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Based on observation, the facility failed to ensure corridor doors resist the passage of smoke, as evidenced by doors that failed to positive latch. This affected 2 of 2 floors at the Main Hospital and had the potential to allow the spread of smoke and fire, in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff, from October 22, 2012 through October 25, 2012, the corridor doors were observed.

Main Hospital - Main Level (1st Floor) - 10/22/12
1. At 10:35 a.m., the door to Housekeeping 1-263 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch upon closure.

2. At 10:38 a.m., the door to Room 1-198 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch upon closure.


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Main Hospital - Upper Level (Second Floor) - 10/23/12
3. At 9:21 a.m., the bed in Patient Room 250, obstructed the corridor door from closing, on South Med.

4. At 9:25 a.m., the bed in Patient Room 255, obstructed the corridor door from closing, on South Med.

5. At 9:28 a.m., the bed in Patient Room 256, obstructed the corridor door from closing, on South Med.

6. At 9:41 a.m., the corridor door to Patient Room 206, was obstructed from closing by a blue soiled linen bin in North Telemetry.

7. At 10:28 a.m., the corridor door to Patient Room 225, was obstructed from closing by a blue soiled linen bin in West Telemetry.

8. At 10:30 a.m., the corridor door to Patient Room 227, was obstructed from closing by a blue soiled linen bin in West Telemetry.

9. At 10:35 a.m., the corridor door to Patient Room 224, was obstructed from closing by a blue soiled linen bin in West Telemetry.

10. At 11:23 a.m., the corridor door to Patient Room 291, failed to latch when manually closed, in the Labor Delivery Department. The door hit the top of the door frame.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls, as evidenced by penetrations in one smoke barrier wall. This could result in the increased spread of smoke and fire and risk of injury to the patients. This affected 1 of 2 floors at the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Hospital Staff, on October 22, 2012, the smoke barrier walls were observed in the Main Hospital - Main Level (1st Floor).

At 10:15 a.m., there was an approximately 4 inch by 4 inch penetration, in the smoke barrier wall, above the door between OP Surgery and the Lobby. During an interview the Director of Facilities stated that the fire alarm system was being upgraded and the penetration around the wires was not yet sealed.

Based on observation, the facility failed to maintain their fire rated smoke barrier doors. This was evidenced by doors that failed to close and latch after activation of the fire alarm system. This could result in the spread of smoke and fire from one smoke compartment to another and affected 2 of 2 floors in the Main Hospital.

Findings:

During fire alarm system testing with Hospital Staff and the Fire Alarm Technician, on October 23, 2012, the smoke barrier doors were observed.

Main Hospital - Main Level (1st Floor)
1. At 3:01 p.m., the smoke barrier door in the Emergency Department failed to positive latch on the left side after activation of a manual pull station. The door was equipped with latching hardware.



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Main Hospital - Upper Level (Second Floor)
2. At 2 p.m., the smoke barrier door leaf next to Office 2-507 failed to latch during fire alarm system testing in Med Surge Unit C.

3. At 2:45 p.m., the smoke barrier door, closest to the employee elevators, failed to latch during fire alarm system testing in the Transition Hallway in Telemetry .

4. At 3:08 p.m., in ICU-A, the smoke barrier door next to Patient Room 2-345, failed to latch during fire alarm system testing.

5. At 3:23 p.m., the fire rated corridor door to the Gift Shop failed to latch upon self-closure during fire alarm system testing. The door hit the door frame and was obstructed from closing.

Based on observation and interview, the facility failed to ensure their aisles or corridors, serving as an exit, were clear and unobstructed at all times. This was evidenced by medical equipment in the corridors and in front of the exit doors in the Emergency Department. This had the potential to delay evacuation and cause harm to patients, in the event of a fire or other emergency. This affected 1 of 2 floors at the Main Hospital.

Findings:

During the tour of the facility with Hospital Staff, on October 22, 2012 and throughout the survey, the corridors and exits were observed in the Emergency Department.

Main Hospital - Main Level (1st Floor)
1. On October 22, 2012, at 2:26 p.m., in the "Hall 4" corridor, there was a Computer on Wheels (COW) placed approximately six (6) inches from the fire doors. Other medical equipment, gurneys and chairs were placed directly behind the COW.

2. At 2:35 p.m., in the "Hall 5" corridor, there were two gurneys with patients, privacy screens and COWs placed along the right wall. A chair with a patient family member was directly across from the gurney. The width of the corridor was reduced to approximately 1.5 ft. of space between the chair and the gurney.

During an interview at 2:36 p.m., the Director of Facilities reported that gurneys and patient screens were used in the aisles, inside the Emergency Department, for patient overflow.

Based on observation and interview, the facility failed to provide battery powered emergency lighting in the anesthetizing locations in accordance with NFPA 99. This was evidenced by no battery powered emergency lighting in 3 of 3 Operating Rooms at the Outpatient Surgery Pavilion, by one emergency lighting unit that failed to illuminate, and by no record of maintenance and testing for the emergency lighting system at the Outpatient Perinatal Testing. This failure affected patients in 3 of 3 operating rooms and the Basement level at the Outpatient Perinatal Testing building.

NFPA 99, Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 70, National Electrical Code (1999) Edition
Section 700-12
e. Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following.
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facilities on October 24, 2012, the emergency lighting was observed and tested at two off site locations.

Outpatient Services - Perinatal Testing, Suite 600-A
1. At 3:50 p.m., 2 of 2 emergency lighting units in the IT Training Room, Basement level of Suite 600-A, failed to illuminate when tested.

At 3:51 p.m., the Director of Facilities was asked if the lighting units had been tested monthly and annually as required by NFPA 101. He stated that they did not test the emergency battery backup lighting in the off sites locations.



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Outpatient Services at Outpatient Surgery Pavilion
2. At 2:30 p.m., operating rooms 1, 2 and 3 did not have Battery-Powered Emergency Lighting Units.

At 2:38 p.m., during an interview, the Director of Facilities confirmed there were no battery-powered emergency back up lights in the operating rooms.

Based on document review and interview, the facility failed to ensure all staff are familiar with fire drill procedures. This was evidenced by no records for fire drill participation for 121 of 125 Emergency Department (ED) staff, by staff who could not locate the fire alarm pull station, and by missing documentation for 1 of 4 required fire drills, in the past 12 months, at the Outpatient Surgery Pavilion. This affected the Emergency Department and the Outpatient Surgery Pavilion and could result in a delay in staff response to a fire or disaster.

NFPA 101, Life Safety Code, 2000 Edition
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During document review with the Security Officer, Director of Facilities, Accreditation Readiness Risk Manager, and an interview with the ED Supervisor, on October 22, 2012 and October 25, 2012, the fire and disaster drills were reviewed and staff was interviewed.

Main Hospital - Main Level (1st Floor) Emergency Department on 10/22/12:
1. At 3:15 p.m., the ED Supervisor was interviewed and asked if she knew where the manual pull station was. The ED Supervisor looked up and down the corridors but could not locate the pull station. The ED Supervisor was asked when she had last participated in a fire drill. She reported that it had been about 3 years ago.

2. At 4:20 p.m., the Security Officer, who conducts the fire drills, was interviewed and asked if the ED had participated in any fire drills during the last 12 months. The Security Officer stated that fire drills were conducted by zone and the ED zone had not participated in fire drills in 2012 or 2011. The Security Officer stated that 4 employees from the Emergency Department had responded to fire drills in other zones in the 4th quarter 2011. When asked how many staff the Emergency Department has, the Accreditation Readiness Risk Manager, stated there are 125 employees working in the ED.


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Outpatient Services at Outpatient Surgery Pavilion - 10/25/12
3. At 12:30 p.m., the facility failed to provide documentation for the 3rd quarter (July, August, September) 2012, fire drill. During an interview, the Director of Facilities confirmed there was no fire drill for the 3rd quarter.

Based on observation, fire alarm testing and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This was evidenced by no smoke detector protection for their fire alarm control panel (FACP), by blocked manual pull stations, and by no current documentation for annual certification of the Fire Alarm Control Panel (FACP) and devices. This could result in a delay in notification of the fire department or building occupants in the event of a fire. This affected 1 of 2 floors at the Main Hospital, the Outpatient Surgery Pavilion and one suite at the Outpatient Clinics, Hesperia Community Health Center building.

NFPA 72 National Fire Alarm Code, 1999 Edition
1-5.6 Protection of Fire Alarm Control Unit(s).
In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with hospital staff, from October 22, 2012 through October 25, 2012, the fire alarm control panels and manual pull stations were observed.

Main Hospital - Main Level (1st Floor) - 10/22/12
1. At 10:20 a.m., the fire alarm control panel in the "FACP" equipment room, in Recovery, did not have a smoke detector. The room was locked and not continuously occupied.

2. At 3:20 p.m., in the Emergency Department, a desk and computer were blocking the manual pull station, by the check in desk, next to the entrance to the Triage Room.

Outpatient Services - Surgery at Out Patient Surgery Pavilion - 10/24/12
3. At 1:35 p.m., the manual pull station in the nurse charting area was blocked by a shelf containing a printer and other equipment.

Family Practice at Hesperia Community Health Center - 10/22/12
4. During record review, at 9:45 a.m., the annual certification of the Fire Alarm Control Panel was requested. The facility failed to provide records for annual testing and certification for the complete fire alarm system.

5. On 10/24/12 at 11:32 a.m., the manual pull stations were observed and tested. The Director of Facilities was asked if there was an annual certification for the complete fire alarm system. He stated that he would check.
On 10/25/12 at 1:45 p.m., the Director of Facilities reported that there is a new vendor contract. The vendor no longer reminds the facility the annual is due. The Director of Facilities confirmed no annual testing and certification was conducted for the complete fire alarm system.

Based on observation, the facility failed to maintain the automatic sprinkler system, as evidenced by a Fire Department Hose Valve that was blocked from access. This failure could result in a delay to access water in the event of a fire, and affected 1 of 2 floors at the Main Hospital.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.3.2* The valve inspection shall verify that the valves are in the following condition:
(a) In the normal open or closed position
(b) *Properly sealed, locked, or supervised
(c) Accessible
(d) Provided with appropriate wrenches
(e) Free from external leaks
(f) Provided with appropriate identification

Findings:

During a tour of the facility with hospital staff, from October 22, 2012 - October 24, 2012, the sprinkler system was observed.

Main Hospital - Main Level (1st Floor) - 10/22/12
At 3:22 p.m., there was a "Fire Department Hose Valve" that was blocked by chairs with patients sitting in them, in the Emergency Department.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically, as evidenced by sprinklers that were not flush with the ceiling, by missing escutcheon rings and by a sprinkler head that was contaminated with paint. This failure could result in a failure of the sprinkler system or a delay in extinguishing a fire. This affected patients on 1 of 2 floors at the Main Hospital.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection Systems, 1998 Edition
2-2 Inspection. 2-2.1 Sprinklers.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with hospital staff, from October 22, 2012, through October 24, 2012, the sprinkler system was observed in the Main Hospital.

Main Hospital - Upper Level - 10/22/12
1. At 10:45 a.m., the sprinkler escutcheon ring was missing above bed "B" in Med Surge South, Room 266.

Main Hospital -10/23/12
2. At 11:46 a.m., 1 of 2 sprinklers was not flush with the ceiling, in the Main Fire Alarm Control Panel Room. An approximately 1/2 inch gap was exposed around the sprinkler head. 1 of 2 sprinklers was contaminated with paint.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that failed to have documented monthly visual inspections, and by three fire extinguishers that failed to have the required annual maintenance. This could result in a failure of the fire extinguishers or a delay in extinguishing a fire. This affected 1 of 2 floors at the Main Hospital and the Outpatient Services at the Outpatient Surgery Pavilion.

NFPA 10, Standard for Portable Fire Extinguishers (1998) Edition
Chapter 4 Inspection, Maintenance and Recharging
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

4-4 Maintenance.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During a tour of the facility with hospital staff, from October 22, 2012 through October 24, 2012, the fire extinguishers were observed.

Main Hospital - Upper Level - 10/23/12
1. At 10:58 a.m., the fire extinguisher in the doctor's Dictation Office, Room 2-259, failed to have monthly visual inspections documented on the tag for 10 of 12 months. The annual maintenance was documented as 12/2011. This was confirmed by the Director of Facilities during the survey.

Outpatient Services at Outpatient Surgery Pavilion - 10/24/12
2. At 2:38 p.m., the fire extinguishers in Operating Rooms 1, 2 and 3 were expired. The tag attached to the fire extinguisher documented the last annual maintenance as 7/13/2011. This was confirmed by the Director of Facilities during the survey.

Based on observation, the facility failed to maintain their smoking area, as evidenced by cigarette butts on the ground in the designated smoking area, and by cigarette butts on the ground in a non designated smoking area. This could result in an increased risk of fire in the smoking area. This affected 2 of 2 floors at the Main Hospital and the Out Patient Surgery Pavilion.

Findings:

During a tour of the facility with hospital staff, from October 22, 2012 through October 25, 2012, the grounds and smoking area were observed around the facility buildings.

Main Hospital - Main Level (1st Floor) - 10/23/12
1. At 10:45 a.m., there were more than 50 cigarette butts on the dirt in the designated smoking area. Four goose neck cigarette receptacles were located in the smoking area. There were more than 100 cigarette butts on the dirt, in the city wash area. The area is not designated for smoking.

Out Patient Surgery Pavilion - 10/24/12
2. At 2:37 p.m., there was a goose neck receptacle placed approximately 6 inches from the high voltage meter in the back parking lot, next to the generator. There were more than 12 cigarette butts on the ground next to the receptacle.

During an interview, Nursing Staff 1 reported that this was the designated smoking area for the surgery center.

Based on observation and interview, the facility failed to ensure portable space heating devices were not used in patient areas. This was evidenced by the use of a portable space heater in one patient interview area. This could potentially cause harm to patients, visitors and staff in the event the portable space heater caused a fire. This affected Suite 130 at the Outpatient Services - Patient Assessment building.

Findings:

During a tour of the facility with hospital staff on October 24, 2012, a portable space heater was observed in one area.

Outpatient Services - Patient Assessment, Suite 130 - 10/24/12
At 1:45 p.m., the "RN Interview Office" had a Honeywell portable space heater approximately 1.5 feet from the desk.

When interviewed, the RN stated that she does see patients in that office. She reported that the heater was issued by the hospital.

During an interview on 10/24/12, the manufacturer's specification for the use of the portable heater were requested. No information was provided by the facility. The Director of Engineering stated that it met the "not to exceed 212?F" requirement.

Based on observation, the hospital failed to ensure that exit access corridors were maintained free of obstructions or impediments. This was evidenced by chairs and other equipment located in exit access corridors. This could delay evacuation of patients in the event of a fire and affected 1 of 2 floors in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facilities, from October 22, 2012, through October 24, 2012, the corridors and exits were observed.

Main Hospital, Main Level (1st Floor) Emergency Department - 10/22/12
At 2:30 p.m., there were 20 chairs placed against one wall, and 21 patients standing along the other wall, directly across from the chairs. The chairs were in the corridor leading to the Emergency Department Waiting Room and exit from the facility. There was approximately 2.5 ft. of clearance between the chairs and the patients.

During an interview at 2:35 p.m., the Director of Facilities reported that there was not enough room in the emergency department waiting room for the patients and families.

10/23/12
At 3:01 p.m., there were 17 chairs against one wall, and 5 patients standing along the other wall, directly across from the chairs. The chairs were in the corridor leading to the Emergency Department Waiting Room and exit. There was approximately 2.5 ft. of clearance between the chairs and the patients.

At 3:05 p.m., in corridor G, there were two gurneys with patients, and a chair with a patient family member obstructing full access to the exit. The chair was directly across from the gurney.

Based on observation and interview, the facility failed to ensure oxygen storage areas were in compliance with NFPA 99. This was evidenced by unsecured oxygen tanks, by oxygen cylinders stored next to combustible items, by no precautionary signs, and by empty cylinders that were not separated from full cylinders. This could result in damage to a cylinder, an increased risk to spread a fire, and a delay in accessing a full cylinder during an emergency. This affected 1 of 2 floors at the Main Hospital.

NFPA 99, Standard for Health Care Facilities (1999 Edition)
21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.

NFPA 99, Standard for Health Care Facilities (1999 Edition).
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a tour of the facility with hospital staff, on October 23, 2012, the oxygen storage areas were observed.

Main Hospital - Main Level (1st Floor) on 10/23/12:
1. At 9:50 a.m., there were 12 E-Tank oxygen cylinders stored in a metal cart approximately 1 foot away from a 2 plug electrical outlet, in the Oxygen Storage Room 1-132, in the Emergency Department. The full cylinders were not separated from the empty cylinders. The door did not have the proper precautionary sign stating that the room was used for oxygen storage.

2. At 10:30 a.m., there were 12 E-Tank oxygen cylinders and 1 unsecured E-Tank oxygen cylinder stored within approximately 6 inches of a 2 plug electrical outlet in the "Old ER" "Mattress" room. The oxygen cylinders were within approximately 12 inches of a plastic cart stacked with mattresses. The door did not have the proper precautionary sign stating that the room was used for oxygen storage.

During an interview, Hospital Staff 2 stated that the oxygen was stored in the "Mattress" room for the cardiac rehab patients down the hall.

Based on document review, the facility failed to provide written documentation of weekly testing of the emergency generator for 2 of 52 weeks. This could result in the potential for generator failure during a power outage. This affected the Out Patient Surgery Pavilion building.

Findings:

During document review with hospital staff, on October 25, 2012, the generator maintenance records were reviewed.

Out Patient Surgery Pavilion
At 11:30 a.m., the weekly generator records were reviewed. The records indicated that there was no inspection for 2 of 4 weeks for the month of June 2012.

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 National Electrical Code. This was evidenced by appliances plugged into multi-plug power strips, by a broken electrical cover plate, by no circuit directory for the areas served inside an electrical panel, and by electrical panels that were not covered. This could increase the risk of electrical shock or fire and could result in potential harm to patients on 2 of 2 floors at the Main Hospital and the Outpatient Services for Perinatal Testing.

NFPA 70, National Electrical Code, 1999 Edition.
384-13 requires all panel board circuits and circuit modifications be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

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

Findings:

During a tour of the facility with hospital staff, from October 22, 2012 through October 24, 2012, the electrical wiring and equipment were observed.

Main Hospital - Main Level (1st Floor) - 10/22/12
1. At 10:36 a.m., in Pantry Room 1-264, there was a cracked 2 plug electrical cover plate, on the wall behind the coffee stand, next to the refrigerator.

2. At 10 a.m., in the "Old ER" EVS Manager Office, there was a refrigerator and a microwave plugged into a power strip and not directly into the wall.


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Main Hospital - Upper Level - 10/22/12
3. At 10:33 a.m., the microwave in the Pharmacy Breaker was plugged into a power strip and not directly into the wall receptacle.

4. At 10:41 a.m., a refrigerator was plugged into a power strip and not directly into the wall receptacle, in the Med Surge Supervisor office room 2-504.

Main Hospital - Upper Level - 10/23/12
5. At 11:10 a.m., Electrical Panel EMC, located next to Labor Delivery Room 9, did not have a circuit directory located on the face or inside of the panel door.

6. At 11:12 a.m., Electrical Panel EMD, located next to Labor Delivery Room 10, was missing a blank cover for breaker 17.

Outpatient Services-Perinatal Testing at Suite 600-A - 10/24/12
7. At 3:30 p.m., in the front exercise room, there was a 3 outlet adapter, in use, with no overcurrent protection.