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Based on observation and hospital staff interview, the hospital was unable to demonstrate a flame spread rating of Class A or Class B for exposed interior finish on the corridor walls of the OB unit.

Failure to ensure Class A or Class B flame spread rating for interior finish on corridor walls increases the risk of fire spread and jeopardizes the ability of occupants to exit during a fire event.

Findings:

During a tour of the OB Unit on 1/19/11, 3/8 inch painted bead board wainscot was observed installed 4 feet up the corridor walls.

Hospital maintenance staff (Staff Member #7) and the Engineering Manager (Staff Member #8) stated the wainscoting had been installed about 1.5 years ago and neither the material or the paint had a flame spread rating.

Based on observation and interview, the hospital failed to connect magnetic hold open device on a smoke barrier door to the fire alarm system for automatic closure upon activation.

Failure to connect smoke door magnetic hold open devices to the fire alarm system for automatic closure, risks the passage of smoke into the corridor during a fire and jeopardizes the ability of occupants to exit during a fire emergency.

Findings:

During a tour of the main floor on 1/19/11, the door to the OB/Conference/Staff lounge room was noted to be on a magnetic hold open device. Maintenance staff (Staff Member #7) stated that the device was not connected to the fire/sprinkler system, and would not close automatically during activation of the fire alarm/sprinkler system.

Based on observation, the hospital failed to locate 50 gallon recycling containers in a room protected as a hazardous area.

Failure to place trash collection receptacles in a protected area risks the production of a smoky fire in corridors and jeopardizes the ability of occupants to exit during a fire.

Findings:

During a tour of the lower level of the hospital on 1/19/11, 3 - 50 gallon paper recycling containers were found in the lower level exit corridor.

Based on review of hospital records and interview with hospital staff, the hospital failed to maintain relative humidity in each operating room equal to or greater than 35%.

Failure to ensure relative humidity is at least 35% in each operating room increases the risk of electrostatic spark discharges which may ignite a fire and endanger patients and others. :

Findings

During a tour of the Surgery Department on 1/19/11, logs of relative humidity readings in the OR were reviewed. Entry's showed that a minimum of 35% relative humidity was not recorded for 16 of 16 operating days in January, 12 of 12 operating days in February, 19 of 21 operating days in March, 10 of 16 operating days in April, 13 of 21 operating days in May, 3 of 21 operating days in October, and 17 of 18 operating days in December 2010.

The Surgery Manager (Staff Member #9) stated maintenance is notified but that surgery is done on days when low relative humidity is noted.

Based on observation, the hospital did not seal conduit penetrations in smoke and fire barriers.

Failure to seal conduit penetrations in smoke and fire barriers risks the passage of smoke through the barrier and places all building occupants at risk.

Findings:

During a tour of the main floor on 1/19/11, penetrations were observed in the smoke barrier wall. During a tour of the lower level on 1/20/11, penetrations were observed in the communication closet wall above the old receiving room.

THESE PENETRATIONS WERE CORRECTED DURING THE SURVEY.

Based on interview and review of hospital maintenance documents, the hospital was not able to demonstrate that the emergency generator was run under load (30% of the name plate rating) at least 20 to 40 day intervals (NFPA 99 3.4.4.1).

Failure to test the generator under load risks failure during times of need.

Findings:

Maintenance staff (Staff Member #1) stated during an interview on 1/19/11 that the control panel for the generator had been replaced and the system recalibrated and since that time the 30% of name plate rating for the load run was not achieved. The hospital did not check generator exhaust temperatures and had not done any load banking to ensure generator function under load.

Based upon staff interviews, observations and hospital plan reviews, the facility was unable to verify that the Type One Essential Electrical System (EES) was divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99 (3.4.2.2.2).

Failure to divide the EES in accordance with applicable codes risks failure of essential electrical systems during a power outage.

Findings include but are not limited to:

Examination of hospital electrical plans on 1/19/11, showed the blood bank alarm, elevator controls, and the medical gas alarms on the fire life safety branch of the Type I emergency power system.

During an interview on 1/21/11, hospital maintenance staff (Staff Member #1) explained that a project is underway to configure the critical care and life safety branches of the emergency power system to conform to NFPA 99.

Based on observation, the hospital failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2.

Failure to maintain electrical wiring and equipment in accordance with the National Electrical Code increase the risk of fire and places all building occupant at risk.

Findings:

During a tour of the Radiology Department on 1/19/11, piggy backed electrical multi outlet power strips were found in use in the reception area.

During a tour of the exterior of the hospital Emergency Department on 1/19/11, the outside Emergency Department sign was found to be connected to the electrical supply with an extension cord. Hospital staff (Staff Member #7) stated that this had been the installation for over two years. The hospital engineering manager (Staff Member #9) confirmed this.

Based on observation and hospital staff interview, the hospital was unable to demonstrate a flame spread rating of Class A or Class B for exposed interior finish on the corridor walls of the OB unit.

Failure to ensure Class A or Class B flame spread rating for interior finish on corridor walls increases the risk of fire spread and jeopardizes the ability of occupants to exit during a fire event.

Findings:

During a tour of the OB Unit on 1/19/11, 3/8 inch painted bead board wainscot was observed installed 4 feet up the corridor walls.

Hospital maintenance staff (Staff Member #7) and the Engineering Manager (Staff Member #8) stated the wainscoting had been installed about 1.5 years ago and neither the material or the paint had a flame spread rating.

Based on observation and interview, the hospital failed to connect magnetic hold open device on a smoke barrier door to the fire alarm system for automatic closure upon activation.

Failure to connect smoke door magnetic hold open devices to the fire alarm system for automatic closure, risks the passage of smoke into the corridor during a fire and jeopardizes the ability of occupants to exit during a fire emergency.

Findings:

During a tour of the main floor on 1/19/11, the door to the OB/Conference/Staff lounge room was noted to be on a magnetic hold open device. Maintenance staff (Staff Member #7) stated that the device was not connected to the fire/sprinkler system, and would not close automatically during activation of the fire alarm/sprinkler system.

Based on observation, the hospital failed to locate 50 gallon recycling containers in a room protected as a hazardous area.

Failure to place trash collection receptacles in a protected area risks the production of a smoky fire in corridors and jeopardizes the ability of occupants to exit during a fire.

Findings:

During a tour of the lower level of the hospital on 1/19/11, 3 - 50 gallon paper recycling containers were found in the lower level exit corridor.

Based on review of hospital records and interview with hospital staff, the hospital failed to maintain relative humidity in each operating room equal to or greater than 35%.

Failure to ensure relative humidity is at least 35% in each operating room increases the risk of electrostatic spark discharges which may ignite a fire and endanger patients and others. :

Findings

During a tour of the Surgery Department on 1/19/11, logs of relative humidity readings in the OR were reviewed. Entry's showed that a minimum of 35% relative humidity was not recorded for 16 of 16 operating days in January, 12 of 12 operating days in February, 19 of 21 operating days in March, 10 of 16 operating days in April, 13 of 21 operating days in May, 3 of 21 operating days in October, and 17 of 18 operating days in December 2010.

The Surgery Manager (Staff Member #9) stated maintenance is notified but that surgery is done on days when low relative humidity is noted.

Based on observation, the hospital did not seal conduit penetrations in smoke and fire barriers.

Failure to seal conduit penetrations in smoke and fire barriers risks the passage of smoke through the barrier and places all building occupants at risk.

Findings:

During a tour of the main floor on 1/19/11, penetrations were observed in the smoke barrier wall. During a tour of the lower level on 1/20/11, penetrations were observed in the communication closet wall above the old receiving room.

THESE PENETRATIONS WERE CORRECTED DURING THE SURVEY.

Based on interview and review of hospital maintenance documents, the hospital was not able to demonstrate that the emergency generator was run under load (30% of the name plate rating) at least 20 to 40 day intervals (NFPA 99 3.4.4.1).

Failure to test the generator under load risks failure during times of need.

Findings:

Maintenance staff (Staff Member #1) stated during an interview on 1/19/11 that the control panel for the generator had been replaced and the system recalibrated and since that time the 30% of name plate rating for the load run was not achieved. The hospital did not check generator exhaust temperatures and had not done any load banking to ensure generator function under load.

Based upon staff interviews, observations and hospital plan reviews, the facility was unable to verify that the Type One Essential Electrical System (EES) was divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99 (3.4.2.2.2).

Failure to divide the EES in accordance with applicable codes risks failure of essential electrical systems during a power outage.

Findings include but are not limited to:

Examination of hospital electrical plans on 1/19/11, showed the blood bank alarm, elevator controls, and the medical gas alarms on the fire life safety branch of the Type I emergency power system.

During an interview on 1/21/11, hospital maintenance staff (Staff Member #1) explained that a project is underway to configure the critical care and life safety branches of the emergency power system to conform to NFPA 99.

Based on observation, the hospital failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2.

Failure to maintain electrical wiring and equipment in accordance with the National Electrical Code increase the risk of fire and places all building occupant at risk.

Findings:

During a tour of the Radiology Department on 1/19/11, piggy backed electrical multi outlet power strips were found in use in the reception area.

During a tour of the exterior of the hospital Emergency Department on 1/19/11, the outside Emergency Department sign was found to be connected to the electrical supply with an extension cord. Hospital staff (Staff Member #7) stated that this had been the installation for over two years. The hospital engineering manager (Staff Member #9) confirmed this.