HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments, causing potential harm to patients and staff in the event of a fire. This condition affected one of three floors in the 580 Building, and one of one floors in the 940 Building.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the facility walls and ceilings were observed.


1. On 12/5/11 at 3:09 p.m., in Building 580, there were 5 penetrations in the wall above the light switch in the Women's Locker Room 2J105, with each one measuring approximately 1/4 inch round in diameter.

2. On 12/6/11 at 9:35 a.m., in the Mental Health Building 940, there were two penetrations in the wall of Room 484, with each one measuring approximately 1/4 inch round in diameter.

During the facility tour with staff, the corridor doors were observed.

7. On 12/05/11, at 11:37 a.m., in the 500 Building on the third floor, the doors (#3A030) to the Waiting Room were held open by trash cans. The doors were equipped with self closing mechanisms.

8. On 12/05/11, at 3:43 p.m., in Building 500, on the first floor, the self closing door to the RME waiting room was held open by a sofa.


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Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility, and increase the risk of harm to the patients, staff and visitors in the event of a fire. This condition affected one of three floors in the 580 Building, one of one floor in the 940 Building, and two of three floors in the 500 Building, and could result in the passage of smoke in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the corridor doors were observed.

1. On 12/5/11 at 3:01 p.m., the door to the Clean Utility Room 2J006 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

2. On 12/5/11 at 3:03 p.m., the door to the Soiled Utility Room 2J007 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

3. On 12/5/11 at 3:30 p.m., the door to the Medical Records Room 2D009 on the 2nd floor of Building 580 was equipped with a self-closing device that had been disassembled.

4. On 12/5/11 at 3:35 p.m., the door to the Staff lounge Rehab Room 2E098 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

5. On 12/5/11 at 3:45 p.m., the door to the Oxygen Storage Room 2E028 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

6. On 12/6/11 at 9:30 a.m., in the Mental Health Building 940, the solid-bonded core wood door to the Storage Room next to "Room 454 Laundry" had a hole
drilled through it approximately 1 inch round in diameter.

Based on observation, the facility failed to maintain smoke barrier walls as evidenced by penetrations in the smoke barrier walls, and by a door in the smoke barrier wall that was left open. This deficient condition affected two of four smoke compartments in Building 940, three of four smoke compartments in Building 100, and two of four smoke compartments on the 1st floor of Building 500. This condition could result in failure of smoke containment in the event of a fire.

Findings

During a tour of the facility with a staff member on 12/07/11, the smoke barrier walls were observed.

1. At 9:53 a.m., on the 1st floor of Building 500 in the Emergency Department by room 14, there was an IT raceway that had been removed, and the opening through the smoke barrier wall was left open. The raceway penetrated the smoke barrier wall to the other side.

2. At 10:05 a.m., in Building 940 near the main entrance, the self closing door in the smoke barrier wall was open. The door was located in the crawl space above the double fire doors. A metal guide wire blocked the closure of the door, and the door was open approximately two inches.

3. At 10:21 a.m., in Building 100, above the main entrance fire doors, the fire caulking around a two inch pipe conduit had come off the wall, and exposed a one inch penetration around the pipe.

4. At 10:27 a.m., in Building 100, by the Nourishment Office, the fire caulking around a two inch pipe had fallen off, and exposed a half inch opening around the pipe.

2. At 3:18 p.m., in Building 100, the left hand fire door by the Executive Director's office, did not latch when closed.

3. At 1:30 p.m., in the 500 Building, on the third floor Med Surge 3 unit, by room 314, when the fire alarm was activated the fire doors released and closed, but did not positively latch.

4. At 2:40 p.m., in the 500 Building, on the first floor by room 1A084, the right hand fire door did not fully close and remained open approximately 5 inches.


27961

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. Two of three smoke compartments in the 500 Building, and two of four smoke comparments in Building 100.

Findings:

During fire alarm device testing with Hospital Staff on December 7, 2011, the smoke barrier doors were observed.

1. On 12/7/11 at 3:16 p.m., the smoke barrier door by Room 263 in the Acute Rehabilitation area failed to positive latch on the left side after activation of the fire alarm system.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by 8 carts, 12 boxes and other equipment and/or supplies in the exit access corridor. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This condition affected one of three floors in the 580 Building, and one of two floors in the 200 Building.

Findings:

During the tour of the facility with Hospital Staff on December 5, 2011 through December 7, 2011, the exits were observed.

1. On 12/5/11 at 3:32 p.m., in Building 580, Medical Records Door 2D009 had 8 carts and 5 boxes stored in the hallway in front of the door leading to the corridor leaving approximately 2.5 feet of floor space. The door to this exit discharge was marked with an exit sign.

2. On 12/7/11 at 10:25 a.m., in Building 200 on the 1st Floor, the corridor behind Clinics A, B, and C had an audio test machine on top of a two drawer file cabinet, leaving approximately 3.5 feet of clearance in the corridor that exits to the outside.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by an emergency lighting unit that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors, and affected 1 of 5 smoke compartments.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the emergency lighting was observed and tested.

On 12/6/11 at 9:55 a.m., in Mental Health, Building 940, the emergency lighting in the Nursing Station failed to illuminate when tested.

Based on observation, the facility failed to maintain the emergency exit signs as evidenced by exit signs that pointed to the wrong direction, and by exit signs that were pointed backwards. This deficient condition affected one of one smoke compartments on the 3rd floor of Building 580, and one of two smoke compartments on the first floor of Building 300. This condition could result in a delay of egress in the event of an emergency evacuation.

NFPA 101, Life Safety Code,
SECTION 7.9 EMERGENCY LIGHTING
7.9.1 General.
7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator
that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

Findings:

During a tour of the facility with staff, on 12/05/11, the emergency exit signs were observed.

1. At 10:30 a.m., in Building 580 on the 3rd floor in the Pediatric department by the janitor closet, the exit sign was mounted onto the ceiling in an angle that pointed towards the wall. The door below the exit sign could be mistaken for an exit door. The door led into a dead end corridor.

2. At 3:00 p.m., in Building 300 by room #IK001-2, the exit at the end of the hallway was facing the wrong direction. The exit sign faced the wall at the end of the corridor, and did not face in the direction of the corridor.

Based on document review, the facility failed to maintain the records of the quarterly fire drills as evidenced by not providing a sign in sheet for participants, and by not activating the fire alarm system during fire drills. This deficient condition affected seven of seven buildings, and could result in all staff not participating in fire drills, and in all staff not being trained in fire emergency procedures.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

NFPA 99 Standard for Health Care Facilities, 1999 Edition
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review on 12/06/11, the fire drill records were reviewed.
Twelve of twelve fire drills were conducted in all seven buildings. There was no sign in sheets for staff participants in the 2nd and 3rd quarter of 2011. Staff stated that the facility transferred over to electronic record keeping during the 2nd quarter. Staff was asked how they kept record of staff participation and training, staff stated that they were no longer keeping track. Staff was asked if the fire alarm system was activated during the fire drills, and staff replied that they tried to activate the fire alarm every so often. Records indicated the fire alarm system had not been activated during fire drills in the past 12 months.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by a chimes and strobe devices that did not function during fire alarm testing. This deficient condition affected one of one floor in Building 100, and two of four smoke compartments on the second floor of Building 200. This deficient condition could result in the lack of occupant notification in the event of a fire.

NFPA 72 National Fire Alarm Code, 1999 Edition
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.
NFPA 101, 2000 Edition
9.6.2 Signal Initiation.
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with facility staff on 12/05/11, the fire alarm devices were observed. At 11:25 a.m., in Building 500, on the third floor in Med Surg 3 at the Nursing Station, a Work On Wheels (WOW) Station was plugged into the wall and stored in front of the pull station. The WOW blocked the visibility and access to the pull station.

During fire alerm testing with facility staff on 12/06/2011, the fire alarm system was observed.

1. At 3:15 p.m., in Building 100, 13 chimes did not function. The chimes were part of a strobe/chime combination device. The strobes functioned but the device was not audible. The alarm from other areas in the hospital could be heard, and the overhead announcement with the location of the fire was audible. Staff stated that they did not know why the chimes were not functioning.

2. At 3:32 p.m., in Building 200 on the second floor next to room #2J010, the chime did not function. The chime was part of a strobe/chime combination device, and the strobe functioned but the device was not audible.

3. At 3:35 a.m., in Building 200 in the Specialty Clinic by the Staff Lounge, the chime was not audible. The chime was part of a strobe/chime combination device, and the strobe functioned but the device was not audible.

Based on interview and record review, the facility failed to ensure the maintenance, inspection and testing of smoke detectors as evidenced by not conducting the required smoke detector sensitivity testing. This deficient practice affected seven of seven buildings, and could result in the failure of the smoke detectors.

NFPA 72, National Fire Alarm Code, 1999 edition
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 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 test methods approved by the authority having jurisdiction Detectors found to have a 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 other aerosol into the detector.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.1 Records shall be retained until the next test and for 1 year thereafter.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review of the facility documents on 12/06/11, no documents were provided to show that the facility had conducted the sensitivity testing of the smoke detectors. There was no report for sensitivity testing that included a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. During staff interview, staff stated that they were unaware of this requirement.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that were missing, by missing quarterly flow tests, and by an Inspector's Test Valve that failed to alarm within the 90 second requirement. These deficient conditions affected all seven buildings, and could result in failure of the sprinkler in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-2.4.1* Gauges. Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.
6-3 Testing.
6-3.1* Level indicators shall be tested every 5 years for accuracy and freedom of movement.
9-4 System Valves.
9-4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.
9-5 Pressure Reducing Valves and Relief Valves
9-5.1.2* A full flow test shall be conducted on each valve at 5-year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be.

During a tour of the facility with a staff member on 12/05/11, the facility sprinkler heads were observed.

At 11:27 a.m., in Building 500, on the 3rd floor in Med Surge 3 in the Janitor Closet #3B022, the sprinkler head escutcheon was missing, and a two inch penetration in the ceiling was exposed.

During document review with facility staff on 12/06/11, the records for the quarterly flow tests were requested. The reports provided were missing the 4th quarter of 2010. Staff stated that the records were available, no other records were provided for review.

During fire alarm testing on 12/06/11, the Inspector's Test Valves were tested.
1. At 3:30 p.m., in Building 940, the main drain was opened and tested for pressure. The alarm system was activated when the main drain was opened. The alarm system could not be reset, and the Inspector's Test Valve could not be tested. Documents provided from the vendor for the 5 year certification stated that the system in Building 940 had failed. Repairs had not been made to the sprinkler system.

2. At 3:42 p.m., in Building 300, when the Inspector's Test Valve was tested, the valve was opened and failed to activate the fire alarm system within 90 seconds. The Inspector's Test Valve in Building 300 was open for 95 seconds before the fire alarm system was activated.

Based on document review and interview, the facility failed to maintain the relative humidity level equal to or greater than 35%. This was evidenced by documentation that some of the humidity levels for Operating Rooms 1, 2, 3, 4 and 5 for the months of November, 2011, and December, 2011 fell below the required level of 35% in a two month period, and the facility failed to provide a policy and procedure for the Operating Room Relative Humidity and what to do in the event the relative humidity fell below the facility ' s standard. This failure could result in an increased risk of fire in the operating rooms resulting in potential harm to patients and staff.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
12-4.1.1.4 Rules and Regulations.
(a) Hospital authorities and professional staff shall jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption, rules and regulations shall be prominently posted in the operating room suite. Positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement.

Findings:

During document review with Hospital Staff on December 5, 2011 through December 7, 2011, the humidity levels of all Operating Rooms were reviewed and staff was interviewed.

Relative humidity is checked by the facility every 10 minutes. Documentation stated below is based on a 7:00 a.m. reading/documentation provided by the facility. When interviewed on December 6, 2011 at 11:00 a.m., the Hospital Staff stated that the facility's policy and procedure for the humidity level is between 20% and 60%. The written policy and procedure was requested, but the policy and procedure documentation was not provided by the facility.

1. Humidity Levels documented for December 6, 2011 at 7:00 a.m.:
RM-C: 15.57833, RM-D: 21.86522, RM-E: 16.76608, RM-B: 16.65308, RM-A: 20.19111

2. Humidity Levels documented for December 5, 2011 at 7:00 a.m.:
RM-C: 17.50636, RM-D: 26.83412, RM-E: 21.85143, RM-B: 23.2718, RM-A: 27.72856

3. Humidity Levels documented for December 2, 2011 at 7:00 a.m.
RM-C: 6.458975, RM-D: 15.9226, RM-E: 10.38996, RM-B: 9.759377, RM-A: 13.2877

4. Humidity Levels documented for December 1, 2011 at 7:00 a.m.:
RM-C: 7.856474, RM-D: 15.47294, RM-E: 9.364479, RM-B: 9.209427, RM-A: 13.07742

5. Humidity Levels documented for November 28, 2011 at 7:00 a.m.:
RM-C: 31.16437

6. Humidity Levels documented for November 25, 2011 at 7:00 a.m.:
RM-C: 33.77174, RM-E: 34.78481, RM-B: 33.62369, RM-A: 33.61943

7. Humidity Levels documented for November 23, 2011 at 7:00 a.m.:
RM-C: 31.71107, RM-E: 33.84666, RM-B: 33.99248, RM-A: 33.35416

8. Humidity Levels documented for November 22, 2011 at 7:00 a.m.:
RM-C: 30.46562, RM-E: 31.79247, RM-B: 31.35921, RM-A: 31.87254

9. Humidity Levels documented for November 21, 2011 at 7:00 a.m.:
RM-C: 28.79637, RM-E: 31.24576, RM-B: 32.76318

10. Humidity Levels documented for November 15, 2011 at 7:00 a.m.:
RM-C: 31.0835, RM-B: 33.71426

11. Humidity Levels documented for November 11, 2011 at 7:00 a.m.:
RM-C: 19.94553, RM-D 27.58463, RM-E: 26.84621, RM-B: 22.17516, RM-A: 25.59996

12. Humidity Levels documented for November 10, 2011 at 7:00 a.m.:
RM-C: 24.61034, RM-D 30.97487, RM-E: 28.0755, RM-B: 26.89496, RM-A: 28.33997

13. Humidity Levels documented for November 9, 2011 at 7:00 a.m.:
RM-C: 25.35115, RM-E: 30.24939, RM-B: 29.0721, RM-A: 34.39905

14. Humidity Levels documented for November 8, 2011 at 7:00 a.m.:
RM-C: 28.06528, RM-D 34.35864, RM-E: 32.98294, RM-B: 30.29491, RM-A: 31.65581

15. Humidity Levels documented for November 3, 2011 at 7:00 a.m.:
RM-C: 14.97016, RM-D 22.83247, RM-E: 20.06573, RM-B: 16.54956, RM-A: 18.86153

16. Humidity Levels documented for November 2, 2011 at 7:00 a.m.:
RM-C: 19.58968, RM-D 23.99383, RM-E: 25.40341, RM-B: 20.52856, RM-A: 23.7075

3. On 12/05/11, at 11:20 a.m., in Building 500, third floor Med Surge 3, in the corridor across from resident room 326, a power strip was attached to the wall with screws. The power strip was used to charge equipment when not in use.
4. On 12/05/11, at 11:31 a.m., in Building 500, on third floor Med Surge 3, in room #3B025, a small refrigerator was plugged into a power strip instead of directly into the wall outet.
5. On 12/05/11, at 11:57 a.m., in the NICU break room #2A081, a microwave and a refrigerator were plugged into a power strip instead of dfirectly into the wall outlet.






27961

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by electrical appliances plugged into multi-plug power strips and extension cords, and by broken electrical outlet cover plates. This condition affected one of three floors in the 500 building, one of three floors in the 580 Building, and one of two floors in the 200 Building, and could result in the ignition of an electrical fire.

NFPA 70, National Electric Code, (1999 Edition)
Section 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 a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

NFPA 99 Standard for Healthcare Facilities (1999 Edition)
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Findings:

During a tour of the facility with Hospital Staff on December 5, 2011 through December 7, 2011, the facility's electrical wiring and equipment was observed.

1. On 12/5/11 at 3:36 p.m., in Building 580, the PT/OT room had a broken electrical cover plate in the wall by the hand weights.
2. On 12/6/11 at 10:00 a.m., on the 1st floor of Building 200, Clinic C, Office 1J050, there was an extension cord used to extend power to the coffee pot.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8 - When a required automatic sprinkler system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service.

Findings:

During document review with staff members on 12/08/11, the fire watch plan for the sprinkler system was requested. Staff stated that the fire watch is referred to as the Life Interim Policy. Upon review of the Life Interim Policy, it was determined that the policy only referred to a fire watch in the event the automatic sprinkler system was taken off line due to construction. The policy did not state what steps to follow in the event the sprinkler system failed to function. During an interview, staff stated that there was no policy written for failure of the system.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8: Where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 12/08/11, the fire watch plan for the fire alarm system was requested. Staff stated that the facility fire watch was referred to as the Life Interim Policy. Upon review of the Life Interim Policy, it was determined that the policy only referred to a fire watch in the event the fire alarm system was taken off line due to construction. The policy did not state what steps to follow in the event the fire alarm system failed to function. During an interview, staff stated that there was no policy written for failure of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments, causing potential harm to patients and staff in the event of a fire. This condition affected one of three floors in the 580 Building, and one of one floors in the 940 Building.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the facility walls and ceilings were observed.


1. On 12/5/11 at 3:09 p.m., in Building 580, there were 5 penetrations in the wall above the light switch in the Women's Locker Room 2J105, with each one measuring approximately 1/4 inch round in diameter.

2. On 12/6/11 at 9:35 a.m., in the Mental Health Building 940, there were two penetrations in the wall of Room 484, with each one measuring approximately 1/4 inch round in diameter.

During the facility tour with staff, the corridor doors were observed.

7. On 12/05/11, at 11:37 a.m., in the 500 Building on the third floor, the doors (#3A030) to the Waiting Room were held open by trash cans. The doors were equipped with self closing mechanisms.

8. On 12/05/11, at 3:43 p.m., in Building 500, on the first floor, the self closing door to the RME waiting room was held open by a sofa.


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Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility, and increase the risk of harm to the patients, staff and visitors in the event of a fire. This condition affected one of three floors in the 580 Building, one of one floor in the 940 Building, and two of three floors in the 500 Building, and could result in the passage of smoke in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the corridor doors were observed.

1. On 12/5/11 at 3:01 p.m., the door to the Clean Utility Room 2J006 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

2. On 12/5/11 at 3:03 p.m., the door to the Soiled Utility Room 2J007 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

3. On 12/5/11 at 3:30 p.m., the door to the Medical Records Room 2D009 on the 2nd floor of Building 580 was equipped with a self-closing device that had been disassembled.

4. On 12/5/11 at 3:35 p.m., the door to the Staff lounge Rehab Room 2E098 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

5. On 12/5/11 at 3:45 p.m., the door to the Oxygen Storage Room 2E028 on the 2nd floor of Building 580 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, and failed to positive latch upon closure.

6. On 12/6/11 at 9:30 a.m., in the Mental Health Building 940, the solid-bonded core wood door to the Storage Room next to "Room 454 Laundry" had a hole
drilled through it approximately 1 inch round in diameter.

Based on observation, the facility failed to maintain smoke barrier walls as evidenced by penetrations in the smoke barrier walls, and by a door in the smoke barrier wall that was left open. This deficient condition affected two of four smoke compartments in Building 940, three of four smoke compartments in Building 100, and two of four smoke compartments on the 1st floor of Building 500. This condition could result in failure of smoke containment in the event of a fire.

Findings

During a tour of the facility with a staff member on 12/07/11, the smoke barrier walls were observed.

1. At 9:53 a.m., on the 1st floor of Building 500 in the Emergency Department by room 14, there was an IT raceway that had been removed, and the opening through the smoke barrier wall was left open. The raceway penetrated the smoke barrier wall to the other side.

2. At 10:05 a.m., in Building 940 near the main entrance, the self closing door in the smoke barrier wall was open. The door was located in the crawl space above the double fire doors. A metal guide wire blocked the closure of the door, and the door was open approximately two inches.

3. At 10:21 a.m., in Building 100, above the main entrance fire doors, the fire caulking around a two inch pipe conduit had come off the wall, and exposed a one inch penetration around the pipe.

4. At 10:27 a.m., in Building 100, by the Nourishment Office, the fire caulking around a two inch pipe had fallen off, and exposed a half inch opening around the pipe.

2. At 3:18 p.m., in Building 100, the left hand fire door by the Executive Director's office, did not latch when closed.

3. At 1:30 p.m., in the 500 Building, on the third floor Med Surge 3 unit, by room 314, when the fire alarm was activated the fire doors released and closed, but did not positively latch.

4. At 2:40 p.m., in the 500 Building, on the first floor by room 1A084, the right hand fire door did not fully close and remained open approximately 5 inches.


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Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. Two of three smoke compartments in the 500 Building, and two of four smoke comparments in Building 100.

Findings:

During fire alarm device testing with Hospital Staff on December 7, 2011, the smoke barrier doors were observed.

1. On 12/7/11 at 3:16 p.m., the smoke barrier door by Room 263 in the Acute Rehabilitation area failed to positive latch on the left side after activation of the fire alarm system.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by 8 carts, 12 boxes and other equipment and/or supplies in the exit access corridor. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This condition affected one of three floors in the 580 Building, and one of two floors in the 200 Building.

Findings:

During the tour of the facility with Hospital Staff on December 5, 2011 through December 7, 2011, the exits were observed.

1. On 12/5/11 at 3:32 p.m., in Building 580, Medical Records Door 2D009 had 8 carts and 5 boxes stored in the hallway in front of the door leading to the corridor leaving approximately 2.5 feet of floor space. The door to this exit discharge was marked with an exit sign.

2. On 12/7/11 at 10:25 a.m., in Building 200 on the 1st Floor, the corridor behind Clinics A, B, and C had an audio test machine on top of a two drawer file cabinet, leaving approximately 3.5 feet of clearance in the corridor that exits to the outside.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by an emergency lighting unit that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors, and affected 1 of 5 smoke compartments.

Findings:

During a tour of the facility with the Hospital Staff on December 5, 2011 through December 7, 2011, the emergency lighting was observed and tested.

On 12/6/11 at 9:55 a.m., in Mental Health, Building 940, the emergency lighting in the Nursing Station failed to illuminate when tested.

Based on observation, the facility failed to maintain the emergency exit signs as evidenced by exit signs that pointed to the wrong direction, and by exit signs that were pointed backwards. This deficient condition affected one of one smoke compartments on the 3rd floor of Building 580, and one of two smoke compartments on the first floor of Building 300. This condition could result in a delay of egress in the event of an emergency evacuation.

NFPA 101, Life Safety Code,
SECTION 7.9 EMERGENCY LIGHTING
7.9.1 General.
7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator
that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

Findings:

During a tour of the facility with staff, on 12/05/11, the emergency exit signs were observed.

1. At 10:30 a.m., in Building 580 on the 3rd floor in the Pediatric department by the janitor closet, the exit sign was mounted onto the ceiling in an angle that pointed towards the wall. The door below the exit sign could be mistaken for an exit door. The door led into a dead end corridor.

2. At 3:00 p.m., in Building 300 by room #IK001-2, the exit at the end of the hallway was facing the wrong direction. The exit sign faced the wall at the end of the corridor, and did not face in the direction of the corridor.

Based on document review, the facility failed to maintain the records of the quarterly fire drills as evidenced by not providing a sign in sheet for participants, and by not activating the fire alarm system during fire drills. This deficient condition affected seven of seven buildings, and could result in all staff not participating in fire drills, and in all staff not being trained in fire emergency procedures.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

NFPA 99 Standard for Health Care Facilities, 1999 Edition
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review on 12/06/11, the fire drill records were reviewed.
Twelve of twelve fire drills were conducted in all seven buildings. There was no sign in sheets for staff participants in the 2nd and 3rd quarter of 2011. Staff stated that the facility transferred over to electronic record keeping during the 2nd quarter. Staff was asked how they kept record of staff participation and training, staff stated that they were no longer keeping track. Staff was asked if the fire alarm system was activated during the fire drills, and staff replied that they tried to activate the fire alarm every so often. Records indicated the fire alarm system had not been activated during fire drills in the past 12 months.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by a chimes and strobe devices that did not function during fire alarm testing. This deficient condition affected one of one floor in Building 100, and two of four smoke compartments on the second floor of Building 200. This deficient condition could result in the lack of occupant notification in the event of a fire.

NFPA 72 National Fire Alarm Code, 1999 Edition
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.
NFPA 101, 2000 Edition
9.6.2 Signal Initiation.
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with facility staff on 12/05/11, the fire alarm devices were observed. At 11:25 a.m., in Building 500, on the third floor in Med Surg 3 at the Nursing Station, a Work On Wheels (WOW) Station was plugged into the wall and stored in front of the pull station. The WOW blocked the visibility and access to the pull station.

During fire alerm testing with facility staff on 12/06/2011, the fire alarm system was observed.

1. At 3:15 p.m., in Building 100, 13 chimes did not function. The chimes were part of a strobe/chime combination device. The strobes functioned but the device was not audible. The alarm from other areas in the hospital could be heard, and the overhead announcement with the location of the fire was audible. Staff stated that they did not know why the chimes were not functioning.

2. At 3:32 p.m., in Building 200 on the second floor next to room #2J010, the chime did not function. The chime was part of a strobe/chime combination device, and the strobe functioned but the device was not audible.

3. At 3:35 a.m., in Building 200 in the Specialty Clinic by the Staff Lounge, the chime was not audible. The chime was part of a strobe/chime combination device, and the strobe functioned but the device was not audible.

Based on interview and record review, the facility failed to ensure the maintenance, inspection and testing of smoke detectors as evidenced by not conducting the required smoke detector sensitivity testing. This deficient practice affected seven of seven buildings, and could result in the failure of the smoke detectors.

NFPA 72, National Fire Alarm Code, 1999 edition
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 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 test methods approved by the authority having jurisdiction Detectors found to have a 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 other aerosol into the detector.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.1 Records shall be retained until the next test and for 1 year thereafter.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review of the facility documents on 12/06/11, no documents were provided to show that the facility had conducted the sensitivity testing of the smoke detectors. There was no report for sensitivity testing that included a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. During staff interview, staff stated that they were unaware of this requirement.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that were missing, by missing quarterly flow tests, and by an Inspector's Test Valve that failed to alarm within the 90 second requirement. These deficient conditions affected all seven buildings, and could result in failure of the sprinkler in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-2.4.1* Gauges. Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.
6-3 Testing.
6-3.1* Level indicators shall be tested every 5 years for accuracy and freedom of movement.
9-4 System Valves.
9-4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.
9-5 Pressure Reducing Valves and Relief Valves
9-5.1.2* A full flow test shall be conducted on each valve at 5-year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be.

During a tour of the facility with a staff member on 12/05/11, the facility sprinkler heads were observed.

At 11:27 a.m., in Building 500, on the 3rd floor in Med Surge 3 in the Janitor Closet #3B022, the sprinkler head escutcheon was missing, and a two inch penetration in the ceiling was exposed.

During document review with facility staff on 12/06/11, the records for the quarterly flow tests were requested. The reports provided were missing the 4th quarter of 2010. Staff stated that the records were available, no other records were provided for review.

During fire alarm testing on 12/06/11, the Inspector's Test Valves were tested.
1. At 3:30 p.m., in Building 940, the main drain was opened and tested for pressure. The alarm system was activated when the main drain was opened. The alarm system could not be reset, and the Inspector's Test Valve could not be tested. Documents provided from the vendor for the 5 year certification stated that the system in Building 940 had failed. Repairs had not been made to the sprinkler system.

2. At 3:42 p.m., in Building 300, when the Inspector's Test Valve was tested, the valve was opened and failed to activate the fire alarm system within 90 seconds. The Inspector's Test Valve in Building 300 was open for 95 seconds before the fire alarm system was activated.

Based on document review and interview, the facility failed to maintain the relative humidity level equal to or greater than 35%. This was evidenced by documentation that some of the humidity levels for Operating Rooms 1, 2, 3, 4 and 5 for the months of November, 2011, and December, 2011 fell below the required level of 35% in a two month period, and the facility failed to provide a policy and procedure for the Operating Room Relative Humidity and what to do in the event the relative humidity fell below the facility ' s standard. This failure could result in an increased risk of fire in the operating rooms resulting in potential harm to patients and staff.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
12-4.1.1.4 Rules and Regulations.
(a) Hospital authorities and professional staff shall jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption, rules and regulations shall be prominently posted in the operating room suite. Positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement.

Findings:

During document review with Hospital Staff on December 5, 2011 through December 7, 2011, the humidity levels of all Operating Rooms were reviewed and staff was interviewed.

Relative humidity is checked by the facility every 10 minutes. Documentation stated below is based on a 7:00 a.m. reading/documentation provided by the facility. When interviewed on December 6, 2011 at 11:00 a.m., the Hospital Staff stated that the facility's policy and procedure for the humidity level is between 20% and 60%. The written policy and procedure was requested, but the policy and procedure documentation was not provided by the facility.

1. Humidity Levels documented for December 6, 2011 at 7:00 a.m.:
RM-C: 15.57833, RM-D: 21.86522, RM-E: 16.76608, RM-B: 16.65308, RM-A: 20.19111

2. Humidity Levels documented for December 5, 2011 at 7:00 a.m.:
RM-C: 17.50636, RM-D: 26.83412, RM-E: 21.85143, RM-B: 23.2718, RM-A: 27.72856

3. Humidity Levels documented for December 2, 2011 at 7:00 a.m.
RM-C: 6.458975, RM-D: 15.9226, RM-E: 10.38996, RM-B: 9.759377, RM-A: 13.2877

4. Humidity Levels documented for December 1, 2011 at 7:00 a.m.:
RM-C: 7.856474, RM-D: 15.47294, RM-E: 9.364479, RM-B: 9.209427, RM-A: 13.07742

5. Humidity Levels documented for November 28, 2011 at 7:00 a.m.:
RM-C: 31.16437

6. Humidity Levels documented for November 25, 2011 at 7:00 a.m.:
RM-C: 33.77174, RM-E: 34.78481, RM-B: 33.62369, RM-A: 33.61943

7. Humidity Levels documented for November 23, 2011 at 7:00 a.m.:
RM-C: 31.71107, RM-E: 33.84666, RM-B: 33.99248, RM-A: 33.35416

8. Humidity Levels documented for November 22, 2011 at 7:00 a.m.:
RM-C: 30.46562, RM-E: 31.79247, RM-B: 31.35921, RM-A: 31.87254

9. Humidity Levels documented for November 21, 2011 at 7:00 a.m.:
RM-C: 28.79637, RM-E: 31.24576, RM-B: 32.76318

10. Humidity Levels documented for November 15, 2011 at 7:00 a.m.:
RM-C: 31.0835, RM-B: 33.71426

11. Humidity Levels documented for November 11, 2011 at 7:00 a.m.:
RM-C: 19.94553, RM-D 27.58463, RM-E: 26.84621, RM-B: 22.17516, RM-A: 25.59996

12. Humidity Levels documented for November 10, 2011 at 7:00 a.m.:
RM-C: 24.61034, RM-D 30.97487, RM-E: 28.0755, RM-B: 26.89496, RM-A: 28.33997

13. Humidity Levels documented for November 9, 2011 at 7:00 a.m.:
RM-C: 25.35115, RM-E: 30.24939, RM-B: 29.0721, RM-A: 34.39905

14. Humidity Levels documented for November 8, 2011 at 7:00 a.m.:
RM-C: 28.06528, RM-D 34.35864, RM-E: 32.98294, RM-B: 30.29491, RM-A: 31.65581

15. Humidity Levels documented for November 3, 2011 at 7:00 a.m.:
RM-C: 14.97016, RM-D 22.83247, RM-E: 20.06573, RM-B: 16.54956, RM-A: 18.86153

16. Humidity Levels documented for November 2, 2011 at 7:00 a.m.:
RM-C: 19.58968, RM-D 23.99383, RM-E: 25.40341, RM-B: 20.52856, RM-A: 23.7075

3. On 12/05/11, at 11:20 a.m., in Building 500, third floor Med Surge 3, in the corridor across from resident room 326, a power strip was attached to the wall with screws. The power strip was used to charge equipment when not in use.
4. On 12/05/11, at 11:31 a.m., in Building 500, on third floor Med Surge 3, in room #3B025, a small refrigerator was plugged into a power strip instead of directly into the wall outet.
5. On 12/05/11, at 11:57 a.m., in the NICU break room #2A081, a microwave and a refrigerator were plugged into a power strip instead of dfirectly into the wall outlet.






27961

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by electrical appliances plugged into multi-plug power strips and extension cords, and by broken electrical outlet cover plates. This condition affected one of three floors in the 500 building, one of three floors in the 580 Building, and one of two floors in the 200 Building, and could result in the ignition of an electrical fire.

NFPA 70, National Electric Code, (1999 Edition)
Section 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 a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

NFPA 99 Standard for Healthcare Facilities (1999 Edition)
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Findings:

During a tour of the facility with Hospital Staff on December 5, 2011 through December 7, 2011, the facility's electrical wiring and equipment was observed.

1. On 12/5/11 at 3:36 p.m., in Building 580, the PT/OT room had a broken electrical cover plate in the wall by the hand weights.
2. On 12/6/11 at 10:00 a.m., on the 1st floor of Building 200, Clinic C, Office 1J050, there was an extension cord used to extend power to the coffee pot.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8 - When a required automatic sprinkler system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service.

Findings:

During document review with staff members on 12/08/11, the fire watch plan for the sprinkler system was requested. Staff stated that the fire watch is referred to as the Life Interim Policy. Upon review of the Life Interim Policy, it was determined that the policy only referred to a fire watch in the event the automatic sprinkler system was taken off line due to construction. The policy did not state what steps to follow in the event the sprinkler system failed to function. During an interview, staff stated that there was no policy written for failure of the system.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8: Where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved Fire Watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 12/08/11, the fire watch plan for the fire alarm system was requested. Staff stated that the facility fire watch was referred to as the Life Interim Policy. Upon review of the Life Interim Policy, it was determined that the policy only referred to a fire watch in the event the fire alarm system was taken off line due to construction. The policy did not state what steps to follow in the event the fire alarm system failed to function. During an interview, staff stated that there was no policy written for failure of the fire alarm system.