HospitalInspections.org

Based on document review the facility failed to provide documentation for 1 of 2 required disaster drills. This may result in the staff being unfamiliar with the procedures to follow in the event of an emergency. The effected 3 of 3 smoke compartments and may result in injury to staff and patients.

Findings:
On July 20, 2010 at 11:15 a.m. during an entrance conference the disaster drills were requested.
Documentation for 1 disaster drill was provided on July 21, 2010 at 7:59 a.m. Drills were requested on July 20th and 21st. Facility had no other drill documentation to provide.

Based on observation the facility failed to provide documentation of monthly verification of the fire alarm system to central station. This may cause a delay in the notification of emergency services in the event the signal is not received by central station. This effected 3 of 3 smoke compartments.

Findings:
On July 20, 2010, at 11:15 a.m., documentation for the monthly activation of the fire alarm system to the central station was requested from staff 1 and staff 2. The documentation was again requested at 4:41 p.m. on July 20, 2010. On July 21, 2010 at 8 :26 a.m. staff 4 stated that the facility had documentation for June 2010 when the facility verified the alarm signal with central station, but had no other documentation to provide.

Based on document review the facility failed to provide written documentation of current smoke detector sensitivity testing. This may result in the smoke detectors not functioning as designed in the event of a fire. This effected 3 of 3 smoke compartments.

NFPA 72
7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In the zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or aerosol into the detector.


Findings:
On during document review on July 20th through July 21, 2010, the documentation for smoke detector sensitivity testing was reviewed. The documentation was dated December 20, 2007 there was no other documentation provided.

Based on document review and interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition and NFPA 72, National Fire Alarm Code, 1999 edition. This may result in the sprinkler system not functioning properly in the event of a fire. The effects 3 of 3 smoke compartments.

NFPA 25
2-3.3 ALARM DEVICES
Waterflow alarm devices including but not limited to mechanical water gongs, vane-type water flow devices and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72
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 July 20, 2010 at 11:20 a.m. the quarterly sprinkler testing documentation was requested from staff 1 and staff 2. Documentation was provided for the 1st quarter 2010 and 3rd quarter 2009.
On July 20, 2010 at 4:14 p.m. documentation of the quarterly sprinkler testing for the 2nd quarter 2010 and 4th quarter 2009 was requested from staff 1.
On July 21, 2010 at 9:47 a.m. staff 4 stated the facility had no further documentation to provide for quarterly sprinkler testing. Staff 4 stated that the vendor test the system twice a year.

Based on document review and interview the facility failed to maintain the humidity levels in 2 of 2 operating rooms at 35% or greater in accordance with NFPA 99, Standard for Health Care Facilities, 1999 edition. This had the potential to cause a fire in the operating rooms. This effected 1 of 3 smoke compartments.

Findings:
On July 20, 2010, at 11:20 a.m., the humidity logs were requested for 2 of 2 operating rooms. The humidity logs were reviewed from October 2009 through July 20, 2010.

January 2010:
Operating Room 1 Humidity Levels:
a. 1st - 32 %
b. 3rd - 29%
c. 4th - 24%
d. 5th - 24%
e. 6th - 24%
f. 7th - 28%
g. 8th - 25%
h. 9th - 23%
i. 11th - 25%
j. 12th - 23%
k. 13th - 25%
l. 14th - 26%
m. 15th - 25%
n. 17th -25%

Operating Room 2 Humidity Levels:
a. 1st - 31%
b. 3rd - 30%
c. 4th - 23%
d. 5th - 23%
e. 6th - 24%
f. 7th - 24%
g. 8th - 26%
h. 9th - 22%
i. 11th - 22%
j. 12th - 23%
k. 13th - 24%
l. 14th - 25%
m.15th - 24%
n. 17th - 24%

February 2010
Operating Room 1 Humidity Levels:
a. 17th - 34%
b. 18th - 34%
c. 19th - 32%
d. 23rd - 24%
e. 24th - 28%
f. 25th - 33%
g. 26th - 27%

Operating Room 2 Humidity Levels
a. 16th - 34%
b. 17th - 32%
c. 19th - 33%
d. 23rd - 23%
e. 24th - 26%
f. 25th - 31%
g. 26th - 26%

March 2010
Operating Room 1 Humidity Levels:
a. 10th - 32%
b. 11th - 29%
c. 12th - 29%
d. 13th - 27%
e. 15th - 26%
f. 17th - 33%
g. 19th - 34%
h. 22nd - 30%
i. 23rd - 29%
j. 24th - 23%
k. 25th - 32%
l. 26th - 29%
m. 29th - 23%
n. 30th - 24%
o. 31st - 32%

Operating Room 2 Humidity Levels:
a. 1st - 34%
b. 4th - 33%
c. 5th - 28%
d. 10th - 29%
e. 11th - 26%
f. 12th - 27%
g. 13th - 26%
h. 15th - 27%
i. 16th - 32%
j. 17th - 31%
k. 18th - 33%
l. 19th - 32%
m. 22nd - 28%
n. 23rd - 27%
o. 24th - 23%
p. 25th - 33%
q. 26th - 28%
r. 29th - 24%
s. 30th - 22%
t. 31st - 34%

April 2010
Operating Room 1 Humidity Levels
a. 1st - 30%
b. 2nd - 26%
c. 3rd - 30%
d. 5th - 32%
e. 6th - 31%
f. 7th - 21%
g. 8th - 23%
h. 9th - 23%
i. 12th - 32%
j. 13th - 32%
k. 14th - 30%
l. 15th - 30%
m. 16th - 33%
n. 21st - 32%
o. 22nd - 31%
p. 23rd - 34%
q. 26th 33%
r. 27th - 33%
s. 29th - 31%
t. 30th - 24%

Operating Room 2 Humidity Levels
a. 1st - 29%
b. 2nd - 28%
c. 3rd - 31%
d. 5th - 33%
e. 6th - 32%
f. 7th - 22%
g. 8th - 23%
h. 9th - 24%
i. 12th - 30%
j. 13th - 31%
k. 14th - 30%
l. 15th - 29%
m. 16th - 34%
n. 19th - 34%
o. 21st - 34%
p. 22nd - 30%
q. 23rd - 31%
r. 26th - 31%
s. 27th - 30%
t. 29th - 30%
u. 30th - 24%

May 2010
Operating Room 1 Humidity Levels:
a. 3rd - 28%
b. 4th - 26%
c. 5th - 33%
d. 6th - 33%
e. 7th - 25%
f. 8th - 30%
g. 10th - 33%
h. 11th - 34%
i. 12th - 26%
j. 13th - 32%
k. 17th - 34%
l. 25th - 31%
m. 26th - 34%

Operating Room 2 Humidity Levels:
a. 3rd - 29%
b. 4th - 25%
c. 5th - 29%
d.6th - 31%
e. 7th - 22%
f. 8th - 31%
g. 10th - 29%
h. 11th -30%
i. 12th - 25%
j. 13th - 31%
k. 14th - 32%
l. 17th - 32%
m. 25th - 30%

January 2010:
14 of 25 days humidity level below 35%
3 days plant operations not notified.
16 days plant operations was notified but there was no follow up results documented

February 2010:
9 of 22 days humidity level below 35%
6 days plant operations not notified.
3 days plant operations was notified but no results documented.

March 2010:
20 of 25 days humidity level below 35%
8 days plant operations not notified.
12 days plant operations was notified but no results documented.

April 2010:
21 of 23 days humidity level below 35%
13 days plant operations not notified.
8 days plant operations notified 4 times results given but remained below 35% no follow up results

May 2010:
14 of 21 days humidity level below 35%
8 days plant operations not notified.
6 days plant operations were notified results given but remained below 35% not follow up results.


From January 2010 through May 2010 the humidity level fell below 35% on 116 days, the facility notified plant operations on 38 days of low humidity levels, 10 of the 38 days plant operations was notified the humidity level was rechecked with documented results but remained below 35%.

Based on document review and interview the facility failed to maintain the alarm panels for the oxygen in reliable working condition in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by documentation that the panels failed during the annual inspection. This had the potential to result in the in accurate delivery of oxygen to patients and staff could be unaware of the problem.

Findings:
On June 20, 2010 at 2:00 p.m. the Annual Medical Gas report dated March 16th, 2010, was reviewed. The report indicated that the Master Alarm Panel and the Area Alarm panel failed, the report stated both panels were inoperable and required conversion.
1. The Master Alarm Panel (MAP) is located at the nurses station, and the area served is Hospital, monitors reserved 02 manifold, and main 02 tank, there were no audible or visual indicators.
2. The Area Alarm Panel (AAP) is located in Major Surgery, area served is major surgery, minor surgery, delivery room, there were no audible or visual indicators.
On July 21st, 2010, at 8:33 a.m., during an interview with staff 3 regarding the results of the annual medical gas report, staff 3 stated they were unaware of the results.
At 8:40 a.m, during an interview with staff 1 regarding the annual medical gas report staff 1 stated they were unaware of the results that Plant Operations is in charge of it.
At 8:45 a.m., during interviews with staff 1 and staff 4 they were unaware of the test results.
At 9:03 a.m., during an interview with the contracted vendor the vendor stated that the company sent a quote to the facility on March 18, 2010 and the facility had not responded to the quote as of July 20, 2010.
At 9:30 a.m., during an interview with staff 1, 2 and 4 they were not aware of a quote that had been sent to the previous Operations Manager.
At 10:15 a.m., staff 4 provided the quote that had been sent by the vendor. The quote was sent to purchasing on June 30, 2010, purchasing sent the quote to the Chief Financial Officer (CFO) on July 6, 2010. The purchase order had not been signed by the CFO as of July 20, 2010. During an interview with staff 1 at this time staff stated the purchase order had been signed and the facility was in the process of looking for someone to repair the panels as soon as possible.
At 11:15 a.m. during an interview with staff 3 regarding the system staff 3 stated had they known about the results of the medical gas testing they would have proceeded differently such as cancel elective surgeries and would only do life threating surgeries.
At 1:40 p.m. during an interview with staff 5 regarding back up procedures in the operating rooms, staff 5 stated by law all anesthesia machines must have a Fail Safe Alarm. The alarm sounds if the supply of oxygen is out of range and in that case he would turn the 'E' cylinder on the anesthesia machine on to finish the procedure.

NFPA 99 1999 edition
3-4.1.1.15 Alarm Annunciator
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator, shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning
(b) Individual visual signals plus common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel- when the main fuel storage tank contains less than a 3 hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.
3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
6-3.4 A written record of the EPSS inspection, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a.) The date of the maintenance report.
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

Based on document review and interview the facility failed to maintain the emergency generator in reliable operating condtion in accordance with NFPA 99, Standard for Health Care Facilities, 1999 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition, as evidenced by failure to provide documentation of weekly visual inspections for 34 of 51 weeks, and no remote annunicator. This had the potential for the emergency generator not function in the event of an emergency. This effected 3 of 3 smoke compartments.

Findings:
On July 20, 2010 during document review at 3:04 p.m. the Generator Test Logs were reviewed from July 2009 through June 2010.
A. The facility failed to provide weekly visual inspection documentation for the following weeks:
1. Three of 4 weeks in July 2009 (July 5, July 12 and July 19)
2. Three of 5 weeks in August 2009 (August 9, August 16 and August 30)
3. Three of 4 weeks in September 2009 (September 6, Setember 13 and September 20)
4. Three of 4 weeks in October 2009 (October 4, October 11 and October 18)
5. Three of 4 weeks in November 2009 (November 1, Nobember 8, November 15 and November 22)
6. Three of 4 weeks in December 2009 (December 6, December 13 and December 21)
7. Three of 5 weeks in January 2010 (January 3, January 10 and January 17)
8. Two of 4 weeks in February 2010 (February 7 and February 14)
9. Three of 4 weeks in March 2010 (March 7, March 14 and March 21)
10. Three of 4 weeks in April 2010 (April 4, April 11 and Apri 18)
11. Four of 5 weeks in May 2010 (May 2, May 9, May 16 and May 23)
12. One of 4 weeks in June 2010 (June 2)

B . On July 22, 2010 during a tour of the facility with staff 1 and 4, staff was interviewed as to the location of the remote annunciator of the emergency generator. Staff 1 and 4 stated there was no remote annunciator for the emergency generator in the facility.

Based on document review the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, The National Electrical Code. This was evidenced by failure to repair outlets identified as needing repair or replacement during the inspection. The has the potential to cause a fire or injury to staff or patients.

Findings:
On July 20, 2010 during document review at 3:50 p.m. the Semi-Annual Emergency Outlet Inspections were reviewed.
1. Labor and Delivery bed B identified the outlet needs to be replaced dated January 29, 2010.
2. Intensive Care Unit Beds B and C outlets have open ground.

On July 22, 2010 during a tour of the facility with staff at 10:16 a.m. in the clerical pool office there is a surge protector plugged into a surge protector.

Based on document review the facility failed to provide documentation for 1 of 2 required disaster drills. This may result in the staff being unfamiliar with the procedures to follow in the event of an emergency. The effected 3 of 3 smoke compartments and may result in injury to staff and patients.

Findings:
On July 20, 2010 at 11:15 a.m. during an entrance conference the disaster drills were requested.
Documentation for 1 disaster drill was provided on July 21, 2010 at 7:59 a.m. Drills were requested on July 20th and 21st. Facility had no other drill documentation to provide.

Based on observation the facility failed to provide documentation of monthly verification of the fire alarm system to central station. This may cause a delay in the notification of emergency services in the event the signal is not received by central station. This effected 3 of 3 smoke compartments.

Findings:
On July 20, 2010, at 11:15 a.m., documentation for the monthly activation of the fire alarm system to the central station was requested from staff 1 and staff 2. The documentation was again requested at 4:41 p.m. on July 20, 2010. On July 21, 2010 at 8 :26 a.m. staff 4 stated that the facility had documentation for June 2010 when the facility verified the alarm signal with central station, but had no other documentation to provide.

Based on document review the facility failed to provide written documentation of current smoke detector sensitivity testing. This may result in the smoke detectors not functioning as designed in the event of a fire. This effected 3 of 3 smoke compartments.

NFPA 72
7-3.2.1
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In the zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or aerosol into the detector.


Findings:
On during document review on July 20th through July 21, 2010, the documentation for smoke detector sensitivity testing was reviewed. The documentation was dated December 20, 2007 there was no other documentation provided.

Based on document review and interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition and NFPA 72, National Fire Alarm Code, 1999 edition. This may result in the sprinkler system not functioning properly in the event of a fire. The effects 3 of 3 smoke compartments.

NFPA 25
2-3.3 ALARM DEVICES
Waterflow alarm devices including but not limited to mechanical water gongs, vane-type water flow devices and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72
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 July 20, 2010 at 11:20 a.m. the quarterly sprinkler testing documentation was requested from staff 1 and staff 2. Documentation was provided for the 1st quarter 2010 and 3rd quarter 2009.
On July 20, 2010 at 4:14 p.m. documentation of the quarterly sprinkler testing for the 2nd quarter 2010 and 4th quarter 2009 was requested from staff 1.
On July 21, 2010 at 9:47 a.m. staff 4 stated the facility had no further documentation to provide for quarterly sprinkler testing. Staff 4 stated that the vendor test the system twice a year.

Based on document review and interview the facility failed to maintain the humidity levels in 2 of 2 operating rooms at 35% or greater in accordance with NFPA 99, Standard for Health Care Facilities, 1999 edition. This had the potential to cause a fire in the operating rooms. This effected 1 of 3 smoke compartments.

Findings:
On July 20, 2010, at 11:20 a.m., the humidity logs were requested for 2 of 2 operating rooms. The humidity logs were reviewed from October 2009 through July 20, 2010.

January 2010:
Operating Room 1 Humidity Levels:
a. 1st - 32 %
b. 3rd - 29%
c. 4th - 24%
d. 5th - 24%
e. 6th - 24%
f. 7th - 28%
g. 8th - 25%
h. 9th - 23%
i. 11th - 25%
j. 12th - 23%
k. 13th - 25%
l. 14th - 26%
m. 15th - 25%
n. 17th -25%

Operating Room 2 Humidity Levels:
a. 1st - 31%
b. 3rd - 30%
c. 4th - 23%
d. 5th - 23%
e. 6th - 24%
f. 7th - 24%
g. 8th - 26%
h. 9th - 22%
i. 11th - 22%
j. 12th - 23%
k. 13th - 24%
l. 14th - 25%
m.15th - 24%
n. 17th - 24%

February 2010
Operating Room 1 Humidity Levels:
a. 17th - 34%
b. 18th - 34%
c. 19th - 32%
d. 23rd - 24%
e. 24th - 28%
f. 25th - 33%
g. 26th - 27%

Operating Room 2 Humidity Levels
a. 16th - 34%
b. 17th - 32%
c. 19th - 33%
d. 23rd - 23%
e. 24th - 26%
f. 25th - 31%
g. 26th - 26%

March 2010
Operating Room 1 Humidity Levels:
a. 10th - 32%
b. 11th - 29%
c. 12th - 29%
d. 13th - 27%
e. 15th - 26%
f. 17th - 33%
g. 19th - 34%
h. 22nd - 30%
i. 23rd - 29%
j. 24th - 23%
k. 25th - 32%
l. 26th - 29%
m. 29th - 23%
n. 30th - 24%
o. 31st - 32%

Operating Room 2 Humidity Levels:
a. 1st - 34%
b. 4th - 33%
c. 5th - 28%
d. 10th - 29%
e. 11th - 26%
f. 12th - 27%
g. 13th - 26%
h. 15th - 27%
i. 16th - 32%
j. 17th - 31%
k. 18th - 33%
l. 19th - 32%
m. 22nd - 28%
n. 23rd - 27%
o. 24th - 23%
p. 25th - 33%
q. 26th - 28%
r. 29th - 24%
s. 30th - 22%
t. 31st - 34%

April 2010
Operating Room 1 Humidity Levels
a. 1st - 30%
b. 2nd - 26%
c. 3rd - 30%
d. 5th - 32%
e. 6th - 31%
f. 7th - 21%
g. 8th - 23%
h. 9th - 23%
i. 12th - 32%
j. 13th - 32%
k. 14th - 30%
l. 15th - 30%
m. 16th - 33%
n. 21st - 32%
o. 22nd - 31%
p. 23rd - 34%
q. 26th 33%
r. 27th - 33%
s. 29th - 31%
t. 30th - 24%

Operating Room 2 Humidity Levels
a. 1st - 29%
b. 2nd - 28%
c. 3rd - 31%
d. 5th - 33%
e. 6th - 32%
f. 7th - 22%
g. 8th - 23%
h. 9th - 24%
i. 12th - 30%
j. 13th - 31%
k. 14th - 30%
l. 15th - 29%
m. 16th - 34%
n. 19th - 34%
o. 21st - 34%
p. 22nd - 30%
q. 23rd - 31%
r. 26th - 31%
s. 27th - 30%
t. 29th - 30%
u. 30th - 24%

May 2010
Operating Room 1 Humidity Levels:
a. 3rd - 28%
b. 4th - 26%
c. 5th - 33%
d. 6th - 33%
e. 7th - 25%
f. 8th - 30%
g. 10th - 33%
h. 11th - 34%
i. 12th - 26%
j. 13th - 32%
k. 17th - 34%
l. 25th - 31%
m. 26th - 34%

Operating Room 2 Humidity Levels:
a. 3rd - 29%
b. 4th - 25%
c. 5th - 29%
d.6th - 31%
e. 7th - 22%
f. 8th - 31%
g. 10th - 29%
h. 11th -30%
i. 12th - 25%
j. 13th - 31%
k. 14th - 32%
l. 17th - 32%
m. 25th - 30%

January 2010:
14 of 25 days humidity level below 35%
3 days plant operations not notified.
16 days plant operations was notified but there was no follow up results documented

February 2010:
9 of 22 days humidity level below 35%
6 days plant operations not notified.
3 days plant operations was notified but no results documented.

March 2010:
20 of 25 days humidity level below 35%
8 days plant operations not notified.
12 days plant operations was notified but no results documented.

April 2010:
21 of 23 days humidity level below 35%
13 days plant operations not notified.
8 days plant operations notified 4 times results given but remained below 35% no follow up results

May 2010:
14 of 21 days humidity level below 35%
8 days plant operations not notified.
6 days plant operations were notified results given but remained below 35% not follow up results.


From January 2010 through May 2010 the humidity level fell below 35% on 116 days, the facility notified plant operations on 38 days of low humidity levels, 10 of the 38 days plant operations was notified the humidity level was rechecked with documented results but remained below 35%.

Based on document review and interview the facility failed to maintain the alarm panels for the oxygen in reliable working condition in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by documentation that the panels failed during the annual inspection. This had the potential to result in the in accurate delivery of oxygen to patients and staff could be unaware of the problem.

Findings:
On June 20, 2010 at 2:00 p.m. the Annual Medical Gas report dated March 16th, 2010, was reviewed. The report indicated that the Master Alarm Panel and the Area Alarm panel failed, the report stated both panels were inoperable and required conversion.
1. The Master Alarm Panel (MAP) is located at the nurses station, and the area served is Hospital, monitors reserved 02 manifold, and main 02 tank, there were no audible or visual indicators.
2. The Area Alarm Panel (AAP) is located in Major Surgery, area served is major surgery, minor surgery, delivery room, there were no audible or visual indicators.
On July 21st, 2010, at 8:33 a.m., during an interview with staff 3 regarding the results of the annual medical gas report, staff 3 stated they were unaware of the results.
At 8:40 a.m, during an interview with staff 1 regarding the annual medical gas report staff 1 stated they were unaware of the results that Plant Operations is in charge of it.
At 8:45 a.m., during interviews with staff 1 and staff 4 they were unaware of the test results.
At 9:03 a.m., during an interview with the contracted vendor the vendor stated that the company sent a quote to the facility on March 18, 2010 and the facility had not responded to the quote as of July 20, 2010.
At 9:30 a.m., during an interview with staff 1, 2 and 4 they were not aware of a quote that had been sent to the previous Operations Manager.
At 10:15 a.m., staff 4 provided the quote that had been sent by the vendor. The quote was sent to purchasing on June 30, 2010, purchasing sent the quote to the Chief Financial Officer (CFO) on July 6, 2010. The purchase order had not been signed by the CFO as of July 20, 2010. During an interview with staff 1 at this time staff stated the purchase order had been signed and the facility was in the process of looking for someone to repair the panels as soon as possible.
At 11:15 a.m. during an interview with staff 3 regarding the system staff 3 stated had they known about the results of the medical gas testing they would have proceeded differently such as cancel elective surgeries and would only do life threating surgeries.
At 1:40 p.m. during an interview with staff 5 regarding back up procedures in the operating rooms, staff 5 stated by law all anesthesia machines must have a Fail Safe Alarm. The alarm sounds if the supply of oxygen is out of range and in that case he would turn the 'E' cylinder on the anesthesia machine on to finish the procedure.

NFPA 99 1999 edition
3-4.1.1.15 Alarm Annunciator
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator, shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning
(b) Individual visual signals plus common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel- when the main fuel storage tank contains less than a 3 hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.
3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition
6-3.4 A written record of the EPSS inspection, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a.) The date of the maintenance report.
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

Based on document review and interview the facility failed to maintain the emergency generator in reliable operating condtion in accordance with NFPA 99, Standard for Health Care Facilities, 1999 edition, and NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition, as evidenced by failure to provide documentation of weekly visual inspections for 34 of 51 weeks, and no remote annunicator. This had the potential for the emergency generator not function in the event of an emergency. This effected 3 of 3 smoke compartments.

Findings:
On July 20, 2010 during document review at 3:04 p.m. the Generator Test Logs were reviewed from July 2009 through June 2010.
A. The facility failed to provide weekly visual inspection documentation for the following weeks:
1. Three of 4 weeks in July 2009 (July 5, July 12 and July 19)
2. Three of 5 weeks in August 2009 (August 9, August 16 and August 30)
3. Three of 4 weeks in September 2009 (September 6, Setember 13 and September 20)
4. Three of 4 weeks in October 2009 (October 4, October 11 and October 18)
5. Three of 4 weeks in November 2009 (November 1, Nobember 8, November 15 and November 22)
6. Three of 4 weeks in December 2009 (December 6, December 13 and December 21)
7. Three of 5 weeks in January 2010 (January 3, January 10 and January 17)
8. Two of 4 weeks in February 2010 (February 7 and February 14)
9. Three of 4 weeks in March 2010 (March 7, March 14 and March 21)
10. Three of 4 weeks in April 2010 (April 4, April 11 and Apri 18)
11. Four of 5 weeks in May 2010 (May 2, May 9, May 16 and May 23)
12. One of 4 weeks in June 2010 (June 2)

B . On July 22, 2010 during a tour of the facility with staff 1 and 4, staff was interviewed as to the location of the remote annunciator of the emergency generator. Staff 1 and 4 stated there was no remote annunciator for the emergency generator in the facility.

Based on document review the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, The National Electrical Code. This was evidenced by failure to repair outlets identified as needing repair or replacement during the inspection. The has the potential to cause a fire or injury to staff or patients.

Findings:
On July 20, 2010 during document review at 3:50 p.m. the Semi-Annual Emergency Outlet Inspections were reviewed.
1. Labor and Delivery bed B identified the outlet needs to be replaced dated January 29, 2010.
2. Intensive Care Unit Beds B and C outlets have open ground.

On July 22, 2010 during a tour of the facility with staff at 10:16 a.m. in the clerical pool office there is a surge protector plugged into a surge protector.