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Based on observation and interview, the hospital failed to provide emergency lighting in each operating room to provide illumination automatically in the event of opening a circuit breaker or manual accidental opening of a switch controlling normal lighting..

Failure to provide emergency lighting in each operating room risks patient safety during a procedure should an accidental loss of power to the lighting.

Findings:

During a tour of the Surgery Department on 9/29/10, no emergency lighting was found in Operating Room #1 or Operating Room #2.

Environment for Care Manager (Staff Member #3) stated during an interview on 9/29/10 at 10:00 AM "The operating rooms are on the emergency generator, but the generator would not activate if a circuit breaker or switch as turned off."

Based on review of fire alarm system maintenance records, the hospital failed to maintain the fire alarm system in accordance with NFPA 72. Failure to maintain the fire alarm system risks building occupant ability to exit the building during an emergency event.

Findings:

Review of fire alarm system maintenance records showed not evidence of preventative maintenance since May 28, 2009.

Based on observation, the hospital failed to install the automatic sprinkler system in accordance with NFPA 13 for the full coverage of the spaces. Failure to ensure full automatic sprinkler system coverage risks failure of the system to extinguish a fire.

Findings:

During tour of the hospital on 9/28/10, the information technology server room was found to have one sprinkler install on one side of a drop down partition approximately 12 inches. On the other side of this partition, there was no sprinkler coverage.

The Environment for Care Manager (Staff Member #3) confirmed this finding.

Based on review of automatic sprinkler system maintenance records and interview, the hospital failed to continuously maintain the automatic sprinkler system in a reliable operating condition. Failure to maintain the automatic sprinkler system risk building occupants from fire spread should an operational failure occur.

Findings:

Automatic sprinkler system maintenance documents for 1/14/10 stated "Both tamper switches on OS&Y control valves ... did not activate any signals to fire alarm panel (same as last few years)."

The Environment for Care Manager (Staff Member #3) stated during an interview on 9/29/10 at 3:30 PM "I was told this was repaired, but I can't find an document to show this."

Based on review of kitchen hood maintenance records, observation, and interview, the hospital failed to install and maintain the kitchen hood [Reference NFPA 96]. Failure to install and maintain the kitchen hood risks failure to operate during a fire event.

Findings:

Hospital maintenance records for the kitchen grill hood had no evidence of 6 months inspection and cleaning intervals.

During a tour of the kitchen on 9/28/10 screen baffles were observed on the kitchen hood.

Interview with the Environment for Care Manager (Staff Member #3) on 9/29/10 confirmed the kitchen hood is not serviced every 6 months.

Based on observation, the hospital failed to ensure exit corridor clearance. Failure to maintain the exit corridor clear and free of obstructions, risks the ability of building occupants to exit during a fire event.

Findings:

During a tour of the hospital on 9/28/10, the corridor near the information technology office and Bragg Conference Room was found to be obstructed with a copy machine, printer, and computer server rack.

Based on observation and interview the hospital failed to instal oxygen shutoff valves outside each anesthetizing location: Operating Room #1, Operating Room #2, and the Postanesthesia Recovery Room.

Failure to provide these shutoff valves risks loss of oxygen to patients in all spaces should an emergency require shutoff to one of the spaces.

[Reference : NFPA 994.3.1.2.3(n) "A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others..."

Findings:

During a tour of the Surgery Department on 9/29/10, the Environment for Care Manager (Staff Member #3) stated at 9:30 AM "All the operating rooms and the PACU are on the same oxygen shut off valve."

Based on review of hospital maintenance records and interview with hospital staff, the hospital failed to document generator monthly load testing. Failure to document generator monthly load testing risks generator failure during emergency demand.

Findings:

Generator maintenance records did not have evidence for run test under load for May 2010. The records did not include complete information on: date of inspection, time of inspection, generator condition (leaks, hoses, fuel supply, oil, belts, battery, cooling system, transfer switch), start and end times of the load test, generator output readings during load test, and signature of individual conducting inspection, testing,or repair.

The Environment for Care Manager (Staff Member #3) confirmed generator maintenance records were not complete.

Based on observation and interview, the hospital failed to provide emergency lighting in each operating room to provide illumination automatically in the event of opening a circuit breaker or manual accidental opening of a switch controlling normal lighting..

Failure to provide emergency lighting in each operating room risks patient safety during a procedure should an accidental loss of power to the lighting.

Findings:

During a tour of the Surgery Department on 9/29/10, no emergency lighting was found in Operating Room #1 or Operating Room #2.

Environment for Care Manager (Staff Member #3) stated during an interview on 9/29/10 at 10:00 AM "The operating rooms are on the emergency generator, but the generator would not activate if a circuit breaker or switch as turned off."

Based on review of fire alarm system maintenance records, the hospital failed to maintain the fire alarm system in accordance with NFPA 72. Failure to maintain the fire alarm system risks building occupant ability to exit the building during an emergency event.

Findings:

Review of fire alarm system maintenance records showed not evidence of preventative maintenance since May 28, 2009.

Based on observation, the hospital failed to install the automatic sprinkler system in accordance with NFPA 13 for the full coverage of the spaces. Failure to ensure full automatic sprinkler system coverage risks failure of the system to extinguish a fire.

Findings:

During tour of the hospital on 9/28/10, the information technology server room was found to have one sprinkler install on one side of a drop down partition approximately 12 inches. On the other side of this partition, there was no sprinkler coverage.

The Environment for Care Manager (Staff Member #3) confirmed this finding.

Based on review of automatic sprinkler system maintenance records and interview, the hospital failed to continuously maintain the automatic sprinkler system in a reliable operating condition. Failure to maintain the automatic sprinkler system risk building occupants from fire spread should an operational failure occur.

Findings:

Automatic sprinkler system maintenance documents for 1/14/10 stated "Both tamper switches on OS&Y control valves ... did not activate any signals to fire alarm panel (same as last few years)."

The Environment for Care Manager (Staff Member #3) stated during an interview on 9/29/10 at 3:30 PM "I was told this was repaired, but I can't find an document to show this."

Based on review of kitchen hood maintenance records, observation, and interview, the hospital failed to install and maintain the kitchen hood [Reference NFPA 96]. Failure to install and maintain the kitchen hood risks failure to operate during a fire event.

Findings:

Hospital maintenance records for the kitchen grill hood had no evidence of 6 months inspection and cleaning intervals.

During a tour of the kitchen on 9/28/10 screen baffles were observed on the kitchen hood.

Interview with the Environment for Care Manager (Staff Member #3) on 9/29/10 confirmed the kitchen hood is not serviced every 6 months.

Based on observation, the hospital failed to ensure exit corridor clearance. Failure to maintain the exit corridor clear and free of obstructions, risks the ability of building occupants to exit during a fire event.

Findings:

During a tour of the hospital on 9/28/10, the corridor near the information technology office and Bragg Conference Room was found to be obstructed with a copy machine, printer, and computer server rack.

Based on observation and interview the hospital failed to instal oxygen shutoff valves outside each anesthetizing location: Operating Room #1, Operating Room #2, and the Postanesthesia Recovery Room.

Failure to provide these shutoff valves risks loss of oxygen to patients in all spaces should an emergency require shutoff to one of the spaces.

[Reference : NFPA 994.3.1.2.3(n) "A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others..."

Findings:

During a tour of the Surgery Department on 9/29/10, the Environment for Care Manager (Staff Member #3) stated at 9:30 AM "All the operating rooms and the PACU are on the same oxygen shut off valve."

Based on review of hospital maintenance records and interview with hospital staff, the hospital failed to document generator monthly load testing. Failure to document generator monthly load testing risks generator failure during emergency demand.

Findings:

Generator maintenance records did not have evidence for run test under load for May 2010. The records did not include complete information on: date of inspection, time of inspection, generator condition (leaks, hoses, fuel supply, oil, belts, battery, cooling system, transfer switch), start and end times of the load test, generator output readings during load test, and signature of individual conducting inspection, testing,or repair.

The Environment for Care Manager (Staff Member #3) confirmed generator maintenance records were not complete.