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Based on observation the facility failed to maintain the building construction to prevent the passage of smoke and flames in the event of a fire. This had the potential to cause injury to staff, patients and visitors in the event of a fire.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility the walls and ceilings were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:48 a.m., in the EVS Break Room, there was an approximately 1/2 inch by 2 inch unsealed penetration across the top of the electrical outlet on the left wall.
2. At 11:17 a.m., in the Employee Lounge, there was an approximately 1/4 inch by 3 inch unsealed penetration across the cover plate located under the control panel.

August 24, 2010:
1. At 10:15 a.m., in the ICU North Staff Lounge, 2nd Floor, there was an approximately one inch round penetration in the center left wall.
2. At 10:24 a.m. in the emergency room medication room on the back wall there was 1 unsealed penetration approximately 1 inch.
3. At 10:25 a.m. in the emergency room triage just above the thermostat there was an unsealed penetration approximately 1 inch.
4. At 10:43 a.m. X-Ray registration desk on the right side a sprinkler escutcheon ring was not flush with the ceiling exposing an approximately 4 inch unsealed penetration.
5. At 11:07 a.m., in the Surgical Unit Kitchen, 1st Floor, there were three approximately 1/2 inch penetrations and two 1/4 inch penetrations in the back center wall.
6 . At 11: 09 a.m. in the Lab special chemistry area there were 4 unsealed penetrations on the right wall, 1 approximately 1 inch and 3 approximately 1/2 inch.
7. At 11:15 a.m., in the Med Room inside Patient Room 108, 1st Floor, there was an approximately 1 and 1/2 inch penetration surrounding the door knob stop.
8. At 11:17 a.m. in S-2 Air Handler room in the drain room for the sterilizer there were 5 unsealed penetrations approximately 1/2 inch to 1 inch.
9. At 11:30 a.m., in the L & D Employee Kitchen, 1st Floor, there was an approximately 1/2 inch round penetration in the center left wall.

August 25, 2010:
1. At 10:33 a.m. in the doctor's old dining room on the back wall there were 8 unsealed penetrations approximately 1/2 inch to 1 inch each.


27272

Based on observation the facility failed to maintain the corridor walls with a 1/2 hour fire resistance rating in 1 of 4 smoke compartments on the lower level. This may result in the passage of smoke and flames in the event of a fire.

Findings:
On August 23, 2010 during a tour of the facility with staff the corridor walls were observed.
1. At 10:33 a.m. in the doctor's old dining room the corridor wall had 2 approximately 2 inch unsealed penetrations.

Based on observation the facility failed to maintain the doors to resist the passage of smoke in the event of a fire. This was evidenced by doors being held in the open position with devices that do not release upon activation of the fire alarm system. This effected 2 of 4 smoke compartments on the lower level.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the corridor doors were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:40 a.m., in the Outpatient Group Room 106, the door was blocked open with a chair.
2. At 10:43 a.m., in the Therapist office across from Group Room 107, the self-closing corridor door failed to fully close and positive latch.
August 24, 2010: Main Campus
1. At 10:35 a.m., in the Conference Room, 2nd Floor, the self-closing corridor door by ICU Nurses' Station South was blocked open with a chair.

August 25, 2010:
1. At 10:30 a.m., in the Storage Room across from the Concierge, 1st Floor, there was a 1 and 1/2 inch circular penetration above the inside by the door knob.
2. At 10:39 a.m. the door to GI lab 2 was held in the open position with a stool. The door is equipped with a self closing device.
3. At 10:40 a.m. the door to GI lab 1 was held in the open position with a stool. The door is equipped with a self closing device.
4. At 3:05 p.m., in the Women's Restroom by Diagnostic Imaging, Lower Floor, there was a 3/4 inch by 1/2 penetration abutting the inside of the door knob
5. At 10:47 a.m. the door for pre admitting services is held in the open position with a wedge.
6. At 10:55 a.m. the Medical Director of Emergency Services door is held in the open position with a wedge.
7. At 11:01 a.m. the Director of Emergency Services, Nurse Manager of Emergency Services office door was held in the open position with a wedge.


27272


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Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to positive latch upon closure. These findings could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with facility staff on August 23, 2010 through August 26, 2010, the smoke barrier doors were observed.

On August 23, 2010 at the Magnolia Campus:

At 2:12 p.m., the smoke barrier double door, by Resident Room 726, the right leaf failed to positive latch.

On August 25, 2010 at the Main Campus:

At 3:10 p.m., the smoke barrier double door, Lower Level by Smoke Detector 1D in the corridor to the Pavilion, the left leaf failed to positive latch.

Based on observation and interview, the facility failed to ensure the hazardous areas were maintained to resist the passage of smoke, as evidenced by penetrations in hazardous area and hazardous areas without self closures. These findings could result in the spread of smoke and fire within the facility and increase the risk of injury to patients, visitors and staff due to fire.

Findings:

During the facility tour with facility staff on August 23, 2010 through August 26, 2010, the hazardous areas were observed.

On August 23, 2010 at the Magnolia Campus:

At 10:42 a.m., the Activity Room located inside the Copy Room, measuring over 50 square feet, contained an abundant amount of combustible materials including paper, plastics and miscellaneous supplies. The room was not equipped with a self-closing device.

On August 24, 2010 at the Main Campus:

At 11:04 a.m., the Physical Therapy Closet, measuring over 50 square feet, contained an abundant amount of combustible materials including electrical equipment, building supplies, paint and miscellaneous supplies. The room was not equipped with a self-closing device.

On August 25, 2010 at the Main Campus:

At 9:42 a.m., the Volunteer Storage Room, measuring over 50 square feet, contained an abundant amount of combustible materials including paper, plastics and miscellaneous supplies. The room was not equipped with a self-closing device.

Based on document review the facility failed to conduct fire drills at unexpected times on 2 of 3 shifts. Fire drills conducted at the same times may result in staff not being familiar with assignments to be followed at other times of the shift. This effected the entire hospital.

Findings:
On August 23, 2010 at 3:18 p.m. during document review the fire drills were reviewed from August 2009 through July 2010. The following fire drills were not held at unexpected times.
1. P.M. Shift - 3 of 4 drills were held between 8:25 p.m. and 8:50 p.m.
2. Night Shift - 4 of 4 drills were held between 11:00 p.m. and 11:10 p.m.

Based on observation the facility failed to maintain unobstructed access to all pull stations in the event of an emergency and to ensure that early warning devices were installed in all areas to warn staff and patients of a fire. This may cause a delay in activation of the fire alarm system in the event of a fire.
This effected 2 of 4 smoke compartments on the lower levels.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the pull stations ( manual fire alarm boxes) were observed.
August 24, 2010: Main Campus
1. At 10:42 a.m. at the back entrance to x-ray, a copy machine placed in front of the pull statin obstructed access to the pull station.
2. At 11:25 a.m. in the kitchen the Sham Food Warmer obstructed access to the pull station marked number 25.
August 25, 2010:
1. At 2:25 p.m., in Labor and Delivery OR, the alarm could not be heard in the OR. Staff interviewed were not aware of a policy and procedure to notify staff inside of OR in the event of an emergency.
2. At 3:28 p.m., during testing of the fire alarm system the fire alarm could not be heard in the Microbiology area of the lab. During an interview with 2 staff at the front desk where the alarms could be heard when asked what the policy was 2 of 2 staff stated they would here if the operated announced the code red overhead but neither staff stated that they would inform staff working in the microbiology area of the fire alarm
3. At 3:30 p.m., in the Cafeteria, the alarm could not be heard from the kitchen into the cafeteria. There were no audible devices in the cafeteria.






27272

NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the systems sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees F (38C).
2-4.1.5 The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers -- no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers -- no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers -- no fewer than 24 sprinklers

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, 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.


Based on observation the facility failed to maintain the automatic sprinkler system which is evidenced by sprinklers with that are dirty, escutcheon rings missing and not providing spare sprinklers of the type used in the area. These findings could result in a sprinkler system malfunction and increase the risk of injury to patients, visitors and staff in the event of a fire.



Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the sprinklers were observed.

On August 23, 2010 at the Magnolia Campus:
1. At 10:20 a.m., in the Kitchen area by the Office, there were 2 of 3 sprinkler heads with a build-up of debris.
2. At 10:25 a.m., in the Kitchen area by the Hood, there were 1 of 3 sprinkler heads with a 1/2 inch gap from the ceiling and the escutcheon ring.
3. At 11:00 a.m., in Room 733, the handle to the Inspector Test Valve was broke in half.
4. At 2:30 p.m., in the Kitchen area by the Dish Room, the sprinkler located above the pull station was missing an escutcheon ring.


August 24, 2010:
1. At 10:18 a.m. in the old emergency room by the restroom the sprinkler was dirty.
2. At 10:42 a.m. at the back entrance to X-Ray the copy machine obstructed the fire hose cabinet from opening completely.
3. At 10:47 a.m. in X-Ray 3, 1 of 6 sprinklers was missing the escutcheon ring.
4. At 10:50 a.m. in the lower level stand pipe the spare sprinkler box had only 4 spare sprinklers, there was no spare sprinklers provided for each type used.
5. At 11:20 a.m. in the kitchen the sprinkler at the door was missing the escutcheon ring.
6. At 11:25 a.m. in the kitchen the sprinkler in front of the oven was missing the escutcheon ring.
7. At 11:31 a.m. in the cafeteria in front of the soda machine the escutcheon ring was missing.

On August 25, 2010 at the Main Campus:
1. At 9:30 a.m., in the Nursing Supervisors Office, 1st Floor, there was 1 of 2 sprinklers missing an escutcheon ring.
2. At 10:45 a.m., in the OR Frozen Section, Lower Floor, there was 1 of 1 sprinklers missing an escutcheon ring.
3. At 10:59 a.m., in the Janitors Closet by the Phone Room, Lower Floor, there was 1 of 1 sprinkler heads with a build-up of debris.
4. At 3:40 p.m., in the ER, Lower Floor, there was sprinkler head with a build-up of debris located in the corridor outside of Bed 11 and Bed 12.



27272

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 Standard for Portable Fire Extinguishers (1998 edition)
4-3.2 * Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose and nozzle checked (for wheeled units)
( i) HMIS label is in place

Based on observation, the facility failed to maintain their fire extinguishers as evidenced by obstructions to the access of the fire extinguishers and a K-Class fire extinguisher mounted at greater than 42 inches. These findings could result in delayed response to a fire emergency and increase the risk of injury to patients, visitors and staff in the event of a fire.


Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the fire extinguishers were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:30 a.m., in the Kitchen, 1 of 2 K-Class fire extinguishers was installed at 68 inches from the floor to the top of the fire extinguisher.

August 24, 2010: Main Campus
1. At 10:42 a.m. at the back entrance to X- Ray the fire extinguisher cabinet was obstructed by a copy machine.

On August 25, 2010 at the Main Campus:
1. At 2:30 p.m., in OR 4, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
2. At 2:35 p.m., in OR 3, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
3. At 2:40 p.m., in OR 2, Lower Floor, the fire extinguisher was blocked by 1 biohazard cart and 1 soiled linen cart.
4. At 2:55 p.m., in OR 6, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
5. At 3:00 p.m., in OR 5, Lower Floor, the fire extinguisher was blocked by a gray barrel.
6. At 3:30 p.m., in the Lab, Lower Floor, the fire extinguisher located in the chemistry area, was blocked by a cabinet.





27272

Based on observation and interview, the facility failed to maintain 2 of 2 designated smoking areas as evidenced by the facility failure to provide cigarette butt containers with self-closing cover devices. These findings could result in an increased risk of fire in the area around or within the designated smoking areas.

Findings:

During the facility tour with facility staff on August 23, 20210 to August 26, 2010, the smoking areas were observed.

On August 23, 2010 at the Magnolia Campus:

At 10:35 a.m., in the PHP smoking area, the 4 open containers with cigarette butts were not equipped with self-closing cover devices. Staff stated that EVS cleans the area and removes the cigarette butts.

At 10:50 a.m., in the Acute Psychiatric smoking area, the 2 open containers on the patio tables with cigarette butts were not equipped with self-closing cover devices.

Based on observation the facility failed to maintain the oxygen storage in accordance with NFPA 99. This was evidenced by an electrical switch that was installed at a level that may cause physical damage. This has the potential to cause damage to the switch and may cause injury to staff.

NFPA, 1999 Edition
4-3.1.1.2 Storage Requirements

11. d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

On August 25, 2010 at the Main Campus:

At 2:50 p.m., in the OR Nitrous Oxide Room, Lower Level, used for the storage of nitrous oxide, oxygen and Co2, the light switch was installed at approximately 48 inches above the floor.

Based on document review and interview the facility failed to maintain the humidity levels in 5 of 6 operating rooms, at 35% or greater, and failed to provide documentation of daily humidity levels in 2 of 2 GI procedure rooms. This had the potential to cause a fire and injury to patients and staff.

Findings:
During document review from August 23, 2010 through August 26, 2010 the policy and procedure for humidity for the operating rooms and procedure rooms and the humidity logs were requested.

At 10:20 a.m., on August 23, 2010 during an interview with Staff 3 regarding the policy and procedure, Staff 3 stated they were unable to locate a policy and procedure for humidity levels. The facility provided a photo copy of pages 418-419 from the 2009 Perioperative Standards and Recommended Practices. Per Staff 3, the Operating Room Nurse stated this document is what they use. The documentation states humidity levels should be maintained between 30% and 60%. The facility has 6 operating rooms (OR's). Five are used as OR's, and one is used for storage. The Temperature & Humidity logs have printed at the top "Humidity level should be maintained at 30% to 60% and to notify engineering if out of range".

On August 23, 2010 the Temperature and Humidity Logs were reviewed.
July 2010:
a. On July 29, 2010, OR 5, there was no documentation of the humidity level.

March 2010:
a. On March 10, 2010, OR 3 there was no documentation of the humidity level.
b. On March 10, 2010, OR 5, there was no documentation of the humidity level
c. On March 11, 2010, OR 2, the humidity level was 25%; there was no documentation of corrective action taken.
d. On March 11, 2010, OR 4, the humidity level was 29%; there was no documentation of corrective action taken.

December 2009:
a. On December 1, OR 6 the humidity level was 28%; engineering was notified but no documentation of recheck.
b. On December 18, 2009, OR 2, there was no documentation of the humidity level.
c. On December 18, 2009, OR 3, there was no documentation of the humidity level.
d. On December 18, 2009, OR 4, there was no documentation of the humidity level.
e. On December 18, 2009, OR 5, there was no documentation of the humidity level.
f. On December 30, 2009, OR 2, there was no documentation of the humidity level.
g. On December 30, 2009, OR 3, there was no documentation of the humidity level.
h. On December 30, 2009, OR 5, there was no documentation of the humidity level.
i. On December 31, 2009, OR 2, there was no documentation of the humidity level.
j. On December 31, 2009, OR 3, there was no documentation of the humidity level.
k. On December 31. 2009, OR 5, there was no documentation of the humidity level.
November 2009:
a. On November 1, 2009, OR 6, there was no documentation of the humidity level.
b. On November 11, 2009, OR 6, there was no documentation of the humidity level.
c. On November 11, 2009, OR 5, there was no documentation of the humidity level.
d. On November 11, 2009, OR 3, there was no documentation of the humidity level.
e. On November 11, 2009, OR 2, there was no documentation of the humidity level.
f. On November 12, 2009, OR 2, there was no documentation of the humidity level.
g. On November 13, 2009, OR 5, there was no documentation of the humidity level.
h. On November 13, 2009, OR 4, there was no documentation of the humidity level.
i. On November 13, 2009, OR 3, there was no documentation of the humidity level.
j. On November 13, 2009, OR 2, there was no documentation of the humidity level.
k. On November 16, 2009, OR 4, there was no documentation of the humidity level.
l. On November 16, 2009, OR 3, there was no documentation of the humidity level.
m. On November 17, 2009, OR 6, there was no documentation of the humidity level.
n. On November 18, 2009, OR 6, there was no documentation of the humidity level.
o. On November 18, 2009, OR 5, there was no documentation of the humidity level.
p. On November 18, 2009, OR 4, there was no documentation of the humidity level.
October 2009:
a. On October 7, 2009, OR 5, there was no documentation of the humidity level.
b. On October 16, 2009, OR 2, the humidity level was 16%, engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
c. On October 28, 2009, OR 3, there was no documentation of the humidity level
d. On October 28, 2009, OR 4, there was no documentation of the humidity level
e. On October 28, 2009, OR 5, there was no documentation of the humidity level.
f. On October 28, 2009, OR 6, there was no documentation of the humidity level.
g. On October 29, 2009, OR 3, the humidity level was 17%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
h. On October 29, 2009, OR 4, the humidity level was 14%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
i. On October 29, 2009, OR 5, the humidity level was 15%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
j. On October 29, 2009, OR 6, the humidity level was 15%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.

On August 25, 2010 at 10:00 a.m. during an interview with Staff 3, staff stated that humidity levels are not done for the 2 GI procedure rooms and for Operating Room 1.
At 2:30 p.m. during an interview with Staff 3, when asked if the engineering department has a record of humidity levels after it has been corrected following a report of low humidity levels, Staff 3 stated they do not have those records, and only have the engineering ticket they received.
At 2:45 p.m. during an interview with Staff 5, staff was asked what the procedure is if the humidity levels are below 30%. Staff stated that the OR is closed until the humidity level is back at an acceptable level.

On August 25, 2010, at 11:30 a.m., the Temperature and Humidity Logs were reviewed for Labor and Delivery -Cesarean Section room.
October 2009:
a. On October 30, 2009, the humidity level was 20%. An order was submitted to engineering "65 plus 10% at 1435 submitted ticket".
November 2009:
a. On November 16, 2009, the humidity level was 16%. The OR was closed, engineering was notified. No follow up humidity levels were recorded.
b. On November 16, 2009 at 0500, the humidity level was 12%, work order put in. Work order does not give follow up humidity level, or if the OR was closed due to the humidity level.
c. On November 17, 2009, the humidity level was 20%, work order was submitted. No follow up humidity levels were recorded, or notes if the OR was closed.
d. On November 17, 2009, at 0200, the humidity level was 15%. No notes indicating what staff did such as notify engineering or close the delivery room.
e. On November 20, 2009, at 0101, the humidity level was 22%. A work order was put in at 5:45 a.m., no follow up.
f. On November 24, 2009, at 0400, the humidity level was 18%. Staff did not note what action was taken.
g. On November 24, 2009, the humidity level was 15%, note "F/C with engineering", no follow up.
h. On November 30, 2009, the humidity level was 25%, and the humidifier was turned on. No follow up level recorded.

December 2009:
a. On December 8, 2009, 9:55 a.m., the humidity level was 28%, and the humidifier was turned on. There was no documentation that engineering was notified.

NFPA 101, 2000 Edition
4.6.10.1* Buildings or portions of buildings shall be permitted
to be occupied during construction, repair, alterations, or
additions only where required means of egress and required
fire protection features are in place and continuously maintained
for the portion occupied or where alternative life safety
measures acceptable to the authority having jurisdiction are in
place

Based on document review and interview, the facility failed to follow the written ILSM (Interim Life Safety Measures) by failure to conduct Daily Construction Project Inspections. This may result in a risk of fire in the construction area. This effected one of four smoke compartments on the lower level.

Findings:
On August 23, 2010 through August 26, 2010, during document review the ILSM Policy and Criteria was reviewed. The policy states that daily, weekly, and monthly inspections will be done, and each inspection has areas that will be checked under that time frame. On August 25, 2010 the Daily Construction Project Inspection Logs were reviewed from December 14, 2009 through August 25, 2010. The documentation is incomplete, the facility failed to conduct the inspections per policy daily.

No inspection documentation was provided for the following.
August 2010:
4 of 25 days no documentation of inspection
Sunday August 1, 2010
Sunday August 8, 2010
Sunday August 15, 2010
Sunday August 22, 2010

July 2010:
4 of 31 days no documentation of inspection
Sunday July 4, 2010
Sunday July 11, 2010
Sunday July 18, 2010
Sunday July 25, 2010

June 2010:
5 of 30 days no documentation of inspection
Saturday June 5, 2010
Sunday June 6, 2010
Sunday June 13, 2010
Sunday June 20, 2010
Sunday June 27, 2010

May 2010:
8 of 31 days no documentation of inspection
Saturday May 1, 2010
Sunday May 2, 2010
Sunday May 9, 2010
Saturday May 15, 2010
Sunday May 16, 2010
Sunday May 23, 2010
Sunday May 30, 2010
Monday May 31, 2010

April 2010:
15 of 30 days no documentation of inspection
Saturday April 3, 2010
Sunday April 4, 2010
Saturday April 10, 2010
Sunday April 11, 2010
Saturday April 17, 2010
Sunday April 18, 2010
Saturday April 24, 2010
Sunday April 25, 2010
Monday April 26, 2010
Tuesday April 27, 2010
Wednesday April 28, 2010
Thursday April 29, 2010
Friday April 30, 2010

March 2010:
8 of 31 days no documentation of inspection
Saturday March 6, 2010
Sunday March 7, 2010
Saturday March 13, 2010
Sunday March 14, 2010
Saturday March 20, 2010
Sunday March 21, 2010
Saturday March 27, 2010
Sunday March 28, 2010

February 2010:
9 of 28 days no documentation of inspection
Saturday February 6, 2010
Sunday February 7, 2010
Monday February 8, 2010
Saturday February 13, 2010
Sunday February 14, 2010
Saturday February 20, 2010
Sunday February 21, 2010
Saturday February 27, 2010
Sunday February 28, 2010

January 2010:
10 of 31 days no documentation of inspection
Saturday January 2, 2010
Sunday January 3, 2010
Saturday January 9, 2010
Sunday January 10, 2010
Saturday January 16, 2010
Sunday January 17, 2010
Saturday January 23, 2010
Sunday January 24, 2010
Saturday January 30, 2010
Sunday January 31, 2010

December 2009
6 of 18 days no documentation of inspection
Saturday December 19, 2009
Sunday December 20, 2009
Monday December 21, 2009
Saturday December 26, 2009
Sunday December 27, 2009
Monday December 28, 2009

During a telephone interview at 3:14 p.m., on September 1, 2010 with staff 4, staff stated that the project started on December 14, 2009.

27272

Based on observation the facility failed to maintain its electrical equipment and appliances, as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets, by failing to prevent the use of extension cords, and by failing to maintain the electrical panels. These findings could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

NFPA 70
110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) #2 Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

NFPA 70 Section 400-8 1999 Ed. 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

Findings:

During the facility tour with facility staff from August 23, 2010 to August 26, 2010, the electrical equipment and appliances were observed.

On August 23, 2010 at the Magnolia Campus:

1. At 10:45 a.m., in the EVS Break Room, there was a microwave, refrigerator and a toaster plugged into an extension cord.

2. At 11:15 a.m., in the Acute Rehab Employee Lounge, there was a microwave plugged into a multi-outlet adapter.

On August 24, 2010 at the Main Campus:

1. At 9:55 a.m., there was a junction box missing a cover plate above the smoke barrier door, below the exit sign, in ICU South, 2nd Floor.

2. At 11:00 a.m., there was an orange extension cord in use for the Baby Alarm for the Hug System, in the Physical Therapy Closet, 1st Floor.
3. At 11:15 a.m., there was an outlet cover plate that was not flush with the wall, in the Lower Level ATM hallway .
4. At 11:23 a.m., there were carts stored in front of electrical panel KA, in the Kitchen.
5. At 11:25 a.m., there was a supply cart stored in front of electrical panel KB, in the Kitchen.
6. At 11:25 a.m., the Electrical Room in the L&D Nurses Station, 1st Floor, was blocked by a mobile cart. The sign on the door said "Fire Extinguisher Inside".

7. At 11:35 a.m., there was a TV plugged into an extension cord and a microwave plugged into a multi-outlet adapter, in the L&D Employee Lounge, 1st Floor.

On August 25, 2010 at the Main Campus:

1. At 11:00 a.m., there was a refrigerator plugged into a multi-outlet adapter, in the Cardio Supervisor Office, Lower Floor.
2. At 2:13 p.m., there was a computer screen obstructing electrical panels IN3 and IE3, in the Maternity Nurses Station.

Based on observation, the facility failed to ensure the Alcohol Based Hand Dispensers were installed away from ignition sources. This was evidenced by an Alcohol Based Hand Dispenser mounted over an electrical source. This failure could result in a fire emergency and increase the risk of injury to patients, visitors and staff in the event of a fire, and affected one of five smoke compartments.

Findings:

During the facility tour with facility staff on August 23, 2010 through August 26, 2010, the Alcohol Based Hand Dispensers were observed.

On August 23, 2010 at the Magnolia Campus:

At 10:47 a.m., there was an Alcohol Based Hand Dispenser installed over an an electrical outlet, in the EVS Break Room.

Based on observation the facility failed to maintain the building construction to prevent the passage of smoke and flames in the event of a fire. This had the potential to cause injury to staff, patients and visitors in the event of a fire.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility the walls and ceilings were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:48 a.m., in the EVS Break Room, there was an approximately 1/2 inch by 2 inch unsealed penetration across the top of the electrical outlet on the left wall.
2. At 11:17 a.m., in the Employee Lounge, there was an approximately 1/4 inch by 3 inch unsealed penetration across the cover plate located under the control panel.

August 24, 2010:
1. At 10:15 a.m., in the ICU North Staff Lounge, 2nd Floor, there was an approximately one inch round penetration in the center left wall.
2. At 10:24 a.m. in the emergency room medication room on the back wall there was 1 unsealed penetration approximately 1 inch.
3. At 10:25 a.m. in the emergency room triage just above the thermostat there was an unsealed penetration approximately 1 inch.
4. At 10:43 a.m. X-Ray registration desk on the right side a sprinkler escutcheon ring was not flush with the ceiling exposing an approximately 4 inch unsealed penetration.
5. At 11:07 a.m., in the Surgical Unit Kitchen, 1st Floor, there were three approximately 1/2 inch penetrations and two 1/4 inch penetrations in the back center wall.
6 . At 11: 09 a.m. in the Lab special chemistry area there were 4 unsealed penetrations on the right wall, 1 approximately 1 inch and 3 approximately 1/2 inch.
7. At 11:15 a.m., in the Med Room inside Patient Room 108, 1st Floor, there was an approximately 1 and 1/2 inch penetration surrounding the door knob stop.
8. At 11:17 a.m. in S-2 Air Handler room in the drain room for the sterilizer there were 5 unsealed penetrations approximately 1/2 inch to 1 inch.
9. At 11:30 a.m., in the L & D Employee Kitchen, 1st Floor, there was an approximately 1/2 inch round penetration in the center left wall.

August 25, 2010:
1. At 10:33 a.m. in the doctor's old dining room on the back wall there were 8 unsealed penetrations approximately 1/2 inch to 1 inch each.


27272

Based on observation the facility failed to maintain the corridor walls with a 1/2 hour fire resistance rating in 1 of 4 smoke compartments on the lower level. This may result in the passage of smoke and flames in the event of a fire.

Findings:
On August 23, 2010 during a tour of the facility with staff the corridor walls were observed.
1. At 10:33 a.m. in the doctor's old dining room the corridor wall had 2 approximately 2 inch unsealed penetrations.

Based on observation the facility failed to maintain the doors to resist the passage of smoke in the event of a fire. This was evidenced by doors being held in the open position with devices that do not release upon activation of the fire alarm system. This effected 2 of 4 smoke compartments on the lower level.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the corridor doors were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:40 a.m., in the Outpatient Group Room 106, the door was blocked open with a chair.
2. At 10:43 a.m., in the Therapist office across from Group Room 107, the self-closing corridor door failed to fully close and positive latch.
August 24, 2010: Main Campus
1. At 10:35 a.m., in the Conference Room, 2nd Floor, the self-closing corridor door by ICU Nurses' Station South was blocked open with a chair.

August 25, 2010:
1. At 10:30 a.m., in the Storage Room across from the Concierge, 1st Floor, there was a 1 and 1/2 inch circular penetration above the inside by the door knob.
2. At 10:39 a.m. the door to GI lab 2 was held in the open position with a stool. The door is equipped with a self closing device.
3. At 10:40 a.m. the door to GI lab 1 was held in the open position with a stool. The door is equipped with a self closing device.
4. At 3:05 p.m., in the Women's Restroom by Diagnostic Imaging, Lower Floor, there was a 3/4 inch by 1/2 penetration abutting the inside of the door knob
5. At 10:47 a.m. the door for pre admitting services is held in the open position with a wedge.
6. At 10:55 a.m. the Medical Director of Emergency Services door is held in the open position with a wedge.
7. At 11:01 a.m. the Director of Emergency Services, Nurse Manager of Emergency Services office door was held in the open position with a wedge.


27272


.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to positive latch upon closure. These findings could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with facility staff on August 23, 2010 through August 26, 2010, the smoke barrier doors were observed.

On August 23, 2010 at the Magnolia Campus:

At 2:12 p.m., the smoke barrier double door, by Resident Room 726, the right leaf failed to positive latch.

On August 25, 2010 at the Main Campus:

At 3:10 p.m., the smoke barrier double door, Lower Level by Smoke Detector 1D in the corridor to the Pavilion, the left leaf failed to positive latch.

Based on observation and interview, the facility failed to ensure the hazardous areas were maintained to resist the passage of smoke, as evidenced by penetrations in hazardous area and hazardous areas without self closures. These findings could result in the spread of smoke and fire within the facility and increase the risk of injury to patients, visitors and staff due to fire.

Findings:

During the facility tour with facility staff on August 23, 2010 through August 26, 2010, the hazardous areas were observed.

On August 23, 2010 at the Magnolia Campus:

At 10:42 a.m., the Activity Room located inside the Copy Room, measuring over 50 square feet, contained an abundant amount of combustible materials including paper, plastics and miscellaneous supplies. The room was not equipped with a self-closing device.

On August 24, 2010 at the Main Campus:

At 11:04 a.m., the Physical Therapy Closet, measuring over 50 square feet, contained an abundant amount of combustible materials including electrical equipment, building supplies, paint and miscellaneous supplies. The room was not equipped with a self-closing device.

On August 25, 2010 at the Main Campus:

At 9:42 a.m., the Volunteer Storage Room, measuring over 50 square feet, contained an abundant amount of combustible materials including paper, plastics and miscellaneous supplies. The room was not equipped with a self-closing device.

Based on document review the facility failed to conduct fire drills at unexpected times on 2 of 3 shifts. Fire drills conducted at the same times may result in staff not being familiar with assignments to be followed at other times of the shift. This effected the entire hospital.

Findings:
On August 23, 2010 at 3:18 p.m. during document review the fire drills were reviewed from August 2009 through July 2010. The following fire drills were not held at unexpected times.
1. P.M. Shift - 3 of 4 drills were held between 8:25 p.m. and 8:50 p.m.
2. Night Shift - 4 of 4 drills were held between 11:00 p.m. and 11:10 p.m.

Based on observation the facility failed to maintain unobstructed access to all pull stations in the event of an emergency and to ensure that early warning devices were installed in all areas to warn staff and patients of a fire. This may cause a delay in activation of the fire alarm system in the event of a fire.
This effected 2 of 4 smoke compartments on the lower levels.

Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the pull stations ( manual fire alarm boxes) were observed.
August 24, 2010: Main Campus
1. At 10:42 a.m. at the back entrance to x-ray, a copy machine placed in front of the pull statin obstructed access to the pull station.
2. At 11:25 a.m. in the kitchen the Sham Food Warmer obstructed access to the pull station marked number 25.
August 25, 2010:
1. At 2:25 p.m., in Labor and Delivery OR, the alarm could not be heard in the OR. Staff interviewed were not aware of a policy and procedure to notify staff inside of OR in the event of an emergency.
2. At 3:28 p.m., during testing of the fire alarm system the fire alarm could not be heard in the Microbiology area of the lab. During an interview with 2 staff at the front desk where the alarms could be heard when asked what the policy was 2 of 2 staff stated they would here if the operated announced the code red overhead but neither staff stated that they would inform staff working in the microbiology area of the fire alarm
3. At 3:30 p.m., in the Cafeteria, the alarm could not be heard from the kitchen into the cafeteria. There were no audible devices in the cafeteria.






27272

NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the systems sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees F (38C).
2-4.1.5 The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers -- no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers -- no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers -- no fewer than 24 sprinklers

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, 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.


Based on observation the facility failed to maintain the automatic sprinkler system which is evidenced by sprinklers with that are dirty, escutcheon rings missing and not providing spare sprinklers of the type used in the area. These findings could result in a sprinkler system malfunction and increase the risk of injury to patients, visitors and staff in the event of a fire.



Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the sprinklers were observed.

On August 23, 2010 at the Magnolia Campus:
1. At 10:20 a.m., in the Kitchen area by the Office, there were 2 of 3 sprinkler heads with a build-up of debris.
2. At 10:25 a.m., in the Kitchen area by the Hood, there were 1 of 3 sprinkler heads with a 1/2 inch gap from the ceiling and the escutcheon ring.
3. At 11:00 a.m., in Room 733, the handle to the Inspector Test Valve was broke in half.
4. At 2:30 p.m., in the Kitchen area by the Dish Room, the sprinkler located above the pull station was missing an escutcheon ring.


August 24, 2010:
1. At 10:18 a.m. in the old emergency room by the restroom the sprinkler was dirty.
2. At 10:42 a.m. at the back entrance to X-Ray the copy machine obstructed the fire hose cabinet from opening completely.
3. At 10:47 a.m. in X-Ray 3, 1 of 6 sprinklers was missing the escutcheon ring.
4. At 10:50 a.m. in the lower level stand pipe the spare sprinkler box had only 4 spare sprinklers, there was no spare sprinklers provided for each type used.
5. At 11:20 a.m. in the kitchen the sprinkler at the door was missing the escutcheon ring.
6. At 11:25 a.m. in the kitchen the sprinkler in front of the oven was missing the escutcheon ring.
7. At 11:31 a.m. in the cafeteria in front of the soda machine the escutcheon ring was missing.

On August 25, 2010 at the Main Campus:
1. At 9:30 a.m., in the Nursing Supervisors Office, 1st Floor, there was 1 of 2 sprinklers missing an escutcheon ring.
2. At 10:45 a.m., in the OR Frozen Section, Lower Floor, there was 1 of 1 sprinklers missing an escutcheon ring.
3. At 10:59 a.m., in the Janitors Closet by the Phone Room, Lower Floor, there was 1 of 1 sprinkler heads with a build-up of debris.
4. At 3:40 p.m., in the ER, Lower Floor, there was sprinkler head with a build-up of debris located in the corridor outside of Bed 11 and Bed 12.



27272

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 Standard for Portable Fire Extinguishers (1998 edition)
4-3.2 * Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose and nozzle checked (for wheeled units)
( i) HMIS label is in place

Based on observation, the facility failed to maintain their fire extinguishers as evidenced by obstructions to the access of the fire extinguishers and a K-Class fire extinguisher mounted at greater than 42 inches. These findings could result in delayed response to a fire emergency and increase the risk of injury to patients, visitors and staff in the event of a fire.


Findings:
On August 23, 2010 through August 26, 2010 during a tour of the facility with staff the fire extinguishers were observed.
On August 23, 2010 at the Magnolia Campus:
1. At 10:30 a.m., in the Kitchen, 1 of 2 K-Class fire extinguishers was installed at 68 inches from the floor to the top of the fire extinguisher.

August 24, 2010: Main Campus
1. At 10:42 a.m. at the back entrance to X- Ray the fire extinguisher cabinet was obstructed by a copy machine.

On August 25, 2010 at the Main Campus:
1. At 2:30 p.m., in OR 4, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
2. At 2:35 p.m., in OR 3, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
3. At 2:40 p.m., in OR 2, Lower Floor, the fire extinguisher was blocked by 1 biohazard cart and 1 soiled linen cart.
4. At 2:55 p.m., in OR 6, Lower Floor, the fire extinguisher was blocked by 2 biohazard carts and 1 soiled linen cart.
5. At 3:00 p.m., in OR 5, Lower Floor, the fire extinguisher was blocked by a gray barrel.
6. At 3:30 p.m., in the Lab, Lower Floor, the fire extinguisher located in the chemistry area, was blocked by a cabinet.





27272

Based on observation and interview, the facility failed to maintain 2 of 2 designated smoking areas as evidenced by the facility failure to provide cigarette butt containers with self-closing cover devices. These findings could result in an increased risk of fire in the area around or within the designated smoking areas.

Findings:

During the facility tour with facility staff on August 23, 20210 to August 26, 2010, the smoking areas were observed.

On August 23, 2010 at the Magnolia Campus:

At 10:35 a.m., in the PHP smoking area, the 4 open containers with cigarette butts were not equipped with self-closing cover devices. Staff stated that EVS cleans the area and removes the cigarette butts.

At 10:50 a.m., in the Acute Psychiatric smoking area, the 2 open containers on the patio tables with cigarette butts were not equipped with self-closing cover devices.

Based on observation the facility failed to maintain the oxygen storage in accordance with NFPA 99. This was evidenced by an electrical switch that was installed at a level that may cause physical damage. This has the potential to cause damage to the switch and may cause injury to staff.

NFPA, 1999 Edition
4-3.1.1.2 Storage Requirements

11. d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

On August 25, 2010 at the Main Campus:

At 2:50 p.m., in the OR Nitrous Oxide Room, Lower Level, used for the storage of nitrous oxide, oxygen and Co2, the light switch was installed at approximately 48 inches above the floor.

Based on document review and interview the facility failed to maintain the humidity levels in 5 of 6 operating rooms, at 35% or greater, and failed to provide documentation of daily humidity levels in 2 of 2 GI procedure rooms. This had the potential to cause a fire and injury to patients and staff.

Findings:
During document review from August 23, 2010 through August 26, 2010 the policy and procedure for humidity for the operating rooms and procedure rooms and the humidity logs were requested.

At 10:20 a.m., on August 23, 2010 during an interview with Staff 3 regarding the policy and procedure, Staff 3 stated they were unable to locate a policy and procedure for humidity levels. The facility provided a photo copy of pages 418-419 from the 2009 Perioperative Standards and Recommended Practices. Per Staff 3, the Operating Room Nurse stated this document is what they use. The documentation states humidity levels should be maintained between 30% and 60%. The facility has 6 operating rooms (OR's). Five are used as OR's, and one is used for storage. The Temperature & Humidity logs have printed at the top "Humidity level should be maintained at 30% to 60% and to notify engineering if out of range".

On August 23, 2010 the Temperature and Humidity Logs were reviewed.
July 2010:
a. On July 29, 2010, OR 5, there was no documentation of the humidity level.

March 2010:
a. On March 10, 2010, OR 3 there was no documentation of the humidity level.
b. On March 10, 2010, OR 5, there was no documentation of the humidity level
c. On March 11, 2010, OR 2, the humidity level was 25%; there was no documentation of corrective action taken.
d. On March 11, 2010, OR 4, the humidity level was 29%; there was no documentation of corrective action taken.

December 2009:
a. On December 1, OR 6 the humidity level was 28%; engineering was notified but no documentation of recheck.
b. On December 18, 2009, OR 2, there was no documentation of the humidity level.
c. On December 18, 2009, OR 3, there was no documentation of the humidity level.
d. On December 18, 2009, OR 4, there was no documentation of the humidity level.
e. On December 18, 2009, OR 5, there was no documentation of the humidity level.
f. On December 30, 2009, OR 2, there was no documentation of the humidity level.
g. On December 30, 2009, OR 3, there was no documentation of the humidity level.
h. On December 30, 2009, OR 5, there was no documentation of the humidity level.
i. On December 31, 2009, OR 2, there was no documentation of the humidity level.
j. On December 31, 2009, OR 3, there was no documentation of the humidity level.
k. On December 31. 2009, OR 5, there was no documentation of the humidity level.
November 2009:
a. On November 1, 2009, OR 6, there was no documentation of the humidity level.
b. On November 11, 2009, OR 6, there was no documentation of the humidity level.
c. On November 11, 2009, OR 5, there was no documentation of the humidity level.
d. On November 11, 2009, OR 3, there was no documentation of the humidity level.
e. On November 11, 2009, OR 2, there was no documentation of the humidity level.
f. On November 12, 2009, OR 2, there was no documentation of the humidity level.
g. On November 13, 2009, OR 5, there was no documentation of the humidity level.
h. On November 13, 2009, OR 4, there was no documentation of the humidity level.
i. On November 13, 2009, OR 3, there was no documentation of the humidity level.
j. On November 13, 2009, OR 2, there was no documentation of the humidity level.
k. On November 16, 2009, OR 4, there was no documentation of the humidity level.
l. On November 16, 2009, OR 3, there was no documentation of the humidity level.
m. On November 17, 2009, OR 6, there was no documentation of the humidity level.
n. On November 18, 2009, OR 6, there was no documentation of the humidity level.
o. On November 18, 2009, OR 5, there was no documentation of the humidity level.
p. On November 18, 2009, OR 4, there was no documentation of the humidity level.
October 2009:
a. On October 7, 2009, OR 5, there was no documentation of the humidity level.
b. On October 16, 2009, OR 2, the humidity level was 16%, engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
c. On October 28, 2009, OR 3, there was no documentation of the humidity level
d. On October 28, 2009, OR 4, there was no documentation of the humidity level
e. On October 28, 2009, OR 5, there was no documentation of the humidity level.
f. On October 28, 2009, OR 6, there was no documentation of the humidity level.
g. On October 29, 2009, OR 3, the humidity level was 17%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
h. On October 29, 2009, OR 4, the humidity level was 14%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
i. On October 29, 2009, OR 5, the humidity level was 15%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.
j. On October 29, 2009, OR 6, the humidity level was 15%; engineering was notified and administration was notified. No recheck of the humidity level was recorded, or if the OR was closed due to the humidity level.

On August 25, 2010 at 10:00 a.m. during an interview with Staff 3, staff stated that humidity levels are not done for the 2 GI procedure rooms and for Operating Room 1.
At 2:30 p.m. during an interview with Staff 3, when asked if the engineering department has a record of humidity levels after it has been corrected following a report of low humidity levels, Staff 3 stated they do not have those records, and only have the engineering ticket they received.
At 2:45 p.m. during an interview with Staff 5, staff was asked what the procedure is if the humidity levels are below 30%. Staff stated that the OR is closed until the humidity level is back at an acceptable level.

On August 25, 2010, at 11:30 a.m., the Temperature and Humidity Logs were reviewed for Labor and Delivery -Cesarean Section room.
October 2009:
a. On October 30, 2009, the humidity level was 20%. An order was submitted to engineering "65 plus 10% at 1435 submitted ticket".
November 2009:
a. On November 16, 2009, the humidity level was 16%. The OR was closed, engineering was notified. No follow up humidity levels were recorded.
b. On November 16, 2009 at 0500, the humidity level was 12%, work order put in. Work order does not give follow up humidity level, or if the OR was closed due to the humidity level.
c. On November 17, 2009, the humidity level was 20%, work order was submitted. No follow up humidity levels were recorded, or notes if the OR was closed.
d. On November 17, 2009, at 0200, the humidity level was 15%. No notes indicating what staff did such as notify engineering or close the delivery room.
e. On November 20, 2009, at 0101, the humidity level was 22%. A work order was put in at 5:45 a.m., no follow up.
f. On November 24, 2009, at 0400, the humidity level was 18%. Staff did not note what action was taken.
g. On November 24, 2009, the humidity level was 15%, note "F/C with engineering", no follow up.
h. On November 30, 2009, the humidity level was 25%, and the humidifier was turned on. No follow up level recorded.

December 2009:
a. On December 8, 2009, 9:55 a.m., the humidity level was 28%, and the humidifier was turned on. There was no documentation that engineering was notified.

NFPA 101, 2000 Edition
4.6.10.1* Buildings or portions of buildings shall be permitted
to be occupied during construction, repair, alterations, or
additions only where required means of egress and required
fire protection features are in place and continuously maintained
for the portion occupied or where alternative life safety
measures acceptable to the authority having jurisdiction are in
place

Based on document review and interview, the facility failed to follow the written ILSM (Interim Life Safety Measures) by failure to conduct Daily Construction Project Inspections. This may result in a risk of fire in the construction area. This effected one of four smoke compartments on the lower level.

Findings:
On August 23, 2010 through August 26, 2010, during document review the ILSM Policy and Criteria was reviewed. The policy states that daily, weekly, and monthly inspections will be done, and each inspection has areas that will be checked under that time frame. On August 25, 2010 the Daily Construction Project Inspection Logs were reviewed from December 14, 2009 through August 25, 2010. The documentation is incomplete, the facility failed to conduct the inspections per policy daily.

No inspection documentation was provided for the following.
August 2010:
4 of 25 days no documentation of inspection
Sunday August 1, 2010
Sunday August 8, 2010
Sunday August 15, 2010
Sunday August 22, 2010

July 2010:
4 of 31 days no documentation of inspection
Sunday July 4, 2010
Sunday July 11, 2010
Sunday July 18, 2010
Sunday July 25, 2010

June 2010:
5 of 30 days no documentation of inspection
Saturday June 5, 2010
Sunday June 6, 2010
Sunday June 13, 2010
Sunday June 20, 2010
Sunday June 27, 2010

May 2010:
8 of 31 days no documentation of inspection
Saturday May 1, 2010
Sunday May 2, 2010
Sunday May 9, 2010
Saturday May 15, 2010
Sunday May 16, 2010
Sunday May 23, 2010
Sunday May 30, 2010
Monday May 31, 2010

April 2010:
15 of 30 days no documentation of inspection
Saturday April 3, 2010
Sunday April 4, 2010
Saturday April 10, 2010
Sunday April 11, 2010
Saturday April 17, 2010
Sunday April 18, 2010
Saturday April 24, 2010
Sunday April 25, 2010
Monday April 26, 2010
Tuesday April 27, 2010
Wednesday April 28, 2010
Thursday April 29, 2010
Friday April 30, 2010

March 2010:
8 of 31 days no documentation of inspection
Saturday March 6, 2010
Sunday March 7, 2010
Saturday March 13, 2010
Sunday March 14, 2010
Saturday March 20, 2010
Sunday March 21, 2010
Saturday March 27, 2010
Sunday March 28, 2010

February 2010:
9 of 28 days no documentation of inspection
Saturday February 6, 2010
Sunday February 7, 2010
Monday February 8, 2010
Saturday February 13, 2010
Sunday February 14, 2010
Saturday February 20, 2010
Sunday February 21, 2010
Saturday February 27, 2010
Sunday February 28, 2010

January 2010:
10 of 31 days no documentation of inspection
Saturday January 2, 2010
Sunday January 3, 2010
Saturday January 9, 2010
Sunday January 10, 2010
Saturday January 16, 2010
Sunday January 17, 2010
Saturday January 23, 2010
Sunday January 24, 2010
Saturday January 30, 2010
Sunday January 31, 2010

December 2009
6 of 18 days no documentation of inspection
Saturday December 19, 2009
Sunday December 20, 2009
Monday December 21, 2009
Saturday December 26, 2009
Sunday December 27, 2009
Monday December 28, 2009

During a telephone interview at 3:14 p.m., on September 1, 2010 with staff 4, staff stated that the project started on December 14, 2009.

27272

Based on observation the facility failed to maintain its electrical equipment and appliances, as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets, by failing to prevent the use of extension cords, and by failing to maintain the electrical panels. These findings could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

NFPA 70
110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) #2 Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

NFPA 70 Section 400-8 1999 Ed. 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

Findings:

During the facility tour with facility staff from August 23, 2010 to August 26, 2010, the electrical equipment and appliances were observed.

On August 23, 2010 at the Magnolia Campus:

1. At 10:45 a.m., in the EVS Break Room, there was a microwave, refrigerator and a toaster plugged into an extension cord.

2. At 11:15 a.m., in the Acute Rehab Employee Lounge, there was a microwave plugged into a multi-outlet adapter.

On August 24, 2010 at the Main Campus:

1. At 9:55 a.m., there was a junction box missing a cover plate above the smoke barrier door, below the exit sign, in ICU South, 2nd Floor.

2. At 11:00 a.m., there was an orange extension cord in use for the Baby Alarm for the Hug System, in the Physical Therapy Closet, 1st Floor.
3. At 11:15 a.m., there was an outlet cover plate that was not flush with the wall, in the Lower Level ATM hallway .
4. At 11:23 a.m., there were carts stored in front of electrical panel KA, in the Kitchen.
5. At 11:25 a.m., there was a supply cart stored in front of electrical panel KB, in the Kitchen.
6. At 11:25 a.m., the Electrical Room in the L&D Nurses Station, 1st Floor, was blocked by a mobile cart. The sign on the door said "Fire Extinguisher Inside".

7. At 11:35 a.m., there was a TV plugged into an extension cord and a microwave plugged into a multi-outlet adapter, in the L&D Employee Lounge, 1st Floor.

On August 25, 2010 at the Main Campus:

1. At 11:00 a.m., there was a refrigerator plugged into a multi-outlet adapter, in the Cardio Supervisor Office, Lower Floor.
2. At 2:13 p.m., there was a computer screen obstructing electrical panels IN3 and IE3, in the Maternity Nurses Station.