HospitalInspections.org

Based on observation the facility failed to maintain the building construction to prevent the passage of smoke and flames in the event of a fire. This affected 1 of 5 smoke comparments on the first floor and 1 of 1 smoke compartments on the second floor.

Findings:
On May 9, 2011 through May 11, 2011, during a tour of the facility with staff the walls and ceilings were observed.
May 10, 2011:
Second Floor:
1. At 1:52 p.m., in the Business Office, left wall front corner there was an approximately 3 inch unsealed penetration with wires running through it.
2. At 1:55 p.m., in the Revenue Cycle Manager's office, the front right corner there was an approximately 1 inch penetration.

First Floor:
1. At 2:10 p.m., in the Social Services Office, the escutcheon ring was not flush with the ceiling revealing an approximately 3" penetration.
2. At 2:59 p.m., in the emergency supplies closet, there were 2 penetrations approximately 1/2 inch each, on the right wall.
3. At 3:03 p.m., in the left front corner of the Operating Room there was an approximately 1/4 inch penetration.

Based on observation the facility failed to maintain the doors to shut and latch upon self closure and to prevent the use of devices that hold the doors in the open position that do not release with the activation of the fire alarm system. This had the potential to cause the spread of smoke and flames in the event of a fire. This affected 2 of 5 smoke compartments on the 1st floor and 1 of 1 smoke compartments on the 2nd floor.

NFPA 101, Life Safety Code, 2000 Edition
193.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf
(22 N) shall be permitted to be kept in service.
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the doors were observed.

May 10, 2011:
Medical Surgical Unit:
1. At 1:31 p.m., the Central Supply Closet door failed to shut and latch on self closure.
2. At 1:33 p.m., the Linen Closet (next to room 202) door failed to shut and latch on self closure.
3. At 1:48 p.m., on the 2nd floor the door for Information Services was held in the open position with a
brick.
4. At 2:22 p.m., the Oxygen Storage closet door failed to shut and latch upon self closure.
May 11, 2011:
1. At 10:24 a.m., the door to the gift shop was obstructed from closing by a cart.

Based on observation the facility failed to prevent the use of items blocking doors open in a hazardous area. This affects 1 of 5 smoke compartments on the 1st floor and has the potential to cause the passage of smoke and flames in the event of a fire.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition
15-2.3.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the doors to hazardous areas were observed.

May 10, 2011:
1. At 2:02 p.m., the lab door was held in the open position by a bio-hazard trash can.

May 11, 2011:
1. At 10:34 a.m., the lab door was held in the open position by a bio hazard trash can.

Based on observation the facility failed to maintain the fire alarm system in accordance with NFPA 70, National Electrical Code, 1999 edition, and NFPA 72, National Fire Alarm Code, 1999 edition. This was evidenced by blocked access to the Fire Alarm Panel and Obstructed access to Pull Stations. This affected 3 of 5 smoke compartments on the first floor and 1 of 1 smoke compartments on the 2nd floor, and may cause a delay in the activation of the fire alarm system in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected are so that they are unobstructed and accessible.

NFPA 72, National Fire Alarm Code, 1999 edition
3-8.4.1.3.3.2 The fire command center and the central control unit shall be located within a minimum 1-hour rated fireresistive area and shall have a minimum 3-ft (1-m) clearance from the front of the fire command center control equipment.

Exception: If approved by the authority having jurisdiction, the fire
command center control equipment shall be permitted to be located in
a lobby or other approved space.


Findings:
On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the fire alarm system was observed.

May 10, 2011:

1. At 1:29 p.m., in the medical surgical hall, there was a scale that was obstructing the pull station by the smoke barrier doors.
2. At 1:49 p.m., on the 2nd floor in the administrative hall on the left there was a file cabinet obstructing the pull station.
3. At 2:03 p.m., in the Lab the access to the fire alarm panel was obstructed by a table top, CO 2 incubator and 2 small refrigerators.

May 11, 2011:

1. At 10:40 a.m., the pull station outside post anesthesia care unit, failed to activate the fire alarm when tested.

Based on observation the facility failed to maintain the automatic sprinkler system, in accordance with NFPA 13, Installation of Sprinkler Systems, 1999 Edition and NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by no 18 inch clearance from sprinklers, and failure of one inspectors test valve. This had the potential to affect the spray pattern of the sprinkler and may delay the activation of the sprinkler system. This affected 1 of 5 smoke compartments in the main hospital and 1 of 1 smoke compartments in the Rural Clinic LA.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4 : The clearance from the top of storage to sprinkler deflectors shall be not less that 3 ft (0.9 m) where rubber tires are stored.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

On May 9, 2011 through May 11, 2011, on a tour of the facility with staff, the sprinkler system was observed.

Main Hospital:

1. At 1:40 p.m., in room 205 the storage was less than 18 inch's from the sprinkler deflector.
2. At 3:01 p.m., in outpatient services the escutcheon ring was not flush with the ceiling.

Rural Health Clinic LA

1. At 12:54 p.m. the Inspectors Test Valve, failed to activate the alarm within 90 seconds.

Based on observation the facility failed to maintain the fire extinguishers unobstructed. This was evidenced by fire extinguishers obstructed in 1 of 5 smoke compartments on the 1st floor and may delay access to the fire extinguishers in the event of a fire.


NFPA 10, Standard for Fire Extinguishers
4-3.2* Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing
outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion,
leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable
range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle
checked (for wheeled units)
(i) HMIS label in place
4-3.3 Corrective Action. When an inspection of any fire extinguisher
reveals a deficiency in any of the conditions listed in 4-3.2
(a), (b), (h), and (i), immediate corrective action shall be taken.


Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff, the fire extinguishers were observed.

May 10, 2011:

1. At 3:02 p.m., in the operating room hallway the fire extinguisher was obstructed by equipment.
2. At 3:06 p.m., in the emergency room the fire extinguisher was obstructed by an EKG machine.

Based on interview the facility failed to maintain the kitchen hood exhaust system in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. This was evidenced by failure to have the kitchen hood exhaust cleaned. This had the potential to cause a fire. This affected 1 of 5 smoke compartments.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition:8-3 Cleaning.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as Quarterly
24 hour cooking, charbroiling or wok cooking
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:

On May 9, 2011, during document review the documentation for cleaning of the kitchen hood exhaust was requested. At 10:16 a.m., during an interview, the Facilities Manager stated that they did not have this documentation.

Based on observation the facility failed to prevent the use of portable heating devices. This was evidenced by use of a portable heater in a patient area. This affected 1 of 5 smoke compartments and may result in a fire and injury to patients and staff.

Findings:

On May 9, 2011 through May 11, 2011, during a tour of the facility with staff, the patient areas were observed.

1. On May 10, 2011 at 2:54 p.m., in the Ultra Sound room there was a floor heater next to the patient gurney. The device was left on with no staff in the area.

Based on observation and interview the facility failed to maintain the means of egress free of all obstructions and impediments to full instant use in the event of a fire or emergency. This may result in the delay of evacuation of patients in the event of a fire or emergency. This affected 1 of 5 smoke compartments on the 1st floor and 1 of 1 smoke compartments on the 2nd floor.

Findings:

On May 9, 2011 through May 11, 2011, on a tour of the facility with staff, the means of egress were observed.

May 10, 2011:

Medical/Surgical Unit; 1st Floor

1. At 1:35 p.m., there was a 3 compartment (2 soiled linen and 1 trash) hamper in the corridor by room 205. During an interview, staff stated that it is stored there.
2. At 1:38 p.m., there was a computer on wheels (COW) stored in the corridor next to room 209.
3. At 1:41 p.m., there were 2 computers and a medication cart outside room 201 (to the right and one to the left of the room). During an interview staff stated that it is stored there.

2nd Floor:
1. At 1:49 p.m., in the Administrative corridor on the right 59 boxes were stored along the corridor with accounting information. There was a file cabinet on the left by the emergency. During an interview, staff from the accounting department stated it may take 6 months to review all the records.

Based on observation and interview the facility failed to store soiled linen and trash receptacles in a room protected as a hazardous area when not attended. This affected 1 of 5 smoke compartments on the 1st floor. This may result in a fire.

Findings:

On a tour of the facility from May 9, 2011 through May 11, 2011, the soiled linen and trash receptacles were observed.

May 10, 2011:
1. At 1:30 p.m., there was a 3 compartment (2 soiled and 1 trash) hamper stored next to the crash cart.
2. At 1:35 p.m., there was a 3 compartment (2 soiled and 1 trash) hamper stored next to the crash cart.
At 2:50 p.m., during an interview, the EVS manager stated that the bags used were about 40 gallons each.

Based on interview the facility failed to monitor the humidity levels in 2 of 2 operating rooms, in accordance with NFPA 99, Health Care Facilities 1999 edition. This may result in an increase risk of fire. This affected 1 of 5 smoke compartments.

Findings:

On May 9, 2011, at 12:15 p.m., during the entrance conference , the documentation of monitoring the humidity in the operating rooms was requested.
On May 10, 2011, at 10:08 a.m., the Facilities Manager stated, there were no records for monitoring the humidity. He stated that humidity was not monitored.

110-22. Identification of Disconnecting Means. Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. Where circuit breakers or fuses are applied in compliance with the series combination ratings marked on the equipment by the manufacturer, the equipment enclosure(s) shall be legibly marked in the field to indicate the equipment has been applied with a series combination rating. The marking shall be readily visible and state the following:
Caution --- Series Combination System Rated --- Amperes, Identified Replacement Components Required.

FPN: See Section 240-83 (c) for interrupting rating marking for end-use equipment.

NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.



Based on observation the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code, 1999 edition. This was evidenced by broken outlet plate covers, appliances plugged into surge protectors, surge protectors plugged into extension cords, and electrical panel switches not all identified.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, the electrical wiring and equipment were observed.

May 10, 2011:

1. At 1:26 p.m., in the medical surgical breakroom a refrigerator was plugged into a surge protector that was plugged into an extension cord.
2. At 1:40 p.m., in room 205 there was a cable outlet cover plate that was not flush with the wall.
3. At 1:46 p.m., all switches were not identified in Panel AA located on the 2nd floor.

May 11, 2011:

Rural Health Clinic - Running Springs

1. At 8:36 a.m., there was a refrigerator plugged into a surge protector.

Based on observation the facility failed to maintain the building construction to prevent the passage of smoke and flames in the event of a fire. This affected 1 of 5 smoke comparments on the first floor and 1 of 1 smoke compartments on the second floor.

Findings:
On May 9, 2011 through May 11, 2011, during a tour of the facility with staff the walls and ceilings were observed.
May 10, 2011:
Second Floor:
1. At 1:52 p.m., in the Business Office, left wall front corner there was an approximately 3 inch unsealed penetration with wires running through it.
2. At 1:55 p.m., in the Revenue Cycle Manager's office, the front right corner there was an approximately 1 inch penetration.

First Floor:
1. At 2:10 p.m., in the Social Services Office, the escutcheon ring was not flush with the ceiling revealing an approximately 3" penetration.
2. At 2:59 p.m., in the emergency supplies closet, there were 2 penetrations approximately 1/2 inch each, on the right wall.
3. At 3:03 p.m., in the left front corner of the Operating Room there was an approximately 1/4 inch penetration.

Based on observation the facility failed to maintain the doors to shut and latch upon self closure and to prevent the use of devices that hold the doors in the open position that do not release with the activation of the fire alarm system. This had the potential to cause the spread of smoke and flames in the event of a fire. This affected 2 of 5 smoke compartments on the 1st floor and 1 of 1 smoke compartments on the 2nd floor.

NFPA 101, Life Safety Code, 2000 Edition
193.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf
(22 N) shall be permitted to be kept in service.
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the doors were observed.

May 10, 2011:
Medical Surgical Unit:
1. At 1:31 p.m., the Central Supply Closet door failed to shut and latch on self closure.
2. At 1:33 p.m., the Linen Closet (next to room 202) door failed to shut and latch on self closure.
3. At 1:48 p.m., on the 2nd floor the door for Information Services was held in the open position with a
brick.
4. At 2:22 p.m., the Oxygen Storage closet door failed to shut and latch upon self closure.
May 11, 2011:
1. At 10:24 a.m., the door to the gift shop was obstructed from closing by a cart.

Based on observation the facility failed to prevent the use of items blocking doors open in a hazardous area. This affects 1 of 5 smoke compartments on the 1st floor and has the potential to cause the passage of smoke and flames in the event of a fire.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition
15-2.3.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the doors to hazardous areas were observed.

May 10, 2011:
1. At 2:02 p.m., the lab door was held in the open position by a bio-hazard trash can.

May 11, 2011:
1. At 10:34 a.m., the lab door was held in the open position by a bio hazard trash can.

Based on observation the facility failed to maintain the fire alarm system in accordance with NFPA 70, National Electrical Code, 1999 edition, and NFPA 72, National Fire Alarm Code, 1999 edition. This was evidenced by blocked access to the Fire Alarm Panel and Obstructed access to Pull Stations. This affected 3 of 5 smoke compartments on the first floor and 1 of 1 smoke compartments on the 2nd floor, and may cause a delay in the activation of the fire alarm system in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected are so that they are unobstructed and accessible.

NFPA 72, National Fire Alarm Code, 1999 edition
3-8.4.1.3.3.2 The fire command center and the central control unit shall be located within a minimum 1-hour rated fireresistive area and shall have a minimum 3-ft (1-m) clearance from the front of the fire command center control equipment.

Exception: If approved by the authority having jurisdiction, the fire
command center control equipment shall be permitted to be located in
a lobby or other approved space.


Findings:
On a tour of the facility on May 9, 2011 through May 11, 2011, with staff the fire alarm system was observed.

May 10, 2011:

1. At 1:29 p.m., in the medical surgical hall, there was a scale that was obstructing the pull station by the smoke barrier doors.
2. At 1:49 p.m., on the 2nd floor in the administrative hall on the left there was a file cabinet obstructing the pull station.
3. At 2:03 p.m., in the Lab the access to the fire alarm panel was obstructed by a table top, CO 2 incubator and 2 small refrigerators.

May 11, 2011:

1. At 10:40 a.m., the pull station outside post anesthesia care unit, failed to activate the fire alarm when tested.

Based on observation the facility failed to maintain the automatic sprinkler system, in accordance with NFPA 13, Installation of Sprinkler Systems, 1999 Edition and NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by no 18 inch clearance from sprinklers, and failure of one inspectors test valve. This had the potential to affect the spray pattern of the sprinkler and may delay the activation of the sprinkler system. This affected 1 of 5 smoke compartments in the main hospital and 1 of 1 smoke compartments in the Rural Clinic LA.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4 : The clearance from the top of storage to sprinkler deflectors shall be not less that 3 ft (0.9 m) where rubber tires are stored.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

On May 9, 2011 through May 11, 2011, on a tour of the facility with staff, the sprinkler system was observed.

Main Hospital:

1. At 1:40 p.m., in room 205 the storage was less than 18 inch's from the sprinkler deflector.
2. At 3:01 p.m., in outpatient services the escutcheon ring was not flush with the ceiling.

Rural Health Clinic LA

1. At 12:54 p.m. the Inspectors Test Valve, failed to activate the alarm within 90 seconds.

Based on observation the facility failed to maintain the fire extinguishers unobstructed. This was evidenced by fire extinguishers obstructed in 1 of 5 smoke compartments on the 1st floor and may delay access to the fire extinguishers in the event of a fire.


NFPA 10, Standard for Fire Extinguishers
4-3.2* Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing
outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion,
leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable
range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle
checked (for wheeled units)
(i) HMIS label in place
4-3.3 Corrective Action. When an inspection of any fire extinguisher
reveals a deficiency in any of the conditions listed in 4-3.2
(a), (b), (h), and (i), immediate corrective action shall be taken.


Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, with staff, the fire extinguishers were observed.

May 10, 2011:

1. At 3:02 p.m., in the operating room hallway the fire extinguisher was obstructed by equipment.
2. At 3:06 p.m., in the emergency room the fire extinguisher was obstructed by an EKG machine.

Based on interview the facility failed to maintain the kitchen hood exhaust system in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. This was evidenced by failure to have the kitchen hood exhaust cleaned. This had the potential to cause a fire. This affected 1 of 5 smoke compartments.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition:8-3 Cleaning.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations Monthly
Systems serving high-volume cooking operations such as Quarterly
24 hour cooking, charbroiling or wok cooking
Systems serving moderate-volume cooking operations Semiannually
Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:

On May 9, 2011, during document review the documentation for cleaning of the kitchen hood exhaust was requested. At 10:16 a.m., during an interview, the Facilities Manager stated that they did not have this documentation.

Based on observation the facility failed to prevent the use of portable heating devices. This was evidenced by use of a portable heater in a patient area. This affected 1 of 5 smoke compartments and may result in a fire and injury to patients and staff.

Findings:

On May 9, 2011 through May 11, 2011, during a tour of the facility with staff, the patient areas were observed.

1. On May 10, 2011 at 2:54 p.m., in the Ultra Sound room there was a floor heater next to the patient gurney. The device was left on with no staff in the area.

Based on observation and interview the facility failed to maintain the means of egress free of all obstructions and impediments to full instant use in the event of a fire or emergency. This may result in the delay of evacuation of patients in the event of a fire or emergency. This affected 1 of 5 smoke compartments on the 1st floor and 1 of 1 smoke compartments on the 2nd floor.

Findings:

On May 9, 2011 through May 11, 2011, on a tour of the facility with staff, the means of egress were observed.

May 10, 2011:

Medical/Surgical Unit; 1st Floor

1. At 1:35 p.m., there was a 3 compartment (2 soiled linen and 1 trash) hamper in the corridor by room 205. During an interview, staff stated that it is stored there.
2. At 1:38 p.m., there was a computer on wheels (COW) stored in the corridor next to room 209.
3. At 1:41 p.m., there were 2 computers and a medication cart outside room 201 (to the right and one to the left of the room). During an interview staff stated that it is stored there.

2nd Floor:
1. At 1:49 p.m., in the Administrative corridor on the right 59 boxes were stored along the corridor with accounting information. There was a file cabinet on the left by the emergency. During an interview, staff from the accounting department stated it may take 6 months to review all the records.

Based on observation and interview the facility failed to store soiled linen and trash receptacles in a room protected as a hazardous area when not attended. This affected 1 of 5 smoke compartments on the 1st floor. This may result in a fire.

Findings:

On a tour of the facility from May 9, 2011 through May 11, 2011, the soiled linen and trash receptacles were observed.

May 10, 2011:
1. At 1:30 p.m., there was a 3 compartment (2 soiled and 1 trash) hamper stored next to the crash cart.
2. At 1:35 p.m., there was a 3 compartment (2 soiled and 1 trash) hamper stored next to the crash cart.
At 2:50 p.m., during an interview, the EVS manager stated that the bags used were about 40 gallons each.

Based on interview the facility failed to monitor the humidity levels in 2 of 2 operating rooms, in accordance with NFPA 99, Health Care Facilities 1999 edition. This may result in an increase risk of fire. This affected 1 of 5 smoke compartments.

Findings:

On May 9, 2011, at 12:15 p.m., during the entrance conference , the documentation of monitoring the humidity in the operating rooms was requested.
On May 10, 2011, at 10:08 a.m., the Facilities Manager stated, there were no records for monitoring the humidity. He stated that humidity was not monitored.

110-22. Identification of Disconnecting Means. Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. Where circuit breakers or fuses are applied in compliance with the series combination ratings marked on the equipment by the manufacturer, the equipment enclosure(s) shall be legibly marked in the field to indicate the equipment has been applied with a series combination rating. The marking shall be readily visible and state the following:
Caution --- Series Combination System Rated --- Amperes, Identified Replacement Components Required.

FPN: See Section 240-83 (c) for interrupting rating marking for end-use equipment.

NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.



Based on observation the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code, 1999 edition. This was evidenced by broken outlet plate covers, appliances plugged into surge protectors, surge protectors plugged into extension cords, and electrical panel switches not all identified.

Findings:

On a tour of the facility on May 9, 2011 through May 11, 2011, the electrical wiring and equipment were observed.

May 10, 2011:

1. At 1:26 p.m., in the medical surgical breakroom a refrigerator was plugged into a surge protector that was plugged into an extension cord.
2. At 1:40 p.m., in room 205 there was a cable outlet cover plate that was not flush with the wall.
3. At 1:46 p.m., all switches were not identified in Panel AA located on the 2nd floor.

May 11, 2011:

Rural Health Clinic - Running Springs

1. At 8:36 a.m., there was a refrigerator plugged into a surge protector.