2009
n. May 11, 2009
o. May 1, 2009
p. April 24, 2009
q. April 17, 2009
r. April 10, 2009
Monthly Load with no signature or initial to identify personnel.
Generator 2:
a. August 14, 2009
b. June 22, 2009
c. May 29, 2009
d. April 3, 2009
e. April 13, 2009
f. February 13, 2009

4. During review of the generator logs the facility noted on 3 dates that the generator had problems but failed to provide documentation of the corrective action taken.
Generator #2
a. August 21, 2009, would not start
b. April 17, 2009, generator ran too hot
c. May 29, 2009, generator ran too long under load
3 .On April 27, 2010, at 9:05 a.m. staff 4 stated that the portable emergency generator was brought in on May 15, 2006, due to failure to 1 of 2 generators.

Based on observation the facility failed to maintain the electrical wiring and equipment as evidenced by use of surge protectors attached to walls, daisy chained and use with large appliances. This affects 6 of 6 smoke compartments and may result in a fire.

NFPA 70, National Electrical Code 1999 Edition
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.

Findings:
On April 26, 2010 through April 28, 2010 from 8:30 a.m. to 4:00 p.m. on a tour of the facility with staff 4 the electrical wiring and equipment was observed.
April 26th, 2010
a. At 11:08 a.m. the refrigerator in the conference room in the basement was plugged into a surge protector.
April 27, 2010
a. At 10:19 a.m. in the Emergency Room waiting/lobby, extension cord with wall mounted fan plugged into it.
b. At 11:07 a.m. in the kitchen a surge protector mounted to the wall behind the ice machine.
c. At 11:09 a.m. in the hallway outside the kitchen soda and snack machine plugged into a surge protector.
d. At 11:12 a.m. in the laboratory in the microscope area 3 surge protectors daisy chained together.
e. At 11:35 a.m. in the obstetrics (OB) department a the refrigerator next to the pyxis machine was plugged into a surge protector.
f. At 1:55 p.m. 100 wing nurse station report room north wall electrical cove plate missing.
g. At 2:02 p.m. in pharmacy storage a refrigerator plugged into a surge protector
h. At 2:04 p.m. in room 209 an extension cord in use.

Based on observation the facility failed to maintain the building construction, as evidenced by failure to seal penetrations through out the facility, which may result in the passage of smoke and flames in the event of a fire. This affected 4 of 6 smoke compartments.

Findings:
On April 26, 2010 through April 28, 2010, on a tour of the facility from 8:30 a.m. to 4:00 p.m., with staff 4 the walls were observed.
April 27, 2010
1. At 10:23 a.m. in the emergency waiting room on the east wall there was an unsealed penetration approximately 2 inches with cable wire running through it.
2. At 10:30 a.m. in the emergency waiting room on the north wall near registration the cover plate to the reset for the roll up door was missing, leaving an unsealed penetration approximately 14 inches in diameter.
3. At 10:54 a.m., in the Electrical Room outside the emergency room there were 2 unsealed penetrations on the back wall approximately 2 inches each and near the ceiling and on the back wall an approximately 14 inch unsealed pipe.
4. At 11:15 a.m., in the housekeeping room by room 309, there were 6 unsealed penetrations on the back wall approximately 1/4 inch to 1/2 inch each.
5. At 1:55 p.m. in the report room of the nurse station 100 wing there were 3 unsealed penetrations on the west wall 1/2 inch to 1 inch each.
6. At 2:00 p.m. in the Pharmacy Office north wall there were 5 unsealed penetrations approximately 1/2 inch each.

Based on observation the facility failed to maintain the doors to shut and latch upon closure and to maintain the doors to prevent the passage of smoke. This was evidenced by doors that failed to shut completely or latch upon closure and doors with holes in the doors. This may result in the passage of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments.

Findings:
On a tour of the facility on April 26, 2010 through April 28, 2010 with staff 4, the doors were observed.
April 27, 2010;
1. At 11:20 a.m. room 307 the door failed to shut and latch. There was a loose door hinge that prevented the door from closing.
2. At 11:25 a.m. in the obstetrics department (300 wing), the convenience doors leading into the wing, the left leaf failed to latch upon closure.
3. At 11:30 a.m., labor room 2 door had 4 unsealed penetrations in the door approximately 1/8 inch to 1/4 inch.
4. At 1:57 p.m., room 205 had 3 unsealed penetrations in the door, approximately 1/2 inch each.
5. At 1:58 p.m., room 207 had 4 unsealed penetrations in the door approximately 1/2 inch each.

Based on observation the facility failed to maintain the exit and directional signs in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code. This was evidenced by exit signs that have expired expiration dates. This may result in confusion and delayed egress in the event of fire or other emergency. This affected 2 of 6 smoke compartments.

Findings:
On a tour of the facility from April 26, 2010 through April 28, 2010, with staff 4 the exit signs were observed.
April 27, 2010;
1. At 11:23 a.m. the exit sign at the doors entering the obstetrics wing was to be replaced by January 2009
2. At 11:24 a.m. the exit sign by the nurses station in obstetrics wing was to be replaced by January 2009.

Based on document review and interview the facility failed to conduct fire drills one per shift per quarter for all staff. This is evidenced by not all staff being trained quarterly during fire drills. This may result in staff being confused about duties and assignments in the event of a fire. This affects 6 of 6 smoke compartments.

19.7.1.2* Fire Drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:
On April 26, 2010 through April 28, 2010, the fire drill records were reviewed from 8:30 a.m. to 4:00 p.m.
1. No documentation was provided for fire drills being conducted for the night shift staff (7:00 p.m. to 7:00 a.m. and 11:00 p.m. to 7:00 a.m.) from April 2009 through March 2010.
2. No fire drills were conducted after 4:00 p.m. from April 2009 through March 2010.
3. No fire drills were conducted prior to 7:15 a.m. from April 2009 through March 2010.
On April 27, 2010 at 3:30 p.m. when asked staff 4 stated that nursing staff work 12 hour shifts from
7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m.. When asked if there were other employees that worked different hours staff 4 stated yes. Records for those departments were requested.
On April 28, 2010, at 1:30 p.m. during an interview with staff 4 the following departments and shifts were provided.
1. Housekeeping
11:00 p.m. to 7:30 a.m.
7:00 a.m. to 3:30 p.m.
3:00 p.m. to 11:00 p.m.
2. Security
Monday through Friday
11:00 p.m. to 7:30 a.m.
3:00 p.m. to 11:00 p.m.
Saturday and Sunday
7:00 a.m. to 3:30 p.m. .
3:00 p.m. to 11 p.m.
11:00 p.m. to 7:30 a.m.
3. Laboratory
7:00 a.m. to 5:30 p.m.
10:00 a.m. to 7:00 p.m.
7:00 p.m. to 6:30 a.m.
Saturday and Sunday
7:00 p.m. to 7:00 a.m.
7:00 a.m. to 7:00 p.m.
4. Certified Nursing Assistants (CNA'S)
6:00 a.m. to 2:00 p.m.
2:00 p.m. to 10: 00 p.m.
5. Dietary Staff
Saturday and Sunday
6:00 a.m. to 5:00 p.m.
2:30 p.m. to 6:30 p.m.
Monday through Friday
6:00 a.m. to 5:00 p.m.
6:30 a.m. to 1:00 p.m.
10:30 a.m. to 12:30 p.m. then 3:30 p.m. to 6:30 p.m.
Staff 4 confirmed that fire drills were not conducted as required to provide training to all staff on all shifts.

Based on document review, interview and observation the facility failed to maintain the fire alarm system as evidenced by, failure to provide a complete list of all components such as smoke detectors, pull stations, chimes, bells and audio visual devices, failure of devices during testing and an annual certification of the fire alarm system. This could result in the fire alarm system not functioning properly in the event of a fire. This affects 6 of 6 smoke compartments.


NFPA 72
7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
#15 f, Fire Alarm Boxes (pull stations) tested annually
# 15 h, All Smoke Detectors - Functional tested annually
#19 a, Audible Devices, tested annually
# 19 c. Visible Devices , tested annually

In accordance with NFPA 72, National Fire Alarm Code, Table 7-3.2 # 23 supervising station fire alarm systems - receivers shall be tested monthly.
NFPA 72
7-5.2.2
A permanent record of all inspections, testing and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
1. Date
2. Test frequency
3. Name of property
4. Address
5. Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
6. Name, address and representative of approving agency (ies)
7. Designation of the detector (s) tested, for example, "Tests performed in accordance with Section _____".
8. Functional test of detectors
9. *Functional test of required sequence of operations
10. Check of all smoke detectors
11. Loop resistance of all fixed-temperature, line-type heat detectors
12. Other tests required by equipment manufactures
13. Other tests as required by the authority having jurisdiction
14. Signatures of tester and approved authority representative
15. Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place.

Findings:
On April 26, 2010 through April 28, 2010 the Fire Alarm Inspection Reports were reviewed.
April 26, 2010;
1. At 11:21 a.m. the Fire Alarm Inspection Report dated March 29, 2010 was reviewed. The report indicated 2 of 32 smoke detectors were not tested, 3 of 15 pull stations were not tested.
2. At 12:25 p.m. the Fire Alarm Inspection Report dated November 5, 2009 was reviewed. indicated 1 bell, 1 chime, 1 visual signal only, Smoke Detectors 79, 11 Pull Stations, 1 Waterflow.
3. At 1:00 p.m. the Fire Alarm Inspection Report dated June 1, 2009 was reviewed. The report indicated 32 Smoke Detectors, 14 Pull Stations, no audio visual devices listed, chimes, or bells. There was no signature of the tester on the report. During an interview at this time with staff 4 a list of the number of all devices was requested. Staff 4 stated that he is in the process of compiling a list of all devices.
April 28, 2010:
1. At 9:25 a.m. the facility did not provide a complete list of all devices such as Smoke Detectors, Pull Stations, and Audio/Visual devices, Bells, Chimes.
2. At 9:35 a.m. a review of the Fire Alarm Inspection Report dated April 2, 2010 indicated 8 of 97 smoke detectors were not tested the report did not indicate any Pull Stations, Bells, Chimes, Strobes or Audio/Visual Devices. There was no signature of the tester on the report.
3. At 9:50 a.m. during an interview with staff 4 and staff 6 it was confirmed that the Fire Alarm System Reports did not give an accurate account of the fire alarm devices in the facility. Staff 4 stated that he was in the process of compiling a report with a list of all devices.
4. At 11:28 a.m. during testing of the fire alarm system the Audio Visual device located by room 303 failed to emit an audible alarm on activation of the fire alarm system.
5. At 11:33 a.m. the Audio/Visual Device located in the Intensive Care Unit hallway failed to emit an audible alarm or strobe upon activation of the fire alarm system.
6. After review of the Fire Alarm Inspection Reports dated April 2, 2010, March 29, 2010, November 5, 2009 and June 1, 2009, and interviews with staff 4 and staff 6 the surveyor was unable to confirm that all devices have been tested during the past year and there is no annual certification of the fire alarm system.

Based on document review and interview the facility failed to maintain the smoke detectors as evidenced by failure to provide evidence that smoke detectors that failed smoke detector sensitivity testing had been repaired or replaced. This affected 6 of 6 smoke compartments and may result in the smoke detectors not functioning properly in the event of a fire.

NFPA 72
7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In the zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or aerosol into the detector.

Findings:
On April 26, 2010 through April 28, 2010 the Fire Alarm Inspection Report dated April 2, 2010 was reviewed.
April 28, 2010
1. At 9:35 a.m. the Fire Alarm Inspection Report dated April 2, 2010 was reviewed for sensitivity testing.
The report indicated a total of 97 smoke detectors and 89smoke detectors were tested. and 16 devices failed.
During review of the report, 8 of the 97 smoke detectors could not be tested due to their age, and 16 of 89 smoke detectors tested failed sensitivity testing. The following smoke detectors failed sensitivity testing:
a. The smoke detector in the Emergency Room (ER) corridor by ER 1.
b. The smoke detector in the Emergency Room corridor by the restroom.
c. The smoke detector in the Emergency Room corridor by treatment room 1.
d. The smoke detector in the Emergency Room corridor by the Private Office.
e. The smoke detector in the Emergency Room lobby by the men' s restroom.
f. The smoke detector by the Emergency Room Nurse Station Window.
g. The smoke detector in the Elevator Lobby (1st floor).
h. The smoke detector in the Elevator Rear.
i. The smoke detector in the Gift Shop.
j. The smoke detector in the Main Lobby.
k. The smoke detector outside the gift shop.
l. The smoke detector by the Radiology Double Door.
m. The smoke detector by the Radiology Double Door.
n. The smoke detector in the Radiology Reception Corridor.
o. The smoke detector in the Radiology Reception Outside Window.
p. The smoke detector in X ray Room 2.

Based on observation the facility failed to maintain the automatic sprinkler system in accordance with National Fire Alarm Code (NFPA) 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 edition. This was evidenced by sprinkler contaminated with dust and lint, missing escutcheon ring and failure of one of two inspectors test valves to activate the fire alarm system. This affects 6 of 6 smoke compartments, and may result in the delayed activation of the automatic sprinkler system.

NFPA 72
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.
NFPA 25
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, corroded, damaged, or loaded; or in the improper orientation.


Findings:
On April 26, 2010 through April 28, 2010, during a tour of the facility from 8:30 a.m. to 4:00 p.m. with staff 4 the automatic sprinkler system was observed.
April 27, 2010
a. At 10:41 a.m. in the restroom by the ambulance entrance in the emergency room the sprinkler was contaminated with dust/lint.
April 28, 2010
a. At 10:56 a.m. the sprinkler in the 100 hall by the nurse's station was missing the escutcheon ring.
b. At 2:13 p.m. the Inspectors Test Valve #1 located in the 200 hall, failed to activate an alarm at 90 seconds and at 2 minutes.

Based on observation the facility failed to prevent the use of portable space heating devices in patient care areas. This may cause a fire or injury to patients or staff. This affects 1 of 6 smoke compartments.

Findings:
On April 27, 2010 during a tour of the facility with staff 4 at 10:39 a.m., in the emergency room a portable space heater was observed in the emergency room nurse reporting station.

Based on observation the facility failed to maintain the oxygen storage areas, as evidenced by empty and full cylinders being stored together in the same racks. This may cause confusion when oxygen tanks are needed and staff pick an empty tank in a emergency as opposed to a full tank. This could delay care or treatment to patients in the event of an emergency due to staff taking a empty cylinder hurriedly. This has the potential to affect 6 of 6 smoke compartments.

NFPA 99 4-3.5.2.2
(b) Nonflammable Gases
#2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:
On April 27, 2010 during a tour of the facility with staff 4 from 8:30 a.m. to 4:00 p.m. the oxygen storage was observed.
At 10:48 a.m. the oxygen storage outside the emergency room at the ambulance entrance was observed. In the room labeled as empty 9 of 52 E size cylinders stored in this room were empty. The cylinders contained different types of air, such as compressed air, lung diffusion mixture, carbon dioxide, and oxygen, and the empty were stored in the same racks as the full tanks.

Based on document review and interview the facility failed to maintain the operating rooms (OR)and the endoscopy procedure room, humidity levels at 35% or greater in accordance with National Fire Protection Association 99 (NFPA),1998 edition, Health Care Facilities, and to follow the written policy and procedure when humidity levels were outside the permissible range. This may cause an increased risk of fire and injury to patients. This affected 2 of operating rooms, the endoscopy procedure room in 1 of 6 smoke compartments.

5-4.1.1*The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:
On April 26, 2010 through April 28, 2010 from 8:30 a.m. to 4:00 p.m., during document review the Policy and Procedure for Maintaining a Safe, Functional Environment # EC.02.06.01 dated January 2, 2010 was reviewed. The policy states in Table 1.1 the Relative Humidity Levels for the Operating/Surgical, Recovery Rooms, Endoscopy Procedure Rooms, will be at 30% to 60%.
At 12:09 p.m., humidity logs dated June 2009 through April 2010 were provided. During an interview with staff 4 at this time it was stated that prior to June 2009 no humidity logs were kept for the operating rooms. During an interview with staff 2 and staff 4 at this time staff 2 stated that once the problem with humidity was identified that they brought in portable humidifiers. These humidifiers are turned on at the end of the day and run during the night and turned off in the morning at approximately 5:00 a.m. The facility began using the portable space heating devices on April 16, 2010.
At 2:07 p.m. during an interview with staff 2 and staff 4 regarding the humidity levels, staff 2 stated that new gauges were ordered for each OR and the Endoscopy Procedure Room on April 21, 2010, with a projected date of arrival of April 30, 2010. During an interview with staff 2 at this time when the humidity logs for the Endoscopy Procedure Room were requested staff 2 stated that there were no logs and that there was not even a gauge in the room. During an interview with staff 2 regarding the documentation of the humidity levels staff 2 stated that the facility is in the process of updating the policy and procedure manual. The old policy states that on weekends and holidays the humidity levels will be recorded prior to the start of procedures, per staff 2 the new policy will be humidity levels will be monitored daily. When staff 2 was asked if the hospital continues with surgeries with humidity levels below the permissible range, staff 2 stated yes.
At 2:15 p.m. documentation of facilities findings and verification that the humidity levels were adjusted in range when reported was requested from staff 4. Staff 4 stated that he did not have any work orders or records. Staff 4 stated that the facility is in the process of replacing the HVAC (Heating, Ventilating and Air Conditioning) system above to operating rooms to help control the humidity levels.
1. Humidity Levels:
June 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd - humidity level 22%
d. 9th - humidity level 33%
e. 11th - no humidity level recorded
f. 15th - humidity level 29%
g. 16th - humidity level 31%
h. 17th - humidity level 33%
i. 18th - humidity level 32%
j. 19th - no humidity level recorded
k. 22nd - humidity level 33%
m. 24th - humidity level 29%
n. 25th - humidity level 27%
o. 26th - humidity level 21%
p. 29th - humidity level 24%
q. 30th - humidity level 21%

July 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - no humidity level recorded
c. 6th - humidity level 28%
d. 7th - humidity level 28 %
e. 8th - humidity level 21%
f. 9th - humidity level 26 %
g. 10th - humidity level 21%
h. 16th - humidity level 31%
i. 17th - humidity level 30%
j. 23rd - no humidity level recorded
k. 24th - humidity level 21%
l. 31st - no humidity level recorded

August 2009: Operating Room 1
a. 3rd - humidity level 32%
b. 4th - humidity level 21%
c. 5th - humidity level 33%
d. 6th - humidity level 26%
e. 7th - humidity level 29%
f. 10th - humidity level 26%
g. 11th - humidity level 28%
h. 13th - humidity level 21%
j. 18th - humidity level 24%
k. 19th - humidity level 34%
l. 20th - humidity level 26%
m. 21st - humidity level 28%
n. 26th - humidity level 28%
o. 27th - humidity level 21%
p. 28th - humidity level 24%
q. 31st - humidity level 33%

September 2009: Operating Room 1
a.1st - no humidity level recorded
b. 2nd - humidity level 29%
c. 3rd - humidity level 31%
d. 8th - humidity level 26%
e. 9th - humidity level 26%
f. 21st - no humidity level recorded
g. 22nd - humidity level 21%
h. 23rd - humidity level 21%
i. 24th - humidity level 21%
j. 25th - no humidity level recorded'
k. 28th - humidity level 29%
l. 29th - humidity level 21%
m. 30th humidity level 21%

October 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 5th - humidity level 23%
d. 6th - humidity level 25%
e. 7th - humidity level 21%
f. 8th - humidity level 24 %
g. 9th - humidity level 24 %
h. 20th - humidity level 31%
i. 21st - humidity level 24%
j. 22nd - humidity level 24%
k. 23rd - humidity level 21%
l. 26th - humidity level 21%
m. 28th - humidity level 21%
n. 29th - humidity level 21%
o. 30th - humidity level 21%

November 2009: Operating Room 1
a. 2nd - humidity level 21%
b. 3rd - humidity level 21%
c. 4th - humidity level 21%
d. 5th - humidity level 21%
e. 6th - no humidity level recorded
f. 9th - humidity level 25%
g. 10th - humidity level 21%
h. 11th - humidity level 21%
i. 12th - humidity level 21%
j. 13th - no humidity level recorded
k. 16th - humidity level 21%
l. 17th - humidity level 21%
m. 18th - humidity level 21%
n. 19th - humidity level 21%
o. 20th - humidity level 21%
p. 23rd - humidity level 21%
q. 24th - humidity level 21%
r. 25th - humidity level 21%
s. 27th - no humidity level recorded
t. 30th - humidity level 21%

December 2009: Operating Room 1
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd - humidity level 21%
d. 4th - humidity level 21%
e. 7th - humidity level 28%
f. 8th - humidity level 21%
g. 9th - humidity level 21%
h. 10th - humidity level 21%
j. 11th - humidity level 24 %
k. 15th - humidity level 24%
l. 16th - humidity level 23%
m. 17th - humidity level 23%
n. 18th - humidity level 21%
o. 21st - humidity level 23%
p. 22nd - humidity level 21%
q. 23 rd - humidity level 21%
r. 24th - no humidity level recorded
s. 25th - no humidity level recorded
t. 28th - no humidity level recorded
u. 29th - humidity level 21%
v. 30th - humidity level 21%
w. 31st - humidity level 21%

January 2010: Operating Room 1



February 2010: Operating Room 1
a. 1st - humidity level 23%
b. 2nd - humidity level 25%
c. 3rd - humidity level 26%
d. 4th - humidity level 24%
e. 5th - humidity level 30%
f. 8th - humidity level 26%
g. 9th - humidity level 29%
h. 10th - humidity level 31%
i. 11th - humidity level 24%
j. 12th - humidity level 24%
k. 15th - humidity level 26%
l. 16th - humidity level 26%
m. 17th - humidity level 33%
n. 18th - humidity level 26%
o. 19th - humidity level 28%
p. 22nd - humidity level 29%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 31%
t. 26th - humidity level 21%

March 2010: Operating Room 1
a. 1st - humidity level 32%
b. 2nd - humidity level 27%
c. 3rd - humidity level 31%
d. 4th - humidity level 25%
e. 5th - humidity level 21%
f. 8th - humidity level 31%
g. 9th - humidity level 21%
h. 10th - no humidity levels recorded
i. 11th - humidity level 21%
j. 12th - humidity level 21%
k. 15th - humidity level 21%
l. 16th - humidity level 23%
m. 17th - humidity level 23%
n. 18th - humidity level 25%
o. 19th - humidity level 21%
p. 22nd - humidity level 25%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 31%
t. 26th - humidity level 28%
u. 29th - humidity level 21%
v. 30th - humidity level 21%
w. 31st - humidity level 31%

April 2010: Operating Room 1
a.1st - humidity level 31%
b. 2nd - humidity level 27%
c. 5th - humidity level 26%
d. 6th - humidity level 23%
e. 7th - humidity level 21%
f. 8th - humidity level 21%
g. 9th - humidity level 31%
h. 13th - humidity level 31%
i. 14th - humidity level 31%
j. 15th - humidity level 29%
k. 16th - humidity level 33%
l. 19th - no humidity level recorded
m. 20th - humidity level 32%
n. 21st - humidity level 21%
o. 22nd - humidity level 27%
p. 23rd - humidity level 30%
q. 24th - humidity level 31%


June 2009: Operating Room 2
a. 1st - humidity level 25%
b. 2nd - humidity level 23%
c. 3rd - humidity level 23%
d. 4th - humidity level 24%
e. 19th - humidity level 33%
f. 22nd - humidity level 32%
g. 24th - humidity level 26%
h. 25th - humidity level 24%
i. 26th - humidity level 22%
j. 29th - humidity level 34%
k. 30th - humidity level 29%

July 2009: Operating Room 2
a. 1st - humidity level 24%
b. 6th - humidity level 21%
c. 7th - humidity level 23%
d. 8th - humidity level 22%
e. 9th - humidity level 28%
f. 10th - humidity level 23%
g. 23rd - no humidity levels recorded
h. 24th - no humidity levels recorded

August 2009: Operating Room 2
a. 3rd - humidity level 25%
b. 4th - humidity level 27%
c. 6th - humidity level 30%
d. 10th - humidity level 29%
e. 13th - humidity level 22%
f. 18th - humidity level 33%
g. 21st - humidity level 30%
h. 24th - humidity level 27%
i. 26th - humidity level 24%
j. 27th - humidity level 24%
k. 28th - humidity level 26%

September 2009: Operating Room 2
a. 18th - humidity level 33%
b. 21st - humidity level 22%
c. 22nd - humidity level 22%
d. 23rd - humidity level 23%
e. 24th - humidity level 24%
f. 25th - humidity level 24%
g. 28th - humidity level 28%
h. 29th - humidity level 25%
i. 30th - humidity level 26%

October 2009: Operating Room 2
a. 1st - humidity level 23%
b. 2nd - humidity level 21%
c. 5th - humidity level 21%
d. 6th - humidity level 21%
e. 7th - humidity level 22%
f. 8th - humidity level 21%
g. 9th - humidity level 22%
h. 21st - humidity level 33%
i. 22nd - humidity level 26%
j. 23rd - no humidity level recorded
k. 26th - humidity level 23%
l. 27th - humidity level 28%
m. 28th - humidity level 19%
n. 29th - humidity level 21%
o. 30th - humidity level 21%


November 2009: Operating Room 2
a. 2nd - humidity level 21%
b. 3rd - humidity level 22%
c. 4th - humidity level 23%
d. 5th - humidity level 24%
e. 9th - humidity level 30%
f. 10th - humidity level 20%
g. 11th - humidity level 19%
h. 12th - humidity level 21%
i. 13th - humidity level 27%
j. 16th - humidity level 22%
k. 17th - humidity level 22%
l. 18th - humidity level 22%
m. 19th - humidity level 23%
n. 20th - humidity level 22%
o. 23rd - humidity level 21%
p. 24th - humidity level 21%
q. 25th - no humidity level recorded
r. 27th - no humidity level recorded
s. 30th - no humidity level recorded


December 2009: Operating Room 2
a. 1st - humidity level 21%
b. 2nd - humidity level 21%
c. 3rd. - humidity level 21%
d. 4th - humidity level 21%
e. 7th - humidity level 25%
f. 8th - humidity level 22%
g. 9th - humidity level 21%
h. 10th - humidity level 22%
i. 11th - humidity level 22%
j. 14th - humidity level 23%
k. 15th - humidity level 22%
l. 16th - humidity level 22%
m. 17th - humidity level 22%
n. 18th - humidity level 22%
o. 21st - humidity level 22%
p. 22nd - humidity level 22%
q. 23rd - humidity level 21%
r. 24th - humidity level 20%
s. 28th - no humidity level recorded
t. 29th - humidity level 21%
u. 30th - humidity level 22%
v. 31st - humidity level 22%

January 2010: Operating Room 2
a. 4th - humidity level 21%
b. 5th - humidity level 20%
c. 6th - humidity level 21%
d. 7th - humidity level 20%
e. 8th - humidity level 21%
f. 11th - humidity level 20%
g. 12th - humidity level 21%
h. 13th - humidity level 24%
i. 14th - humidity level 21%
j. 15th - no humidity level recorded
k. 19th - humidity level 25%
l. 20th - humidity level 25 %
m. 21st - humidity level 30%
n. 22nd - humidity level 26%
o. 25th - humidity level 23%
p. 26th - humidity level 23%
q. 27th - humidity level 32%
r. 28th - no humidity level recorded
s. 29th - humidity level 23%

February 2010: Operating Room 2
a. 1st - humidity level 23%
b. 2nd - humidity level 23%
c. 3rd - humidity level 23%
d. 4th - humidity level 22%
e. 5th - humidity level 25%
f. 8th - humidity level 24 %
g. 9th - humidity level 23%
h. 10th - humidity level 21%
i. 11th - no humidity levels recorded
j.12th - humidity level 23%
k. 15th - humidity level 22%
l. 16th - humidity level 23%
m. 17th - humidity level 30%
n. 18th - humidity level 24%
o. 19th - humidity level 23%
p. 22nd - humidity level 23%
q. 23rd - humidity level 22%
r. 24th - humidity level 20%
s. 25th - humidity level 27%
t. 26th - humidity leve 22%


March 2010: Operating Room 2
a. 1st - humidity level 25%
b. 2nd - humidity level 23%
c. 3rd - humidity level 21%
d. 4th - humidity level 23%
e. 5th - humidity level 22%
f. 8th - no humidity level recorded
g. 9th - humidity level 22%
h. 10th - no humidity level recorded
i. 11th - humidity level 21%
j. 12th - humidity level 21%
k. 15th - humidity level 21%
l. 16th - humidity level 22 %
m. 17th - humidity level 22%
n. 18th - humidity level 22%
o. 19th - humidity level 21%
p. 22nd - humidity level 21%
q. 23rd - humidity level 21%
r. 24th - humidity level 21%
s. 25th - humidity level 30%
t. 26th - humidity level 29%
u. 29th - humidity level 23%
v. 30th - humidity level 23%
w. 31st - humidity level 23%


April 2010: Operating Room 2
a. 1st - humidity level 31%
b. 2nd - humidity level 21%
c. 5th - humidity level 24%
d. 6th - humidity level 23%
e. 7th - humidity level 22%
f. 8th - humidity level 30%
g. 9th - humidity level 22%
h. 12th - humidity level 30%
i. 13th - humidity level 30%
j. 14th - humidity level 22%
k. 15th - humidity level 26%
l. 16th - humidity level 31%
m. 19th - humidity level 22%
n. 20th - humidity level 30%
o. 21st - humidity level 34%
p. 22nd - humidity level 27%
q. 23rd - no humidity level recorded
r. 24th - humidity level 31%

2. The humidity logs for 2 of 2 operating rooms were reviewed from June, 2009 through April 26, 2010. The humidity level for Operating Room 1 was below 35% on 175 days out of 299 days, and for Operating Room 2 175 days out of 299 days.
June 2009: Operating Room 1
a. 16 of 30 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action being taken.

July 2009: Operating Room 1
a. 14 of 31 days the humidity level was below 35%, with engineering being notified 2 of 14 days, but no notation of what corrective action was taken.

August 2009: Operating Room 1
a. 16 of 31 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action being taken.

September 2009: Operating Room 1
a. 13 of 30 days the humidity level was below 35%, with no indication of the engineering department being notified or any corrective action taken.

October 2009: Operating Room 1
a. 15 of 31 days the humidity level was below 35%, with indication of the engineering department being notified 8 time but not notation of what corrective action was taken.

November 2009: Operating Room 1
a. 19 of 30 days the humidity level was below 35%, with indicationof engineering department being notified 8 times but no notation of what corrective action was taken.

December 2009: Operating Room 1
a. 22 of 31 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of correction action taken.

January 2010: Operating Room 1
a. 31 of 31 days no humidity levels documented.

February 2010: Operating Room 1
a. 20 of 28 days the humidity level was below 35%, with 6 days the engineering department was notified but no notation of correction action taken.

March 2010: Operating Room 1
a. 23 of 31 days the humidity level was below 35%, with 18 days the engineering department was notified but no notation of correction action taken.

April 2010: Operating Room 1
a. 17 of 26 days the humidity level was below 35%, with 9 days the engineering department was notified but no notation of correction action taken.


June 2009: Operating Room 2
a. 12 of 30 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

July 2009: Operating Room 2
a. 8 of 31 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

August 2009: Operating Room 2
a. 11 of 31 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

September 2009: Operating Room 2
a. 8 of 30 days the humidity level was below 35%, with no notation of engineering department being notified or any corrective action taken.

October 2009: Operating Room 2
a. 15 of 30 days the humidity level was below 35%, with notation of engineering department being notified, but no notation of corrective action taken.

November 2009: Operating Room 2
a. 19 of 30 days the humidity level was below 35%, with 11 days the engineering department was notified but no notation of corrective action taken.

December 2009: Operating Room 2
a. 22 of 31 days the humidity level was below 35%, with 17 days the engineering department was notified but no notation of corrective action taken.

January 2010: Operating Room 2
a. 19 of 31 days the humidity level was below 35%, with 14 days the engineering department was notified but no notation of corrective action taken.

February 2010: Operating Room 2
a. 20 of 28 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of corrective action taken.

March 2010: Operating Room 2
a. 23 of 31 days the humidity level was below 35%, with 19 days the engineering department was notified but no notation of corrective action taken.

April 2010: Operating Room 2
a. 18 of 26 days the humidity level was below 35%, with 13 days the engineering department was notified but no notation of corrective action taken.

3. No records of humidity levels were provided for the endoscopy procedure room. According to staff 2 there is no gauge in that room and they have not been monitoring the levels. Staff 2 stated that as gauge will be put in that room when the new ones arrive.

4. No humidity levels were recorded for the following:
Operating Room 1:
a. June 11th, 19th, 2009
b. July 2nd, 31st, 2009
c. September 25th, 2009
d. November 6th, 13th, 27th, 2009
e. December 14th, 24th, 2009
f. January 1-31st, 2010
g. March 10, 2010
h. April 19, 2010

Operating Room 2:
a. June 18, 2009
b. July 23rd, 24th, 2009
c. October 23rd, 2009
d. November 24th, 25th, 30th, 2009
e. December 28th, 2009
f. January 15th, 28th, 2010
g. March 8th , 2010
h. April 23rd, 2010

5. Humidity levels using portable humidifiers.
April 2010: Operating Room 1
a. 16th - humidity level 28%
b. 19th - humidity level 26%
c. 20th - humidity level 39%
d. 21st - humidity level 24 %
e. 22nd - humidity level 27%
f. 23rd - humidity level 36%
g. 24th - humidity level 38%
h. 25th - humidity level 27%
i. 26th - humidity level 37 %

April 2010: Operating Room 2
a. 22nd - humidity level 28%
b. 23rd - humidity level a.m. 29%, p.m 28%
c. 24th - humidity level a.m. 31%, p.m. 32%
d. 25th - humidity level a.m.32%, p.m. 25%
e. 26th - humidity level a.m. 40%, p.m. 23%

Based on document review and interview the facility failed to maintain and provide complete documentation for 2 of 2 emergency generators, as evidenced by failure to provide testing records with identification of personnel performing testing, and having an portable generator. This may result in the emergency generator not functioning properly in the event of a power outage. This affects 6 of 6 smoke compartments.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
6-3.4 A written record of the EPSS inspection, tests, exercising, operation, and repairs shall be maintained on the
premises. The written record shall include the following:
(a.) The date of the maintenance report.
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

Findings:
1. On April 26, 2010, at 3:34 p.m. during review of the emergency generator logs the logs provided identified 1 of 2 emergency generators as being a portable generator. During an interview with staff 4 at this time staff stated that the portable generator had been in place for a couple of years. When asked if facility was in the process of replacing the generator staff stated no.
2. On April 27, 2010 at 8:51 a.m. the generator logs were reviewed.
Generator 1: Weekly Visual Inspections no initials or signature to identify the personnel testing.
a. August 7, 2009
b. July 31st , 2009
c. July 24th, 2009
d. July 17, 2009
e. July 3, 2009
f. June 26, 2009
g. June 13, 2009
h. June 5, 2009
i. May 26, 2009
j. May 11, 2009
k. May 1, 2009
l. April 24, 2009
m. April 17, 2009
n. April 10, 2009
Generator 2 (portable)
a. August 21, 2009
b. August 14, 2009
c. August 7, 2009
d. July 31, 2009
e. July 24, 2009
f. July 17, 2009
g. July 10, 2009
h. July 3, 2009
i. June 26, 2009
j. June 13, 2009
k. June 5, 2009
l. May 26, 2009
m. May 15, 2009
n. May 11, 2009
o. May 1, 2009
p. April 24, 2009
q. April 17, 2009
r. April 10, 2009
Monthly Load with no signature or initial to identify personnel.
Generator 2:
a. August 14, 2009
b. June 22, 2009
c. May 29, 2009
d. April 3, 2009
e. April 13, 2009
f. February 13, 2009

4. During review of the generator logs the facility noted on 3 dates that the generator had problems but failed to provide documentation of the corrective action taken.
Generator #2
a. August 21, 2009, would not start
b. April 17, 2009, generator ran too hot
c. May 29, 2009, generator ran too long under load
3 .On April 27, 2010, at 9:05 a.m. staff 4 stated that the portable emergency generator was brought in on May 15, 2006, due to failure to 1 of 2 generators.

Based on observation the facility failed to maintain the electrical wiring and equipment as evidenced by use of surge protectors attached to walls, daisy chained and use with large appliances. This affects 6 of 6 smoke compartments and may result in a fire.

NFPA 70, National Electrical Code 1999 Edition
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.

Findings:
On April 26, 2010 through April 28, 2010 from 8:30 a.m. to 4:00 p.m. on a tour of the facility with staff 4 the electrical wiring and equipment was observed.
April 26th, 2010
a. At 11:08 a.m. the refrigerator in the conference room in the basement was plugged into a surge protector.
April 27, 2010
a. At 10:19 a.m. in the Emergency Room waiting/lobby, extension cord with wall mounted fan plugged into it.
b. At 11:07 a.m. in the kitchen a surge protector mounted to the wall behind the ice machine.
c. At 11:09 a.m. in the hallway outside the kitchen soda and snack machine plugged into a surge protector.
d. At 11:12 a.m. in the laboratory in the microscope area 3 surge protectors daisy chained together.
e. At 11:35 a.m. in the obstetrics (OB) department a the refrigerator next to the pyxis machine was plugged into a surge protector.
f. At 1:55 p.m. 100 wing nurse station report room north wall electrical cove plate missing.
g. At 2:02 p.m. in pharmacy storage a refrigerator plugged into a surge protector
h. At 2:04 p.m. in room 209 an extension cord in use.