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1. Based on observation, it was determined the facility failed to maintain smoke barrier walls to provide a one half hour fire resistance rating as evidenced by unsealed penetrations of smoke barrier walls penetrated by pipes, conduits, and wires with a fire rated material to resist the passage of smoke from one side of the smoke barrier to the other side at four of four locations. The failed practice had the potential to affect all patients admitted to the facility and 59 of 59 patient in the facility on the day of the survey. The findings follow:

A. On a tour of the facility with the Maintenance Director at 1300 on 03/18/10, penetrations at the following locations were observed not sealed with a fire rated material to resist the passage of smoke:
1) Two unsealed penetrations above the smoke barrier doors located near Surgery Waiting.
2) One unsealed penetration above the smoke barrier doors located near Corridor 9.
3) Two unsealed penetrations above the smoke barrier doors located at Surgery.
4) Three unsealed penetrations above the smoke barrier doors located at the entrance to Radiology.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

Based on observation, it was determined the facility failed to maintain smoke barrier walls to provide a one half hour fire resistance rating as evidenced by unsealed penetrations of smoke barrier walls penetrated by pipes, conduits, and wires with a fire rated material to resist the passage of smoke from one side of the smoke barrier to the other side at five of six locations. The failed practice had the potential to affect all patients admitted to the facility and 59 of 59 patient in the facility on the day of the survey. The findings follow:

A. On a tour of the facility with the Maintenance Director at 1300 on 03/18/10, penetrations at the following locations were observed not sealed with a fire rated material to resist the passage of smoke:
1) One unsealed penetrations above the smoke barrier doors located near Corridor 8.
2) Three unsealed penetrations above the smoke barrier doors located near the Health Information Management office.
3) One unsealed penetration above the smoke barrier doors located at the Intensive Care Unit entrance.
4) One unsealed penetration above the smoke barrier doors located near Patient Room.
5) One unsealed penetration above the smoke barrier doors located at the Inpatient Rehabilitation Unit entrance.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

2. Based on humidity log review and interview it was determined the facility failed to maintain the humidity level above 35% in 4 out of 4 operating rooms from December 2009 to March 2010. The failed practice had the potential to affect all patients admitted for surgery and five of five surgical patients on the day of the survey. The findings follow:

A. Review of operating room humidity logs provided by the Director of Surgery on 03/17/10 at 1500 revealed humidity level below 35% were recorded as follows:
1) In Operating Room 2, a humidity level below 35% was recorded on 41 of 74 surgical days from December 2009 to March 2010.
2) In Operating Room 3, a humidity level below 35% was recorded on 38 of 74 surgical days from December 2009 to March 2010.
3) In Operating Room 4, a humidity level below 35% was recorded on 40 of 74 surgical days from December 2009 to March 2010.
4) In the Caesarian Section Operating Room, a humidity level below 35% was recorded on 42 of 74 surgical days from December 2009 to March 2010.
B. In an interview conducted on 03/17/10 at 1515, the Director of Surgery stated the Maintenance Department was contacted on days when humidity outside the required range was recorded.
C. In an interview conducted on 03/18/10 at 1000, the Maintenance Director stated the Maintenance Department had no record of being contacted about the humidity level in the operating rooms and was not aware of any problems with humidity in that area of the facility.

1. Based on observation, it was determined the facility failed to maintain smoke barrier walls to provide a one half hour fire resistance rating as evidenced by unsealed penetrations of smoke barrier walls penetrated by pipes, conduits, and wires with a fire rated material to resist the passage of smoke from one side of the smoke barrier to the other side at four of four locations. The failed practice had the potential to affect all patients admitted to the facility and 59 of 59 patient in the facility on the day of the survey. The findings follow:

A. On a tour of the facility with the Maintenance Director at 1300 on 03/18/10, penetrations at the following locations were observed not sealed with a fire rated material to resist the passage of smoke:
1) Two unsealed penetrations above the smoke barrier doors located near Surgery Waiting.
2) One unsealed penetration above the smoke barrier doors located near Corridor 9.
3) Two unsealed penetrations above the smoke barrier doors located at Surgery.
4) Three unsealed penetrations above the smoke barrier doors located at the entrance to Radiology.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

Based on observation, it was determined the facility failed to maintain smoke barrier walls to provide a one half hour fire resistance rating as evidenced by unsealed penetrations of smoke barrier walls penetrated by pipes, conduits, and wires with a fire rated material to resist the passage of smoke from one side of the smoke barrier to the other side at five of six locations. The failed practice had the potential to affect all patients admitted to the facility and 59 of 59 patient in the facility on the day of the survey. The findings follow:

A. On a tour of the facility with the Maintenance Director at 1300 on 03/18/10, penetrations at the following locations were observed not sealed with a fire rated material to resist the passage of smoke:
1) One unsealed penetrations above the smoke barrier doors located near Corridor 8.
2) Three unsealed penetrations above the smoke barrier doors located near the Health Information Management office.
3) One unsealed penetration above the smoke barrier doors located at the Intensive Care Unit entrance.
4) One unsealed penetration above the smoke barrier doors located near Patient Room.
5) One unsealed penetration above the smoke barrier doors located at the Inpatient Rehabilitation Unit entrance.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

2. Based on humidity log review and interview it was determined the facility failed to maintain the humidity level above 35% in 4 out of 4 operating rooms from December 2009 to March 2010. The failed practice had the potential to affect all patients admitted for surgery and five of five surgical patients on the day of the survey. The findings follow:

A. Review of operating room humidity logs provided by the Director of Surgery on 03/17/10 at 1500 revealed humidity level below 35% were recorded as follows:
1) In Operating Room 2, a humidity level below 35% was recorded on 41 of 74 surgical days from December 2009 to March 2010.
2) In Operating Room 3, a humidity level below 35% was recorded on 38 of 74 surgical days from December 2009 to March 2010.
3) In Operating Room 4, a humidity level below 35% was recorded on 40 of 74 surgical days from December 2009 to March 2010.
4) In the Caesarian Section Operating Room, a humidity level below 35% was recorded on 42 of 74 surgical days from December 2009 to March 2010.
B. In an interview conducted on 03/17/10 at 1515, the Director of Surgery stated the Maintenance Department was contacted on days when humidity outside the required range was recorded.
C. In an interview conducted on 03/18/10 at 1000, the Maintenance Director stated the Maintenance Department had no record of being contacted about the humidity level in the operating rooms and was not aware of any problems with humidity in that area of the facility.