HospitalInspections.org

Based on observations it was determined that the facility failed to maintain the integrity of smoke separations between the corridor and use areas for 1 smoke compartment of the building. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:

On 2/6/2012 at 1:37 p.m., during the facility walk-through, there were two unsealed ceiling penetrations inside the computer room adjacent to room 105/106. The penetrations were approximately 4" diameter.

On 2/6/2012 at 2:58 p.m., during the facility walk-through, there were unsealed ceiling penetrations in the fire alarm control room.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record review it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80 for all corridors of the building. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19/18.2.3.5, (Table 18.3.2.1), 19/18.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Findings include, but are not limited to:

On 2/6/2012 at 11:02 a.m., during the record review process, the facility did not have access to the NFPA 80 1999 edition for inspecting, testing, and maintaining fire and smoke doors in the facility corridors. The facility was not keeping a monthly log of fire and smoke door inspections indicating doors that were found to need correction and the date of completion.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations it was determined that the facility failed to maintain accessible exits for 1 patient room of the building as required by 2000 NFPA 101, 19.2.2.2.4. This resulted in the potential for panic and injury to occupants. Findings include, but are not limited to:

On 2/6/2012 at 1:50 p.m., during the facility walk-through, there was a privacy curtain across the door opening to patient room 5/6 that was obstructing the door from closing in an emergency.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available to all staff, affecting the entire building. These conditions indicated that the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident which constituted immediate jeopardy (LSC 19/18.7.1.1). Findings include, but are not limited to:

On 2/6/2012, at 11:40 a.m., during the facility walk-through there was no emergency plan available to staff at the Emergency Department nurse station. Maintenance Director stated that the plans were no longer available to staff and that they were "all online now".

On 2/6/2012, at 10:33 a.m., during the facility record review process, there was no documentation of an annual review of the emergency plan, agreements, and procedures. The Code Red policy was reviewed 8/2010. The facility did not have a "defend in place" policy. There was no policy regarding notification to the OSFM Healthcare Unit for all fires, explosions, evacuations, and fire watches. There was no short term evacuation site agreements with Dallas High School and Dallas Civic Center. There was no transportation agreements in the plan.

On 2/6/2012, at 11:40 a.m., Staff # 2 acknowledged that the plan was not available to staff since it was put online. He indicated that the disaster box contained the plan, but upon opening the box found it was not there. He indicated that the plan was online, but was unable to show the surveyor any of the requested policies. He indicated the only training he had received on emergency preparedness was during the triage drill in 2011.

On 2/6/2012, at 3:10 p.m., Performance Improvement Coordinator agreed that the plan should have been available to staff and that they should have known the location and contents.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Corrective action to immediately protect residents from harm was implemented prior to the surveyor exiting the facility on February 6, 2012.

Based on record reviews and interviews it was determined that the facility failed to properly document fire drills and train staff on emergency preparedness. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2). Findings include, but are not limited to:

On 2/6/2012, at 10:32 a.m., Maintenance Director acknowledged that the fire drill forms did not contain the required information and stated that they were using the forms they had always used.

On 2/6/2012, at 11:40 a.m., Staff # 2 indicated that the only training he had received while employed at the hospital was the triage drill held in 2011. He also indicated that he had received no formal training on the emergency preparedness plan contents and use.

On 2/6/2012, at 10:33 a.m., during the facility record review process, the fire drill records did not include specific type of fire simulated, and time to complete the simulated evacuation.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions

Based on observations and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19/18.3.4, 9.6). Findings include, but are not limited to:

On 2/6/2012 at 2:17 p.m., during the facility walk-through, there was a chime strobe in the ED bathroom by room 11 and the Radiology bathrooms, a smoke detector in the doctor lounge breakroom at the appliances, there was no FACP sign on the fire alarm room door, and the fire alarm breaker (1LES-14) was painted red with nail polish.

On 2/6/2012 at 2:17 p.m., Maintenance Director acknowledged that the fire alarm items were not installed as required. He indicated he was unaware of the requirement and that they were compliant on previous surveys.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

On 2/6/2012 at 11:00 a.m., during the record review process, the facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company. The monthly and quarterly inspections were not conducted in accordance with NFPA 72.

On 2/6/2012 at 11:00 a.m., Maintenance Director acknowledged that the fire alarm was not inspected in accordance with NFPA and that they were going by what they had always done.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for all portions of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19/18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

On 2/6/2012 at 1:27 p.m., during the facility walk-through, there was an overhang outside the Infusion Clinic exceeding 4' that had combustible picnic tables and landscaping underneath that was not protected with an automatic sprinkler head. There was a CT changing room, a shower in the doctor sleeping room, an alcove by room 105/106, and a closet and shelf area in the ED nurse station that were not sprinklered.

On 2/6/2012 at 1:27 p.m., Maintenance Director acknowledged that the areas were not sprinklered as required in NFPA 13 and indicated that he was unaware of the requirement.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in conditions indicating that the facility's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident which constituted immediate jeopardy (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

On 2/6/2012, at 11:00 a.m., during the facility walk-through, there were no annual inspection tags affixed to the sprinkler riser and no forward flow results posted at the sprinkler riser. The water gauges on the sprinkler system were dated 1972 and were past due for 5 year calibration or replacement since 1977. There was a sprinkler head in the Surgery office that had paint on the fusible link and had not been replaced.

On 2/6/2012, at 11:00 a.m., Maintenance Director acknowledged that sprinkler system was not inspected annually ever since 1972 when it was installed. He indicated that the system had never had a 5 year 3-C inspection conducted ever since installed in 1972. He indicated he was unaware of the 5 year sprinkler gauge requirements. He indicated was not inspected in accordance with NFPA and that they were going by what they had always done.

On 2/6/2012, at 11:00 a.m., during the facility record review process, there was no documentation of weekly, monthly, quarterly, annual, 5 year or any other testing of the sprinkler system in accordance with NFPA 25. The facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company.

On 1/24/2012, at 10:00 a.m., Maintenance Director acknowledged that the forward flow test results were not available for review and were not done ever since installed in 1972.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Corrective action to immediately protect residents from harm was implemented prior to the surveyor exiting the facility on February 6, 2012.

Based on record review, observations and interview it was determined that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

On 2/6/2012 at 11:23 a.m., during the record review process the facility had no access to the adopted standards (NFPA 10 1998 edition) for inspecting, testing, and maintaining fire extinguishers.

On 2/6/2012 at 11:23 a.m., during the facility walk-through, there were several fire extinguishers near the ED nurse station, in the Rehab Gym office area and rear exit, and near room 103/104 that were not a minimum of 2A:10BC size. Fire extinguishers in the Emergency Department, mailroom hallway, and pre-op admitting were installed more than 5' to the top of the handle from the floor.

On 2/6/2012 at 11:23 a.m., Maintenance Director acknowledged that the extinguishers were the incorrect size and height above the floor and stated that they have been incorrect since the 1970's.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices around the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19/18.7.4). Findings include, but are not limited to:

On 2/6/2012, at 11:50 a.m., during the facility walk-through there were improperly discarded cigarettes at the exterior of the building in the combustible landscaping.

On 2/6/2012, at 11:50 a.m., Maintenance Director acknowledged that the cigarettes were improperly discarded and that the "smoke free campus policy was impossible to enforce".

On 2/6/2012, at 10:30 a.m., during the facility record review process, the smoking policy indicated that the facility was a smoke free campus and that smoking was not allowed on the premises or parking lots of the campus.

On 2/6/2012, at 3:10 p.m., Performance Improvement Coordinator acknowledged that the plan was not enforceable as written.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions

Based on record review and interview it was determined that the facility failed to maintain the ventilation hood and duct system in the kitchen per NFPA 96 and 17. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

On 2/6/2012 at 1:27 p.m., during the record review process, the facility was not having the kitchen hood suppression system inspected every 6 months. The records indicated that the hood was inspected on 10/21/10 and 9/21/11 which was 11 months apart. The 9/21/11 report indicated that the hood did not have an electrical shunt installed for the oven and fryer, and that there were missing activation links above the griddle and fryer that were noted on the 10/21/10 and 9/21/11 reports and the facility had not made the corrections when identified. The hood was checked and there were no links above the griddle and fryer.

On 2/6/2012 at 1:27 p.m., Maintenance Director acknowledged that the hood was not inspected every 6 months and that the noted items were not corrected. He indicated he was unaware of the 6 month requirement and that it was never noted on previous inspections. He indicated that the activation links were installed above the appliances.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:

On 2/6/2012 from 9:30 a.m. until 2:22 p.m., during the facility walk-through, there were unattended lifts, wheelchairs, Decon equipment, radiology carts, scales, waiting chairs, housekeeping and linen carts in the corridors. These were located at the Rehab office, in the corridor at room 105/106, at the old ED entrance, and in the mail room hallway.

On 2/6/2012 at 3:00 p.m., Maintenance Director acknowledged that the items were not removed from the corridor within 30 minutes or when staff went on break as required.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interview it was determined that the facility failed to ensure that humidity levels were maintained between 30% and 60% relative humidity in anesthetizing locations complied with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:

On 2/6/2012 at 11:50 a.m., during the facility walk-through, there was no means available for determining the humidity levels in anesthetizing locations.

On 2/6/2012 at 11:50 a.m., during the facility record review process, the facility had no record of the daily checks of anesthetizing locations for humidity levels prior to use.

On 2/6/2012 at 11:50 a.m., Maintenance Director acknowledged that the facility was not checking humidity levels in anesthetizing locations prior to use each day to ensure RH between 30% and 60% was maintained.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record review and interviews it was determined that the facility failed to properly maintain the generator in accordance with NFPA 110 for the entire building emergency power supply. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

On 2/6/2012 at 11:00 a.m., during the facility record review process, the facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company. The facility had no documentation of weekly electrolyte testing for the generator starting batteries, and the weekly and monthly testing was not done per the adopted standards.

On 2/6/2012 at 11:00 a.m., Maintenance Director acknowledged that the generator was not inspected in accordance with NFPA and that they were going by what they had always done. He indicated that they were not logging electrolyte levels weekly and that they were only checking fluid levels in the batteries.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., during the facility walk-through, there were relocatable power taps on the floor and permanently attached to the building that were being used on a permanent basis in lieu of additional outlets or additional wiring, or not listed for patient care areas in several areas of the hospital including Infusion room 6, Cardiopulmonary desk, staff computer training room, data room by 105/106, Rehab Services work stations and gym and office, Radiology doctor office, surgery breakroom, CT control room, I.T. office, Materials Management office, and Mammography.

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., during the facility walk-through, there were household appliances in use in lieu of commercial appliances in the Infusion Clinic, Rehab Gym office, ED Nourishment room, Doctor lounge breakroom, Surgery breakroom

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., Staff # 1, Maintenance Director acknowledged that the power strips were not to be used improperly in the facility. He indicated that they were present on previous surveys and believed they were approved.

Based on observations it was determined that the facility failed to maintain the integrity of smoke separations between the corridor and use areas for 1 smoke compartment of the building. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:

On 2/6/2012 at 1:37 p.m., during the facility walk-through, there were two unsealed ceiling penetrations inside the computer room adjacent to room 105/106. The penetrations were approximately 4" diameter.

On 2/6/2012 at 2:58 p.m., during the facility walk-through, there were unsealed ceiling penetrations in the fire alarm control room.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record review it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80 for all corridors of the building. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19/18.2.3.5, (Table 18.3.2.1), 19/18.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Findings include, but are not limited to:

On 2/6/2012 at 11:02 a.m., during the record review process, the facility did not have access to the NFPA 80 1999 edition for inspecting, testing, and maintaining fire and smoke doors in the facility corridors. The facility was not keeping a monthly log of fire and smoke door inspections indicating doors that were found to need correction and the date of completion.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations it was determined that the facility failed to maintain accessible exits for 1 patient room of the building as required by 2000 NFPA 101, 19.2.2.2.4. This resulted in the potential for panic and injury to occupants. Findings include, but are not limited to:

On 2/6/2012 at 1:50 p.m., during the facility walk-through, there was a privacy curtain across the door opening to patient room 5/6 that was obstructing the door from closing in an emergency.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available to all staff, affecting the entire building. These conditions indicated that the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident which constituted immediate jeopardy (LSC 19/18.7.1.1). Findings include, but are not limited to:

On 2/6/2012, at 11:40 a.m., during the facility walk-through there was no emergency plan available to staff at the Emergency Department nurse station. Maintenance Director stated that the plans were no longer available to staff and that they were "all online now".

On 2/6/2012, at 10:33 a.m., during the facility record review process, there was no documentation of an annual review of the emergency plan, agreements, and procedures. The Code Red policy was reviewed 8/2010. The facility did not have a "defend in place" policy. There was no policy regarding notification to the OSFM Healthcare Unit for all fires, explosions, evacuations, and fire watches. There was no short term evacuation site agreements with Dallas High School and Dallas Civic Center. There was no transportation agreements in the plan.

On 2/6/2012, at 11:40 a.m., Staff # 2 acknowledged that the plan was not available to staff since it was put online. He indicated that the disaster box contained the plan, but upon opening the box found it was not there. He indicated that the plan was online, but was unable to show the surveyor any of the requested policies. He indicated the only training he had received on emergency preparedness was during the triage drill in 2011.

On 2/6/2012, at 3:10 p.m., Performance Improvement Coordinator agreed that the plan should have been available to staff and that they should have known the location and contents.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Corrective action to immediately protect residents from harm was implemented prior to the surveyor exiting the facility on February 6, 2012.

Based on record reviews and interviews it was determined that the facility failed to properly document fire drills and train staff on emergency preparedness. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2). Findings include, but are not limited to:

On 2/6/2012, at 10:32 a.m., Maintenance Director acknowledged that the fire drill forms did not contain the required information and stated that they were using the forms they had always used.

On 2/6/2012, at 11:40 a.m., Staff # 2 indicated that the only training he had received while employed at the hospital was the triage drill held in 2011. He also indicated that he had received no formal training on the emergency preparedness plan contents and use.

On 2/6/2012, at 10:33 a.m., during the facility record review process, the fire drill records did not include specific type of fire simulated, and time to complete the simulated evacuation.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions

Based on observations and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19/18.3.4, 9.6). Findings include, but are not limited to:

On 2/6/2012 at 2:17 p.m., during the facility walk-through, there was a chime strobe in the ED bathroom by room 11 and the Radiology bathrooms, a smoke detector in the doctor lounge breakroom at the appliances, there was no FACP sign on the fire alarm room door, and the fire alarm breaker (1LES-14) was painted red with nail polish.

On 2/6/2012 at 2:17 p.m., Maintenance Director acknowledged that the fire alarm items were not installed as required. He indicated he was unaware of the requirement and that they were compliant on previous surveys.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

On 2/6/2012 at 11:00 a.m., during the record review process, the facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company. The monthly and quarterly inspections were not conducted in accordance with NFPA 72.

On 2/6/2012 at 11:00 a.m., Maintenance Director acknowledged that the fire alarm was not inspected in accordance with NFPA and that they were going by what they had always done.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for all portions of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19/18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

On 2/6/2012 at 1:27 p.m., during the facility walk-through, there was an overhang outside the Infusion Clinic exceeding 4' that had combustible picnic tables and landscaping underneath that was not protected with an automatic sprinkler head. There was a CT changing room, a shower in the doctor sleeping room, an alcove by room 105/106, and a closet and shelf area in the ED nurse station that were not sprinklered.

On 2/6/2012 at 1:27 p.m., Maintenance Director acknowledged that the areas were not sprinklered as required in NFPA 13 and indicated that he was unaware of the requirement.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in conditions indicating that the facility's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident which constituted immediate jeopardy (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

On 2/6/2012, at 11:00 a.m., during the facility walk-through, there were no annual inspection tags affixed to the sprinkler riser and no forward flow results posted at the sprinkler riser. The water gauges on the sprinkler system were dated 1972 and were past due for 5 year calibration or replacement since 1977. There was a sprinkler head in the Surgery office that had paint on the fusible link and had not been replaced.

On 2/6/2012, at 11:00 a.m., Maintenance Director acknowledged that sprinkler system was not inspected annually ever since 1972 when it was installed. He indicated that the system had never had a 5 year 3-C inspection conducted ever since installed in 1972. He indicated he was unaware of the 5 year sprinkler gauge requirements. He indicated was not inspected in accordance with NFPA and that they were going by what they had always done.

On 2/6/2012, at 11:00 a.m., during the facility record review process, there was no documentation of weekly, monthly, quarterly, annual, 5 year or any other testing of the sprinkler system in accordance with NFPA 25. The facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company.

On 1/24/2012, at 10:00 a.m., Maintenance Director acknowledged that the forward flow test results were not available for review and were not done ever since installed in 1972.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Corrective action to immediately protect residents from harm was implemented prior to the surveyor exiting the facility on February 6, 2012.

Based on record review, observations and interview it was determined that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

On 2/6/2012 at 11:23 a.m., during the record review process the facility had no access to the adopted standards (NFPA 10 1998 edition) for inspecting, testing, and maintaining fire extinguishers.

On 2/6/2012 at 11:23 a.m., during the facility walk-through, there were several fire extinguishers near the ED nurse station, in the Rehab Gym office area and rear exit, and near room 103/104 that were not a minimum of 2A:10BC size. Fire extinguishers in the Emergency Department, mailroom hallway, and pre-op admitting were installed more than 5' to the top of the handle from the floor.

On 2/6/2012 at 11:23 a.m., Maintenance Director acknowledged that the extinguishers were the incorrect size and height above the floor and stated that they have been incorrect since the 1970's.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices around the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19/18.7.4). Findings include, but are not limited to:

On 2/6/2012, at 11:50 a.m., during the facility walk-through there were improperly discarded cigarettes at the exterior of the building in the combustible landscaping.

On 2/6/2012, at 11:50 a.m., Maintenance Director acknowledged that the cigarettes were improperly discarded and that the "smoke free campus policy was impossible to enforce".

On 2/6/2012, at 10:30 a.m., during the facility record review process, the smoking policy indicated that the facility was a smoke free campus and that smoking was not allowed on the premises or parking lots of the campus.

On 2/6/2012, at 3:10 p.m., Performance Improvement Coordinator acknowledged that the plan was not enforceable as written.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions

Based on record review and interview it was determined that the facility failed to maintain the ventilation hood and duct system in the kitchen per NFPA 96 and 17. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

On 2/6/2012 at 1:27 p.m., during the record review process, the facility was not having the kitchen hood suppression system inspected every 6 months. The records indicated that the hood was inspected on 10/21/10 and 9/21/11 which was 11 months apart. The 9/21/11 report indicated that the hood did not have an electrical shunt installed for the oven and fryer, and that there were missing activation links above the griddle and fryer that were noted on the 10/21/10 and 9/21/11 reports and the facility had not made the corrections when identified. The hood was checked and there were no links above the griddle and fryer.

On 2/6/2012 at 1:27 p.m., Maintenance Director acknowledged that the hood was not inspected every 6 months and that the noted items were not corrected. He indicated he was unaware of the 6 month requirement and that it was never noted on previous inspections. He indicated that the activation links were installed above the appliances.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:

On 2/6/2012 from 9:30 a.m. until 2:22 p.m., during the facility walk-through, there were unattended lifts, wheelchairs, Decon equipment, radiology carts, scales, waiting chairs, housekeeping and linen carts in the corridors. These were located at the Rehab office, in the corridor at room 105/106, at the old ED entrance, and in the mail room hallway.

On 2/6/2012 at 3:00 p.m., Maintenance Director acknowledged that the items were not removed from the corridor within 30 minutes or when staff went on break as required.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interview it was determined that the facility failed to ensure that humidity levels were maintained between 30% and 60% relative humidity in anesthetizing locations complied with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:

On 2/6/2012 at 11:50 a.m., during the facility walk-through, there was no means available for determining the humidity levels in anesthetizing locations.

On 2/6/2012 at 11:50 a.m., during the facility record review process, the facility had no record of the daily checks of anesthetizing locations for humidity levels prior to use.

On 2/6/2012 at 11:50 a.m., Maintenance Director acknowledged that the facility was not checking humidity levels in anesthetizing locations prior to use each day to ensure RH between 30% and 60% was maintained.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on record review and interviews it was determined that the facility failed to properly maintain the generator in accordance with NFPA 110 for the entire building emergency power supply. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

On 2/6/2012 at 11:00 a.m., during the facility record review process, the facility did not have access to the adopted standards, documentation of technician competence, or third party agreements with a system company. The facility had no documentation of weekly electrolyte testing for the generator starting batteries, and the weekly and monthly testing was not done per the adopted standards.

On 2/6/2012 at 11:00 a.m., Maintenance Director acknowledged that the generator was not inspected in accordance with NFPA and that they were going by what they had always done. He indicated that they were not logging electrolyte levels weekly and that they were only checking fluid levels in the batteries.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., during the facility walk-through, there were relocatable power taps on the floor and permanently attached to the building that were being used on a permanent basis in lieu of additional outlets or additional wiring, or not listed for patient care areas in several areas of the hospital including Infusion room 6, Cardiopulmonary desk, staff computer training room, data room by 105/106, Rehab Services work stations and gym and office, Radiology doctor office, surgery breakroom, CT control room, I.T. office, Materials Management office, and Mammography.

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., during the facility walk-through, there were household appliances in use in lieu of commercial appliances in the Infusion Clinic, Rehab Gym office, ED Nourishment room, Doctor lounge breakroom, Surgery breakroom

On 2/6/2012 between 1:28 p.m. and 2:51 p.m., Staff # 1, Maintenance Director acknowledged that the power strips were not to be used improperly in the facility. He indicated that they were present on previous surveys and believed they were approved.