HospitalInspections.org

Based on observation, during the facility tour, and staff verification it was determined this facility failed to ensure one vertical opening was protected with an at least a one hour fire resistance rating. This had the potential to affect all persons utilizing this area of the facility. The patient census at the beginning of the survey was nine.

Findings include:

The facility tour of the second and third floor took place on 01/21/14 with staff A1, and B2.

During the tour of the third floor medical surgical unit, an observation, at 2:41 PM., of the west stairwell door, located near room 314, revealed this door failed to securely close and latch shut.

This observation was confirmed by staff members A1, and B2, during the tour on 01/21/14.

Based on Observation during the facility tour and staff verification it was determined this facility failed to ensure all exits were marked by approved, readily visible signs in order to provide occupants directions to a safe area. This had the potential to affect all persons who utilized this area of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Tour of the facility occurred on 01/21/14 to 01/22/14, with staff members A1, and B2. At 8:30 AM on 01/22/14, while touring the kitchen area, observation of the double doors, located at the northwest section of the kitchen, revealed there was not an exit sign present. It was difficult to see this exit if a person was standing at the east end of the room.

This finding was verified by Staff B2 during this observation on 01/22/14.

Based on facility tour, and staff verification it was determined the facility failed to ensure smoke barriers on the second and third floors were maintained to provide at least a one hour fire resistance rating. This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Facility tour of the second and third floors took place on 01/21/14, with staff members A1, and B2. An observation, of the third floor smoke barrier, revealed there were penetrations in the smoke barrier, above the ceiling tiles in the following locations:

1) Above the ceiling tiles at the east double doors leading to the medical surgical unit, an observation, on 01/21/14 at 2:50 PM., revealed three unsealed conduits. On 01/21/14 at 2:50 PM., an observation, of the opposite side of the doors, revealed another open end conduit.

2) On 01/21/14 at 2:47 PM., an observation, of the smoke barrier, located within the medication room of the medical surgical unit, adjacent to the smoke barrier, revealed above the ceiling tiles, over the clock, an approximately two and a half inch penetration was not sealed around the annular space.


3) On 01/21/14 at 2:58 PM., an observation, was made of one open end conduit, located above the ceiling tiles of the smoke barrier adjacent to the sleep lab. This observation was made from the nurses' station side.

The above findings were verified by staff members A1, and B2 during the tour on 01/21/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure nine areas in the first floor smoke barrier were maintained to provide at least a one hour fire resistance rating. This had the potential to affect all persons utilizing these nine areas of the first floor of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Tour of the facility occurred on 01/21/14 to 01/22/14, with staff members A1 and B2. During tour of the first floor smoke barrier, penetrations in the one hour fire rated construction were observed in the following nine locations:

1) An observation at 4:23 PM on 01/21/14, of the smoke barrier from within the cardio staff break room revealed an approximate three foot by four inch section of drywall was missing and there were two unsealed conduits observed in the smoke barrier.

2) At 4:47 PM on 01/21/14, while standing in the corridor outside the southwest corner of the gift shop and at the smoke barrier door which leads to the back door of the kitchen, observation revealed four penetrations around conduits above the smoke barrier door. Observation of the area located to the right of the smoke barrier door when facing the small section of the block wall, located between the door and the back of the elevators, revealed four penetrations ranging from one to two inches in diameter.

3) At 5:01 PM on 01/21/14, when standing just inside the double doors of the cafe and along the east/west smoke barrier observation revealed two unsealed conduits with penetrations around the annular space. One of the two conduits observed did not have fire sealant within the inner diameter of the open end.

4) Continuing along the same smoke barrier at approximately fifteen feet further, observation revealed near the upper part of the drywall, a gap of approximate one inch by four inches located between two sections of drywall. Observation also revealed a solid conduit and a flex conduit through the smoke barrier were not sealed around the annular space.

5) At 4:55 PM on 01/21/14, while standing within the volunteers' office an observation revealed a section of drywall missing from both sides of the east wall of the smoke barrier measuring an approximate six foot by two and a half foot.

6) At 8:35 AM on 01/22/14, while standing within the kitchen of the dietary department, an observation revealed multiple penetrations around insulated lines, ducts and conduits in the smoke barrier in the north, south and west walls.

7) At 8:47 AM on 01/22/14, when exiting from the south doors of the kitchen area into the corridor and at the women's locker room, an observation revealed the smoke barrier door of the women's locker room failed to latch securely.

8) At 8:44 AM on 01/22/14, continuing down the corridor and at the small storage room located across from the maintenance department and just north of the double corridor doors, observation revealed an opening at the top of the drywall above the smoke barrier door to the storage room that measured approximately eight inches by three inches.

9) At the west exit door of the emergency department at 9:43 AM on 01/22/14, observation was made of an approximate four inch open end conduit which was not sealed at the bottom around the annular space.

10) Observation was made above the squad equipment room smoke barrier door at 9:48 AM on 01/22/14, of an opening around a row of silver conduits measuring approximately four feet long by three inches wide.


These findings were verified by staff members A1 and B2 during tour of the first floor of the facility on 01/22/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure four doors located in the smoke barrier would close properly providing protection from fire and smoke (Two of these doors were held open by devices that prevented the doors from automatically closing, one of the doors had no automatic closure device, and one of the doors left a gap when closed.). This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the pathology office on 01/21/14 at 4:50 PM., an observation of the pathology office smoke barrier door revealed the door was propped open with a small rubber wedge, preventing the door from closing automatically during a fire alarm.

2) During tour of the kitchen area of the dietary department on 01/22/14, between 8:30 AM and 8:42 AM, an observation revealed kick stops (small metal and rubber door stops utilized to manually hold doors open) were mounted on the bottom corner of three of the four double door smoke barrier doors. Observation revealed the west doors had the kick stops activated and the doors were manually held open. Observation of these doors closing revealed the southeast doors failed to close properly.

3) During tour of the smoke barrier on 01/22/14 at 9:15 AM; at the west end of the central sterile room and at the outside of the east emergency department smoke barrier door, observation revealed this door failed to close securely, which left a gap between the door and the door jam.
Just to the left of this door, observation of a smoke barrier door leading into the steam sterilizer room, and another smoke barrier door leading into the sterile processing department, did not have automatic closing or self-closing devices.

These findings were verified by staff members A1, and B2 during the tour of the facility on 01/21/14 and 01/22/14, at the time of the observations.

Based on observations during the facility tour, and staff verification it was determined this facility failed to ensure two of the facility's smoke barrier doors provided a rating of at least 20 minutes of fire protection. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

A tour of the second and third floors took place, on 01/21/14, with staff members A1, and B2.

1) During the tour of the second floor, observation of the north end smoke barrier doors east of the elevators, revealed a gap, greater than one eighth inch, between the two door leafs, when in the closed position. This observation took place at 3:24 PM.

2) During the tour of the third floor, observation of the south end smoke barrier doors nearest the conference room, revealed a gap, greater than one eighth inch between the two door leafs, when in the closed position. This observation took place at 2:20 PM.

These findings were verified by staff members A1, and B2, at the time of the observations on 01/21/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure three hazardous areas were protected with at least a one hour fire rated barrier. This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the arterial blood gas room on 01/21/14 at 3:50 PM., observation of the smoke barrier revealed an approximate one quarter inch gap between the top of the drywall and the upper deck extending approximately six feet in length. Additionally, seven conduits observed in the smoke barrier were unsealed around the annular space and three were not sealed at the ends.

2) During tour of the medical records room located in the clinic, at 4:02 PM on 01/21/14, an observation revealed a small hole in the west wall and one conduit was not sealed.

3) During tour of the soiled utility room, located adjacent to the cafe, at 4:07 PM on 01/21/14, observation of the smoke barrier on the south wall just left of the door, revealed a set of three conduits that were not sealed around the annular space. Observation of the west wall revealed a duct that was not sealed around the edges.

These findings were verified by staff members A1, and B2 during tour on 01/21/14, at the time of the observations.

Based on observation made during tour of the facility, review of building schematics, and staff verification it was determined the facility failed to ensure hazardous areas on the second floor were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) Tour of the facility's second and third floors took place on 01/21/14, with staff members A1, and B2.

Observation, during tour of the south end of the second floor, revealed a storage room, located adjacent to the east corridor on one side, and an internal chase on the other side, which contained approximately forty cardboard boxes of combustible material, and other miscellaneous storage. This room lacked a fire suppression system. Although the door was equipped with a wired glass panel, the door lacked a fire resistance rating, and was not equipped with a self closing or automatic closing device.

A review, of the second floor schematics on 01/21/14 at 3:19 PM., revealed this room was not constructed with a fire resistance rating or as a hazardous area.

2) At the southwest corner of the second floor, and within the medical records room, located on the north side of the corridor, and at the east end of the room, an observation, of the area above the ceiling tiles, revealed an approximately eighteen foot by three foot section of missing drywall, on both sides of the corridor.

3) Another penetration was observed at 4:30 PM., on the south wall, which appeared to be approximately six inches by four inches, and had conduits passing through. This room contained several open file cabinets filled with combustible medical records and was not equipped with automatic fire suppression, with the exception of a small open closet. This observation was made at 4:30 PM.

These findings were verified by staff members A1, and B2 during the tour, at the time of the observations, on 01/21/14.

Based on observation during a tour of the facility, and staff verification, it was determined the facility failed to ensure at least two smoke detectors were not mounted near air flow devices where air flow may inhibit the normal operation of the device. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

A tour of the second and third floors took place on 01/21/14 with staff members A1, and B2.

1) Observation, during a tour of the second floor outpatient area, in front of the elevators, revealed a smoke detector was mounted near an air flow device. This observation occurred at 3:22 PM., and was verified by staff members A1, and B2 at this time.


2) An observation, at 2:52 PM., during a tour of the facility's third floor intensive care unit, specifically, within the nurse's station, and dictation room, revealed smoke detectors were located near air flow devices in each area. This finding was verified by staff members A1, and B2 at this time.

Based on observation during tour, and staff verification it was determined this facility failed to ensure two smoke detectors were not mounted near air flow devices where air flow may inhibit the normal operation of the device. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During tour, within the west corridor adjacent to the coumadin clinic, just inside the double smoke barrier doors leading to the kitchen, observation, on 01/21/14 at 4:50 PM, revealed a smoke detector was located near an air flow device.

2) During tour at the front entrance of the cafe, observation on 01/21/14 at 4:53 PM, revealed a smoke detector was located near an air flow device.

These findings were verified by staff members A1, and B2 during tour on 01/21/14, at the time of the observations.

Based on facility tour, and staff verification it was determined this facility failed to ensure the sprinkler system was installed to insure complete coverage of all portions of the facility. This had the potential to affect all those who were utilizing this area of the facility. The patient census for at the beginning of the survey was nine.

Findings include:

During a tour of the gift shop, observation, on 01/21/14 at 4:44 PM., revealed a small storage room at the back of the gift shop that lacked sprinkler coverage. The room was observed to store combustible items.

This finding was verified by staff members A1, and B2 during the tour on 01/21/14, at the time of the observation.

Based on observation, during a tour of the facility, and staff verification it was determined the facility failed to ensure at least three fire extinguishers , located on the second and third floors, were not mounted greater than five feet from the floor. This had the potential to affect all persons utilizing these areas of the facility.

The patient census was nine at the beginning of the survey.

Findings include:

Tour of the second and third floors took place on 01/21/14, with staff members A1, and B2.

1) An observation, at 3:36 PM., during a tour of the facility's second floor operating rooms (OR) 2, and 3, specifically, the smaller rooms adjacent to each OR room, revealed a portable fire extinguisher was mounted greater than five feet from the floor and was mounted above a hopper, which would make access to them more difficult in the event of an emergency. This observation was made and verified by staff members A1, and B2 during tour of the OR's.

2) Observation during a tour of the second floor IT room at 4:35 PM, revealed, a portable fire extinguisher was mounted greater than five feet from the floor on the south wall of the IT room. This observation was verified by staff members A1, and B2, during the tour.

3) Observation, at 2:20 PM., during a tour of the third floor east corridor, adjacent to the sleep lab, revealed a portable fire extinguisher was mounted on the wall at a height greater than five feet from the floor. This finding was verified by staff members A1, and B2, at the time of the observation.
,

Based on facility tour, and staff verification it was determined the bulk medical gas storage and medical gas room were not protected in accordance with the National Fire Protection Association (NFPA) 99. This had the potential to affect all those utilizing this facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the bulk medical gas area, observation, on 01/21/14 at 1:40 PM., revealed four unsecured H-tanks standing within the fenced in area.

2) During a tour of the medical gas cylinder room, observation, on 01/21/14 at 2:10 PM., observation of a light switch and a heater control box revealed these were mounted less than five feet from the floor.

3) On 01/21/14 at 11:40 AM., a review of the medical gas systems evaluation report which was dated 11/20/13, revealed four areas were documented as "high priority". They were listed as: A) A local audible and visual signal for the lag pump in use should be installed. B) The lag alarm does not function and is required to be repaired. C) The lag alarm is required to be wired to the master alarm panels.
Additionally, the professional outside company recommended that the vacuum's "lag pump in use" point be wired to both master alarm panels.

The evaluation documentation recommended a "high priority" finding to be acted on as soon as possible.

During an interview, on 01/21/14 at 12:05 PM., Staff A1 was asked if the facility had acted on the recommendations of this report, dated 11/20/13. Staff A1 stated "no". When asked if the facility had any plans to address these issues soon, Staff A1 stated they hope to be able to address it in the next month or two.


These findings were verified by staff members A1, and B2 during the documentation review and the tour on 01/21/14 at the time of the observations and documentation review.

Based on relative humidity (RH) documentation review, and staff interview it was determined this facility failed to ensure the RH levels were maintained at a level of at least 20% or greater in two of two operating rooms providing general anesthesia. This had the potential to affect all persons utilizing this area of the facility. The patient census at the beginning of the survey was nine.

Findings include:

The facility's RH level documentation review took place on 01/21/14, between 11:30 AM., to 12:15 PM. The RH level documentation for operating room numbers two and three revealed the relative humidity level was recorded at below 20%: eleven times during January, 2014; eleven times during the month of December, 2013; eight times during the month of November, 2013; three times during the month of October, 2013; eight times during the month of March, 2013; and ten times during the month of February, 2013.

The facility had applied, on 06/26/13, for a categorical waiver, for the relative humidity levels in the operating rooms to be maintained at or above 20% but not greater than 60% in anesthetizing locations.

This finding was acknowledged by staff members A1, and B2, during RH documentation review on 01/21/14.

Based on facility documentation review, and staff verification, it was determined this facility failed to ensure the battery operated emergency lights were tested on a monthly basis for 30 seconds and on an annual basis for 90 minutes in accordance with the National Fire Protection Association (NFPA) 7.9. , and the facility failed to ensure the fire suppression system was tested on a quarterly basis in accordance with the National Fire Protection Association (NFPA) 13. This had the potential to affect all those utilizing this facility.

The outpatient therapy department had a census of 45 the day of the survey.

Findings include:

1) On 01/22/14 at 9:15 AM., the facility's documentation of the testing of the battery operated emergency lights was requested of staff members A1, and B2. There was no documentation available to review in order to verify the monthly and annual testing of the battery operated emergency lights.

During an interview, on 01/22/14 at 9:23 AM., Staff A1 revealed no testing of the emergency lights has been performed.


2) On 01/22/14 at 9:30 AM., the facility's documentation of the quarterly testing of the fire suppression system was requested of staff members A1, and B2. There was no documentation, available for review, in order to verify the quarterly testing of the suppression system.

During an interview, on 01/22/14 at 10:53 AM., Staff A1 revealed there was no documentation of fire suppression system test reports for the first, second, and third quarters of 2013.

Based on observation, during the facility tour, and staff verification it was determined this facility failed to ensure one vertical opening was protected with an at least a one hour fire resistance rating. This had the potential to affect all persons utilizing this area of the facility. The patient census at the beginning of the survey was nine.

Findings include:

The facility tour of the second and third floor took place on 01/21/14 with staff A1, and B2.

During the tour of the third floor medical surgical unit, an observation, at 2:41 PM., of the west stairwell door, located near room 314, revealed this door failed to securely close and latch shut.

This observation was confirmed by staff members A1, and B2, during the tour on 01/21/14.

Based on Observation during the facility tour and staff verification it was determined this facility failed to ensure all exits were marked by approved, readily visible signs in order to provide occupants directions to a safe area. This had the potential to affect all persons who utilized this area of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Tour of the facility occurred on 01/21/14 to 01/22/14, with staff members A1, and B2. At 8:30 AM on 01/22/14, while touring the kitchen area, observation of the double doors, located at the northwest section of the kitchen, revealed there was not an exit sign present. It was difficult to see this exit if a person was standing at the east end of the room.

This finding was verified by Staff B2 during this observation on 01/22/14.

Based on facility tour, and staff verification it was determined the facility failed to ensure smoke barriers on the second and third floors were maintained to provide at least a one hour fire resistance rating. This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Facility tour of the second and third floors took place on 01/21/14, with staff members A1, and B2. An observation, of the third floor smoke barrier, revealed there were penetrations in the smoke barrier, above the ceiling tiles in the following locations:

1) Above the ceiling tiles at the east double doors leading to the medical surgical unit, an observation, on 01/21/14 at 2:50 PM., revealed three unsealed conduits. On 01/21/14 at 2:50 PM., an observation, of the opposite side of the doors, revealed another open end conduit.

2) On 01/21/14 at 2:47 PM., an observation, of the smoke barrier, located within the medication room of the medical surgical unit, adjacent to the smoke barrier, revealed above the ceiling tiles, over the clock, an approximately two and a half inch penetration was not sealed around the annular space.


3) On 01/21/14 at 2:58 PM., an observation, was made of one open end conduit, located above the ceiling tiles of the smoke barrier adjacent to the sleep lab. This observation was made from the nurses' station side.

The above findings were verified by staff members A1, and B2 during the tour on 01/21/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure nine areas in the first floor smoke barrier were maintained to provide at least a one hour fire resistance rating. This had the potential to affect all persons utilizing these nine areas of the first floor of the facility. The patient census was nine at the beginning of the survey.

Findings include:

Tour of the facility occurred on 01/21/14 to 01/22/14, with staff members A1 and B2. During tour of the first floor smoke barrier, penetrations in the one hour fire rated construction were observed in the following nine locations:

1) An observation at 4:23 PM on 01/21/14, of the smoke barrier from within the cardio staff break room revealed an approximate three foot by four inch section of drywall was missing and there were two unsealed conduits observed in the smoke barrier.

2) At 4:47 PM on 01/21/14, while standing in the corridor outside the southwest corner of the gift shop and at the smoke barrier door which leads to the back door of the kitchen, observation revealed four penetrations around conduits above the smoke barrier door. Observation of the area located to the right of the smoke barrier door when facing the small section of the block wall, located between the door and the back of the elevators, revealed four penetrations ranging from one to two inches in diameter.

3) At 5:01 PM on 01/21/14, when standing just inside the double doors of the cafe and along the east/west smoke barrier observation revealed two unsealed conduits with penetrations around the annular space. One of the two conduits observed did not have fire sealant within the inner diameter of the open end.

4) Continuing along the same smoke barrier at approximately fifteen feet further, observation revealed near the upper part of the drywall, a gap of approximate one inch by four inches located between two sections of drywall. Observation also revealed a solid conduit and a flex conduit through the smoke barrier were not sealed around the annular space.

5) At 4:55 PM on 01/21/14, while standing within the volunteers' office an observation revealed a section of drywall missing from both sides of the east wall of the smoke barrier measuring an approximate six foot by two and a half foot.

6) At 8:35 AM on 01/22/14, while standing within the kitchen of the dietary department, an observation revealed multiple penetrations around insulated lines, ducts and conduits in the smoke barrier in the north, south and west walls.

7) At 8:47 AM on 01/22/14, when exiting from the south doors of the kitchen area into the corridor and at the women's locker room, an observation revealed the smoke barrier door of the women's locker room failed to latch securely.

8) At 8:44 AM on 01/22/14, continuing down the corridor and at the small storage room located across from the maintenance department and just north of the double corridor doors, observation revealed an opening at the top of the drywall above the smoke barrier door to the storage room that measured approximately eight inches by three inches.

9) At the west exit door of the emergency department at 9:43 AM on 01/22/14, observation was made of an approximate four inch open end conduit which was not sealed at the bottom around the annular space.

10) Observation was made above the squad equipment room smoke barrier door at 9:48 AM on 01/22/14, of an opening around a row of silver conduits measuring approximately four feet long by three inches wide.


These findings were verified by staff members A1 and B2 during tour of the first floor of the facility on 01/22/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure four doors located in the smoke barrier would close properly providing protection from fire and smoke (Two of these doors were held open by devices that prevented the doors from automatically closing, one of the doors had no automatic closure device, and one of the doors left a gap when closed.). This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the pathology office on 01/21/14 at 4:50 PM., an observation of the pathology office smoke barrier door revealed the door was propped open with a small rubber wedge, preventing the door from closing automatically during a fire alarm.

2) During tour of the kitchen area of the dietary department on 01/22/14, between 8:30 AM and 8:42 AM, an observation revealed kick stops (small metal and rubber door stops utilized to manually hold doors open) were mounted on the bottom corner of three of the four double door smoke barrier doors. Observation revealed the west doors had the kick stops activated and the doors were manually held open. Observation of these doors closing revealed the southeast doors failed to close properly.

3) During tour of the smoke barrier on 01/22/14 at 9:15 AM; at the west end of the central sterile room and at the outside of the east emergency department smoke barrier door, observation revealed this door failed to close securely, which left a gap between the door and the door jam.
Just to the left of this door, observation of a smoke barrier door leading into the steam sterilizer room, and another smoke barrier door leading into the sterile processing department, did not have automatic closing or self-closing devices.

These findings were verified by staff members A1, and B2 during the tour of the facility on 01/21/14 and 01/22/14, at the time of the observations.

Based on observations during the facility tour, and staff verification it was determined this facility failed to ensure two of the facility's smoke barrier doors provided a rating of at least 20 minutes of fire protection. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

A tour of the second and third floors took place, on 01/21/14, with staff members A1, and B2.

1) During the tour of the second floor, observation of the north end smoke barrier doors east of the elevators, revealed a gap, greater than one eighth inch, between the two door leafs, when in the closed position. This observation took place at 3:24 PM.

2) During the tour of the third floor, observation of the south end smoke barrier doors nearest the conference room, revealed a gap, greater than one eighth inch between the two door leafs, when in the closed position. This observation took place at 2:20 PM.

These findings were verified by staff members A1, and B2, at the time of the observations on 01/21/14.

Based on facility tour, and staff verification it was determined this facility failed to ensure three hazardous areas were protected with at least a one hour fire rated barrier. This had the potential to affect all persons utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the arterial blood gas room on 01/21/14 at 3:50 PM., observation of the smoke barrier revealed an approximate one quarter inch gap between the top of the drywall and the upper deck extending approximately six feet in length. Additionally, seven conduits observed in the smoke barrier were unsealed around the annular space and three were not sealed at the ends.

2) During tour of the medical records room located in the clinic, at 4:02 PM on 01/21/14, an observation revealed a small hole in the west wall and one conduit was not sealed.

3) During tour of the soiled utility room, located adjacent to the cafe, at 4:07 PM on 01/21/14, observation of the smoke barrier on the south wall just left of the door, revealed a set of three conduits that were not sealed around the annular space. Observation of the west wall revealed a duct that was not sealed around the edges.

These findings were verified by staff members A1, and B2 during tour on 01/21/14, at the time of the observations.

Based on observation made during tour of the facility, review of building schematics, and staff verification it was determined the facility failed to ensure hazardous areas on the second floor were constructed to provide at least a one hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) Tour of the facility's second and third floors took place on 01/21/14, with staff members A1, and B2.

Observation, during tour of the south end of the second floor, revealed a storage room, located adjacent to the east corridor on one side, and an internal chase on the other side, which contained approximately forty cardboard boxes of combustible material, and other miscellaneous storage. This room lacked a fire suppression system. Although the door was equipped with a wired glass panel, the door lacked a fire resistance rating, and was not equipped with a self closing or automatic closing device.

A review, of the second floor schematics on 01/21/14 at 3:19 PM., revealed this room was not constructed with a fire resistance rating or as a hazardous area.

2) At the southwest corner of the second floor, and within the medical records room, located on the north side of the corridor, and at the east end of the room, an observation, of the area above the ceiling tiles, revealed an approximately eighteen foot by three foot section of missing drywall, on both sides of the corridor.

3) Another penetration was observed at 4:30 PM., on the south wall, which appeared to be approximately six inches by four inches, and had conduits passing through. This room contained several open file cabinets filled with combustible medical records and was not equipped with automatic fire suppression, with the exception of a small open closet. This observation was made at 4:30 PM.

These findings were verified by staff members A1, and B2 during the tour, at the time of the observations, on 01/21/14.

Based on observation during a tour of the facility, and staff verification, it was determined the facility failed to ensure at least two smoke detectors were not mounted near air flow devices where air flow may inhibit the normal operation of the device. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

A tour of the second and third floors took place on 01/21/14 with staff members A1, and B2.

1) Observation, during a tour of the second floor outpatient area, in front of the elevators, revealed a smoke detector was mounted near an air flow device. This observation occurred at 3:22 PM., and was verified by staff members A1, and B2 at this time.


2) An observation, at 2:52 PM., during a tour of the facility's third floor intensive care unit, specifically, within the nurse's station, and dictation room, revealed smoke detectors were located near air flow devices in each area. This finding was verified by staff members A1, and B2 at this time.

Based on observation during tour, and staff verification it was determined this facility failed to ensure two smoke detectors were not mounted near air flow devices where air flow may inhibit the normal operation of the device. This had the potential to affect all those utilizing these areas of the facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During tour, within the west corridor adjacent to the coumadin clinic, just inside the double smoke barrier doors leading to the kitchen, observation, on 01/21/14 at 4:50 PM, revealed a smoke detector was located near an air flow device.

2) During tour at the front entrance of the cafe, observation on 01/21/14 at 4:53 PM, revealed a smoke detector was located near an air flow device.

These findings were verified by staff members A1, and B2 during tour on 01/21/14, at the time of the observations.

Based on facility tour, and staff verification it was determined this facility failed to ensure the sprinkler system was installed to insure complete coverage of all portions of the facility. This had the potential to affect all those who were utilizing this area of the facility. The patient census for at the beginning of the survey was nine.

Findings include:

During a tour of the gift shop, observation, on 01/21/14 at 4:44 PM., revealed a small storage room at the back of the gift shop that lacked sprinkler coverage. The room was observed to store combustible items.

This finding was verified by staff members A1, and B2 during the tour on 01/21/14, at the time of the observation.

Based on observation, during a tour of the facility, and staff verification it was determined the facility failed to ensure at least three fire extinguishers , located on the second and third floors, were not mounted greater than five feet from the floor. This had the potential to affect all persons utilizing these areas of the facility.

The patient census was nine at the beginning of the survey.

Findings include:

Tour of the second and third floors took place on 01/21/14, with staff members A1, and B2.

1) An observation, at 3:36 PM., during a tour of the facility's second floor operating rooms (OR) 2, and 3, specifically, the smaller rooms adjacent to each OR room, revealed a portable fire extinguisher was mounted greater than five feet from the floor and was mounted above a hopper, which would make access to them more difficult in the event of an emergency. This observation was made and verified by staff members A1, and B2 during tour of the OR's.

2) Observation during a tour of the second floor IT room at 4:35 PM, revealed, a portable fire extinguisher was mounted greater than five feet from the floor on the south wall of the IT room. This observation was verified by staff members A1, and B2, during the tour.

3) Observation, at 2:20 PM., during a tour of the third floor east corridor, adjacent to the sleep lab, revealed a portable fire extinguisher was mounted on the wall at a height greater than five feet from the floor. This finding was verified by staff members A1, and B2, at the time of the observation.
,

Based on facility tour, and staff verification it was determined the bulk medical gas storage and medical gas room were not protected in accordance with the National Fire Protection Association (NFPA) 99. This had the potential to affect all those utilizing this facility. The patient census was nine at the beginning of the survey.

Findings include:

1) During a tour of the bulk medical gas area, observation, on 01/21/14 at 1:40 PM., revealed four unsecured H-tanks standing within the fenced in area.

2) During a tour of the medical gas cylinder room, observation, on 01/21/14 at 2:10 PM., observation of a light switch and a heater control box revealed these were mounted less than five feet from the floor.

3) On 01/21/14 at 11:40 AM., a review of the medical gas systems evaluation report which was dated 11/20/13, revealed four areas were documented as "high priority". They were listed as: A) A local audible and visual signal for the lag pump in use should be installed. B) The lag alarm does not function and is required to be repaired. C) The lag alarm is required to be wired to the master alarm panels.
Additionally, the professional outside company recommended that the vacuum's "lag pump in use" point be wired to both master alarm panels.

The evaluation documentation recommended a "high priority" finding to be acted on as soon as possible.

During an interview, on 01/21/14 at 12:05 PM., Staff A1 was asked if the facility had acted on the recommendations of this report, dated 11/20/13. Staff A1 stated "no". When asked if the facility had any plans to address these issues soon, Staff A1 stated they hope to be able to address it in the next month or two.


These findings were verified by staff members A1, and B2 during the documentation review and the tour on 01/21/14 at the time of the observations and documentation review.

Based on relative humidity (RH) documentation review, and staff interview it was determined this facility failed to ensure the RH levels were maintained at a level of at least 20% or greater in two of two operating rooms providing general anesthesia. This had the potential to affect all persons utilizing this area of the facility. The patient census at the beginning of the survey was nine.

Findings include:

The facility's RH level documentation review took place on 01/21/14, between 11:30 AM., to 12:15 PM. The RH level documentation for operating room numbers two and three revealed the relative humidity level was recorded at below 20%: eleven times during January, 2014; eleven times during the month of December, 2013; eight times during the month of November, 2013; three times during the month of October, 2013; eight times during the month of March, 2013; and ten times during the month of February, 2013.

The facility had applied, on 06/26/13, for a categorical waiver, for the relative humidity levels in the operating rooms to be maintained at or above 20% but not greater than 60% in anesthetizing locations.

This finding was acknowledged by staff members A1, and B2, during RH documentation review on 01/21/14.

Based on facility documentation review, and staff verification, it was determined this facility failed to ensure the battery operated emergency lights were tested on a monthly basis for 30 seconds and on an annual basis for 90 minutes in accordance with the National Fire Protection Association (NFPA) 7.9. , and the facility failed to ensure the fire suppression system was tested on a quarterly basis in accordance with the National Fire Protection Association (NFPA) 13. This had the potential to affect all those utilizing this facility.

The outpatient therapy department had a census of 45 the day of the survey.

Findings include:

1) On 01/22/14 at 9:15 AM., the facility's documentation of the testing of the battery operated emergency lights was requested of staff members A1, and B2. There was no documentation available to review in order to verify the monthly and annual testing of the battery operated emergency lights.

During an interview, on 01/22/14 at 9:23 AM., Staff A1 revealed no testing of the emergency lights has been performed.


2) On 01/22/14 at 9:30 AM., the facility's documentation of the quarterly testing of the fire suppression system was requested of staff members A1, and B2. There was no documentation, available for review, in order to verify the quarterly testing of the suppression system.

During an interview, on 01/22/14 at 10:53 AM., Staff A1 revealed there was no documentation of fire suppression system test reports for the first, second, and third quarters of 2013.