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Based on record review, the facility failed to provide an emergency plan, policy and procedures, to ensure subsistence needs such as sewage and waste disposal are provided in the event of loss of those systems. Failure to provide sewage and waste disposal in the event of a disaster has the potential to limit the facility's ability of providing safe and sanitary continuity of care in an emergency. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of provided Emergency plan, policies and procedures conducted on 3/3/20 from 8:45 - 11:00 AM, no documentation was provided for the procedures, or steps to be taken, for the disposal of sewage and waste during a loss of those available support systems.

Reference:

42 CFR 482.15(b)(1)

Based on record review and observation, the facility failed to ensure the staff testing program was conducted on actual practices of the facility EP program. Failure to provide a testing program on relevant facility EP policies and procedures, lacks the ability to ensure staff knowledge of the EP program, having the potential to create confusion to facility response during emergencies. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of the facility EP training program conducted on 3/3/20 from 8:45 - 11:00 AM, it was revealed the facility used an online training and testing program for staff, to provide education of EP policies and procedures. Actual participation in the online course conducted by the surveyor, failed to demonstrate any of the content in the online course related to, or directed staff to seek further information on, the actual facility EP policies and procedures, only generic information utilizing non-geographically relevant examples.

Reference:
42 CFR 482.15 (d)

Based on record review and observation, the facility failed to ensure the staff training program was conducted on actual facility EP policies and procedures. Failure to provide a training program on relevant facility EP policies and procedures, lacks the ability to ensure staff obtain knowledge of the EP program, potentially creating confusion that hinders facility response during emergencies. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of the facility EP training program conducted on 3/3/20 from 8:45 - 11:00 AM, it was revealed the facility used an online training program for staff education on emergency response during disasters. Actual participation in the online course conducted by the surveyor, failed to demonstrate any of the content in the online course related to actual facility geographically relevant risks, or directed staff to seek further information on, the facility EP policies and procedures. Information contained only referenced non-geographically relevant examples of disasters and emergencies.

Reference:
42 CFR 482.15(d)(1)

Based on observation and interview, the facility failed to ensure the fire resistive properties of the structure were maintained. Failure to maintain required fire coatings on steel support structures and seal penetrations passing between floors, has the potential to decrease the rated assembly load bearing capabilities causing premature structural failure and allow fire, smoke and dangerous gases to pass between compartments during a fire event. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation of the steel support structures separating the multiple levels of the structure, revealed sections of the load-bearing steel framework were missing protective coating(s) in the following areas:

- Elevator power supply room had an approximately five foot by eight inch section of the cementious fiber coating de-laminating from the underside of the metal pan deck.
- Electrical room E-105 had an approximately two foot by two foot section of bare metal, that was missing the cementious protective coating on a replacement "patch" in the ceiling pan deck. Interview of the Maintenance Engineer at the time of this observation revealed this "patch" was done during the removal of a drain in the upper level.
- Electrical room E-105 located in the basement, had a six inches by four inches of missing protective cementious coating on the ceiling pan deck from the installation of a new electrical junction box.
- Radiology Mechanical room abutting the MRI had two (2) sections of the roof pan deck missing the cementious protective coating, ranging in size from approximately one inch by six inche

Based on observation and operational testing, the facility failed to ensure doors to hazardous areas would self-close as designed. Failure to ensure doors to hazardous areas would fully self-close has the potential to allow fire, smoke and dangerous gases to pass into corridors, affecting the safe egress of patients. This deficient practice affected all patients, staff and visitors of the Radiology department on the date(s) of the survey.

Findings include:

During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation and operational testing of the corridor door entering the soiled utility and Housekeeping storage, failed to demonstrate the door would fully self-close when activated.

Actual NFPA standard:

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard

Based on record review and interview, the facility failed to ensure that relative humidity (RH) within operating rooms was maintained in accordance with NFPA 99, ASHRAE 170 and the hospital Anesthesia Safety policy. Failure to ensure RH in operating rooms is maintained within safe ranges prior to and during procedures, has the potential to increase probability of electrostatic discharge and increase patients exposed risk to fire and infection from surface molds and mildew. This deficient practice affected all patients, staff and visitors in the OR suite and C-section suite on the dates of the survey.

Findings include:

During review of provided OR relative humidity logs conducted on 3/3/20 from 8:45 AM - 12:00 PM, documentation revealed the following:

1) Records provided for the months of 1/1/2019 to 12/31/2019, revealed 60 days of relative humidity documented below 20 percent, with levels falling as low as 5 percent; 14 days of documented levels above 60 percent, with highest levels documented at 89 percent; and 12 days of documentation which failed to record humidity in all operating rooms with 8 of those days having recorded RH levels below 10 percent, including the lowest recorded RH as 3.3 percent. This documentation was found to be a systemic condition with no further review deemed necessary.

2) Records provided for the months of 1/1/2020 to 3/1/2020, revealed 25 days of humidity documented below 20 percent, with levels falling as low as 6 percent and 1 day of no documented humidity in all operating rooms.

3) Review of the provided Anesthesia Safety Policy conducted on 3/3/20 from 8:45 AM to 12:00 PM, revealed the policy stated relative humidity "shall be kept between 20 - 60 (percent) at all times" and "any problems shall be immediately reporte

Based on record review and interview, the facility failed to ensure all fire alarm system devices were visually inspected and functionally tested at least annually, along with a sensitivity test completed as defined under NFPA 72. Failure to inspect and test all fire alarm devices at least annually and perform required sensitivity testing in accordance with the required scheduling, has the potential to hinder early detection of incipient failures, limiting system response during a fire event. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of provided fire alarm inspection records conducted on 3/3/20 from 8:45 - 11:00 AM and 3/4/20 from 8:30 - 9:00 AM, records indicated the facility fire alarm inspection(s) were completed on a quarterly basis. Further review determined the quarterly inspection conducted in March of 2018 (first quarter) had a total of 193 inspected items and the first quarter inspection completed in 2019 had a total of 148 devices listed as being tested.

At approximately 8:45 AM on 3/4/20, interview of the Engineering Director established 15 of the identified devices on the report dated 3/28/2019 marked as "Not Inspected", were either part of a remodel or removed/eliminated, leaving annual testing of the remaining 30 installed devices as undetermined. Further asked if he was aware of the lack of documentation on the inspection reports for all devices, the Engineering Director stated he was not aware all devices were not documented as having been inspected and tested annually.

2) During review of provided fire alarm inspection records conducted on 3/3/20 from 8:45 - 11:00 AM and 3/4/20 from 8:30 - 9:00 AM, no records were available indicating the last sensitivity

Based on observation, the facility failed to ensure smoke barriers were maintained to resist the passage of smoke and ensure performance of all protective systems as designed. Failure to ensure smoke compartments are maintained to resist the passage of smoke, has the potential for fire, smoke and dangerous gases to pass into the interstitial spaces, delaying the response of fire alarms and fire suppression systems, hindering their response time. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM and 3/4/20 from 8:30 - 9:30 AM, observation of the suspended ceilings installed in the facility, revealed the following:

- Room 1120 in Radiology had one (1) missing ceiling tile two feet by four feet in size, affecting the installed smoke detection and fire suppression system pendant.
- Second floor Med Surg comms room had six (6) missing ceiling tiles two foot by two foot in size and one (1) missing cling tile approximately four inches by two foot in size, affecting the installed smoke detection and fire suppression system pendant.
- Comms room across from OR 6 had one (1) missing ceiling tile two foot by two foot in size, affecting the installed smoke detection and fire suppression system pendant.

Actual NFPA standard:

19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1.2-hour fire resistance rating, unless otherwise permitted by one of the
following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in ac

Based on observation and operational testing, the facility failed to ensure cross-corridor smoke barrier doors would fully self-close. Failure to ensure doors to smoke barriers would fully self-close has the potential to allow fire, smoke and dangerous gases to pass between compartments during a fire event. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation and operational smoke barrier doors to the east of the main elevator, revealed the doors would not fully self-close when activated, leaving an approximately 3/4 inch gap between the doors.

Actual NFPA standard:

19.3.7.8% Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

8.5.4.4% Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70 and approved, listed assemblies such as UL 1363 XYBS. Use of extension cords and relocatable power taps (RPTs) as the substitution for the fixed wiring of the structure, or outside those approved listed assemblies and installing conductive materials that expose patients to live parts, potentiall exposes patients to the risks of arc fires and electrical shock. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM and 3/7/20 from 8:30 - 11:00 AM, observation of installed electrical systems revealed the following:

- Scheduling office in the basement level using a RPT to supply power to a microwave and mini-fridge.
- Maintenance shop using a RPT connected in series (daisy-chained) to an Uninterrupted Power Supply (UPS).
- The pre-op call center in the basement abutting room E-105 was using a RPT to supply power to a microwave, toaster and a Kuerig coffee maker.
- The upstairs landing entering into the L&D/Med Surg unit, had a microwave and a vending machine, both using extension cords for supplying power from the facility outlet.

2) During the facility tour conducted on 3/4/20 from 8:30 - 11:00 AM, observation of OR 9 revealed one of the installed electrical outlets on the west wall, had an approximately twelve inch by twelve inch stainless steel plate used as the coverplate for the outlet, allowing the potential to contact the open poles on both sides of the fixture to a conductive material.

Actual NFPA standard:

NFPA 70

110.3 Examination, Identification, Installation, and Use of

Based on observation and interview, the facility failed to ensure safe installation and use of portable space heating units in accordance with NFPA 101. Allowing the use of portable space heating devices in patient areas and without ensuring the unit's maximum temperature limit, exposes patients to the historical risk of fires from those devices. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation of the main elevator reception revealed a staff member using a portable heater. Further observation of the Laboratory Pathology office revealed a space heater adjacent to the wooden file storage.

Interview of the Engineering Director at approximately 2:45 PM on 3/3/20, established the facility did not have a testing program for determining the maximum temperature limit of these devices.

Actual NFPA standard:

19.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on observation, operational testing and interview, the facility failed to ensure medical gas storage was in accordance with NFPA 99. Failure to secure and segregate medical gas cylinders such as oxygen in an area designed and suited for cylinder storage, has the potential to increase patient's exposure to fires and explosions associated with the unsafe handling of medical gases. This deficient practice affected all patients staff and visitors on the date of the survey.

1) During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation of room 1118 in the Radiology suite revealed one (1) unsecured e-cylinder.

2) During the facility tour conducted on 3/3/20 from 1:00 - 5:00 PM, observation of the storage room located off of Short Stay Surgery, revealed the storage rack directly inside the door housed 47 "E" size oxygen cylinders, with no labeling or other means of identifying which cylinders were full or empty. Additionally, combustible storage of stacked cardboard boxes was placed directly against the rack.
An interview of the nurse on duty in the surgery unit at approximately 4:30 PM on how cylinders that were used or empty were switched from the rack for full. The nurse stated a full cylinder would be taken from the rack and the empty placed in its place, substantiating the cylinders were not segregated according to full or empty.

3) Further observation of the space conducted on 3/3/20 at approximately 4:30 PM did not establish any static or mechanical ventilation was installed for the storage area and the door entering the space did not indicate oxidizing gas(es) stored within

Operational testing of the door from the main entry off Short Stay Surgery at approximately 4:30 PM, revealed the door was equipped with an astragal on one of the two leaves that was bent and w