HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected four of nineteen smoke compartments in the Main Hospital and one of two Outpatient Buildings. This could result in the spread of smoke from one area to another in the event of a fire.

Findings:

During the facility tour with facility staff on 2/28/12 through 3/1/12, the ceilings and walls were observed.

Main Hospital:

2/28/12 - 1st Floor (D Wing):
1. At 3:14 p.m., there was a penetration that measured approximately 2 x 3 feet in the ceiling in Room 1416. A ceiling tile was missing.

2. At 3:15 p.m., there was a penetration that measured approximately 2 x 3 inches in Room 1416. The cover plate was lifted to the phone/data lines. During an interview, facility staff reported that the phone/data lines were removed.

3. At 3:37 p.m., there was a penetration that measured approximately 3/4 inch on the left wall of Room 1428 B. The penetration was around a metal ring that was securing a nitrogen gas cylinder to the wall.

2/29/12 - 1st Floor:
4. At 10:30 a.m., there was a triangular penetration that measured approximately 10 x 6 inch on the southeast corner of the wall in the Boiler Room.

5. At 10:38 a.m., there was an approximately 1 1/4 inch unsealed pipe sleeve penetrating on the northeast corner wall of the Boiler Room.

6. At 10:41 a.m., there was an approximately 1/2 inch penetration around an approximately 6 inch pipe on the south wall of the Mechanical Room. The drywall below the 6 inch pipe was cracked. There was an approximately 1/2 x 1 1/2 inch penetration below the 6 inch pipe, on the left side.

7. At 10:49 a.m., there was an approximately 10 x 8 inch triangular damage to the drywall on the east wall of the mechanical room, behind the "D" Wing.

8. At 11:38 a.m., there was a large penetration around six pipes that measured approximately 1 inch each that went through the ceiling in Cat Scan Room 1.

9. At 11:47 a.m., there was an approximately 1 1/2 x 3 inch penetration in the employee's lounge, Room 1564, behind the microwave.
During an interview, Staff 3 stated that the phone was removed creating the penetration. He reported that the phones were in the process of being upgraded.

10. At 3:56 a.m., there was a penetration through the ceiling that measured approximately 1/2 to 3/4 inch around a 24 inch surgery light mount, located inside the supply room to Room 1528. During an interview, facility staff stated that the room was once used as a cast room.

PT and In-Home Service Care Staff:

3/1/12 -
11. At 9:36 a.m., there were 2 penetrations in the hot water heater closet. The first penetration measured approximately 1/4 inch that was located around 2 pipes. The second penetration measured 1 inch that was located behind the hot water heater and around the screw that holds the earthquake strap to the wall.


29751


2/28/12
12. At 2:30 p.m., in the staff lounge Room 4214, there were two, one quarter inch round unsealed penetrations in the ceiling adjacent to entry door.

2/29/12
13. At 10:10 a.m., in Room 2125, there was an unsealed penetration where caulking had fallen out around telecommunication wires in 1 of 3 electrical conduits running through the ceiling.

14. At 2:00 p.m., in the cafeteria, there were three escutcheon rings over the two cash registers that were not flush to the ceiling, creating unsealed penetrations.

Based on observation, the facility failed to maintain and ensure that corridor doors were free from obstructions to closing, and that doors close and latch. This was evidenced by eight doors that failed to latch, four doors that were impeded from closing and one missing door. This failure could result in the spread of smoke or fire, in the event of a fire, affecting three of nineteen smoke compartments in the Main Hospital and two of two Outpatient Buildings.

Findings:

During the facility tour with facility staff on 2/28 - 3/1/12 the corridor doors were observed.

Main Hospital:

2/28 - 1st Floor (D Wing)
1. At 3:20 p.m., the door between the Placenta Room and the Grossing Station was impeded from closing by a black floor mat. Once the floor mat was removed a 30 gallon bio-hazard container was impeding the door from closing.

2/29 - 1st Floor (E Wing)
2. At 9:39 a.m., the self-closing corridor door to Room 1546 was impeded from closing. There was a chair directly in front of the door.

3. At 9:40 a.m., the self-closing corridor door to Room 1546 closed but failed to latch. The door was tested three times.

4. At 10:49 a.m., the exterior door to the "D" Wing Mechanical Room failed to fully close and latch. The door was tested three times.

5. At 2:00 p.m., the corridor door to Room 1538 B closed but failed to latch. The striker was stuck inside the mechanism.

6. At 2:53 p.m., the door to the supply room inside the Trauma 2 areas was missing. There was a door frame and the latching mechanism on the door frame. During an interview, facility staff reported he had worked in the facility for over 12 years and had never seen a door to this room.

7. At 2:59 p.m., one of four self closing door to the Trauma 2 Room closed but failed to latch. The door was tested three times.

8. At 3:22 p.m., the corridor door to Room 1512 closed but failed to latch. The door was tested three times.

9. At 3:29 p.m., one of three corridor door to Room 1514 failed to fully close and latch. The door frame was rubbing on the upper portion.

10. At 3:32 p.m., one of three self-closing corridor door to Room 1518 closed but failed to latch. The door was tested a couple of times.

11. At 3:35 p.m., the door to the supply room in Trauma 1 was impeded from closing by an over-the-bed table that was holding the door open. The table was directly in front of the open door.

PT and In-Home Service Care Staff:

3/1/12-
12. At 9:34 a.m., the corridor door to the janitor's closet closed but failed to latch. The door was tested four times.


29751


Sagebrush Outpatient Clinic

3/1/12-
13. At 8:44 a.m., the doors to procedure Rooms 1167 and 1164, were propped open with chairs.

Based on observation and interview, the facility failed to ensure that the smoke barrier doors are capable of resisting the passage of smoke, and that the doors are self-closing. This was evidenced by one smoke barrier door that failed to fully close and latch during testing of the fire alarm system and one smoke barrier door with penetrations. This affected four of nineteen smoke compartments in the Main Hospital and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire.

Findings:

During the facility tour and interview with Staff 3 on 3/1/12, the smoke barrier doors were observed and tested.

Main Hospital

4th floor
1. At 11:41 a.m., the right side smoke barrier door by Room 4046 did not fully close and latch after activation of the fire alarm system. The door remained partially open. There was a gap that measured approximately 6 to 8 inches on the right side.

2nd floor
2. At 2:50 p.m., the smoke barrier doors 206 and 207 were damaged. There were three penetrations that measured approximately 1/4 inch at the top of each door. There were indications that something had been removed from the doors. During an interview, Staff 3 stated that it appeared that the strike plates on the doors had been removed.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resistant partitions and self closing doors. This was evidenced by a hazardous storage area without a self closing door. This could result in the spread of smoke or fire, in the event of a fire, affecting one of nineteen smoke compartments in the Main Hospital.

Findings:

During the facility tour with Staff 3 on 2/28/12, doors to hazardous areas were observed. Combustible storage areas greater than 50 square feet in size are considered hazardous. The doors are required to self close and latch.

Main Hospital

1. At 2:44 p.m., the storage room located inside the gift shop contained more than 26 cardboard boxes of miscellaneous storage and decorations. There were more than 20 stuffed animals, there were more than 10 wicker baskets, and more than 100 gift bags made of paper, in different sizes. There was no self closing device on the door.

2. There was a metal door hanger over the door holding 5 items and 2 hangers on the door knob impeding the door from closing.

Combustible storage rooms greater than 50 square feet in size are required to have doors that self close and latch.

Based on observation, the facility failed to maintain their exit discharges as evidenced by obstructions to the path of exit out of the facility. The failure affected 2 of 19 smoke compartments in the facility and had the potential to delay egress through the exit in the event of an emergency.

Findings:

During a tour of the facility with engineering on 2/29/12, the exit accesses were observed.

1. At 2:25 p.m., in the laundry facility of the hospital, both exit doors were obstructed with laundry carts.



28602


Main Hospital

2/29/12 - 1st Floor
2. At 2:29 p.m., the corridor exit door to Room 1510 was impeded from opening to the waiting area by three large plastic bags storing blankets. There were several other blankets on the floor. The exit door could not be open. Facility staff had to remove all items before the door could be open.

During an interview, facility staff reported that the blankets were donated and that the blankets need to be put away in the storage area where they keep all donated items. She reported that the items have been at this location for approximately a week.

3. At 3:44 p.m., the corridor exit door to Room 1522 was blocked by a clean linen cart directly in front of the door. The clean linen cart reduced the exit path to approximately 18 inches.

Based on observation the facility failed to maintain the complete fire alarm system in accordance with NFPA 72. This was evidenced by the failure of two visual alarms to activate when the fire alarm was activated. This could result in a delay in evacuation, in the event of a fire, affecting eight of nineteen smoke compartments in the Main Hospital.

Findings:

During fire alarm testing with Staff 3 on 3/1 and 3/2/12, the notification devices were observed.

Main Hospital

3/1 - 4 th Floor-
1. At 11:56 a.m., the strobe light failed to activate a visual alarm in the staff lounge, Room 4213, when the manual pull alarm was activated.

2nd Floor-
2. At 3:34 p.m., the strobe light failed to activate a visual alarm in Room 2547, when the manual pull alarm was activated.

Based on observation, the facility failed to maintain their smoke detectors as evidenced by a broken smoke detector and a missing smoke detector in a physician sleeping room. This failure affected 2 of 19 smoke compartments in the facility and had the potential to delay the notification of staff in the event of a fire.

Findings:

During a tour of the facility with engineering on February 29, 2012, the smoke detectors in the facility were observed.

1. At 10:30 a.m., Room 2402 had a smoke detector hanging from the ceiling mounting bracket and missing the battery.

2. At 10:31 a.m., Room 2404 the smoke detector was missing from the ceiling mounting bracket.


28602


Main Hospital

3/1/12 - 3rd Floor

3. At 2:02 p.m., the smoke detector by Room 3114 when tested with can smoke failed to activate the fire alarm system. The smoke detector was tested four times.

Based observation and interview, the hospital failed to maintain their automatic fire alarm sprinkler system as evidenced by staff not knowing how to test their sprinkler equipment and by staff not actually testing the sprinkler equipment during the hospital validation survey. This deficient practice affects all resident and staff of the hospital and could result in the automatic sprinkler system not extinguishing a fire as designed.

Findings:

On 3/2/2012 at 8:30 a.m., two of four inspector's test valves could not be tested.

During an interview, Staff 3 reported that he did not know the location of the other two inspector's test valves. Staff 3 reported that he was not familiar with the testing of the inspector's test valve (waterflow) and was not comfortable testing. He stated that the staff who is familiar with the locations of the test valves was not working that day. Therefore, two of four inspector test valves were not tested during the hospital validation fire alarm testing.

Based on observation the facility failed to ensure maintenance, and inspection of their sprinkler system in accordance with NFPA 13 and NFPA 25, as evidenced by sprinklers that were contaminated with dirt and dust. This affected 3 of 5 smoke compartments and could result in the failure of the sprinklers in the event of a fire.

Findings:

During a tour of the facility with engineering on 2/29/2012, the sprinklers were observed.

1. At 8:20 a.m., Stairwell 10 on 2B North, had a sprinkler covered with dust and debris.

2. At 8:56 a.m., Room 2121 had 2 of 2 sprinklers covered with dust and debris.

3. At 11:50 a.m., Room 1118 had 1 of 1 sprinklers covered with dust and debris.

Sagebrush Facility

3/1/2012
4. At 8:30 a.m., Rooms 1132, 1136, and 1135 procedure rooms had sprinklers covered with dust and debris.



28602


Main Hospital

2/28/12 - 1st Floor
5. At 2:34 p.m., there was an approximately 1/2 to 3/4 inch gap between the escutcheon ring and the ceiling in D Wing Waiting Room, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

6. At 2:53 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling in D Wing Women's Restroom, exposing an approximately 1/8 inch penetration around the sprinkler pipe.

2/29/12 - 1st Floor
7. At 12:04 p.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling in Room 1532, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

8. At 2:07 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling in Room 1549, exposing an approximately 1/2 to 3/4 inch penetration around the sprinkler pipe.

9. At 4:20 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling in the waiting room by triage, exposing an approximately 1/2 inch penetration around the sprinkler pipe.

Based on observation the facility failed to maintain their fire extinguishers as evidenced by the failure to mount the extinguishers according to NFPA 10. This failure affected 2 of 19 smoke compartments in the Main Hospital and had the potential to delay the extinguishment of a fire.

Findings:

During a tour of the facility with engineering on February 28-29, 2012, the fire extinguishers were observed.

1. At 2:15 p.m., in Stairwell 7 on 4C/ Postpartum, there was a seventeen pound fire extinguisher that was mounted at sixty seven inches.
2/29/2012

2. At 2:30 p.m., the fire extinguisher outside of Room 1326, in the laundry facility, was placed on the floor and not mounted as required by regulation.

Based on observation and interview, the facility failed to maintain their designated smoking areas and failed to provide all noncombustible safety type ashtray in the designated smoking areas. This was evidenced by three of three designated smoking areas that had numerous cigarette butts on the ground and two of three smoking areas with noncombustible safety type ashtrays. This could result in ignition of a fire.

Findings:

During a facility tour with Staff 3 on 2/29 to 3/1/12, the designated smoking areas were observed.

Main Hospital

3/29 -
1. At 3:45 p.m., the staff smoking area located outside the ER had more than 15 cigarette butts on the ground. There were more than 50 cigarette butts on an open top ashtray that was on top of a large trash can. The ashtray was attached to the trash can and did not have a lid cover. One of four ashtrays was not a noncombustible safety type ashtray.

During an interview, Staff 3 stated that this smoking area is specifically for staff and that no residents or visitors are allowed in this area. He reported that there maybe times staff will allow people in the ER to use the smoking area.

3/1 -
2. At 9:00 a.m., the staff smoking area located outside "F" Ward had approximately 18 cigarette butts on the ground.

3. At 9:06 a.m., the staff smoking area located outside Trailer 9 had more than 40 cigarette butts on the ground. There were over 50 cigarette butts on an open top ashtray.

Based on observation, interview and record review, the facility failed to maintain the required kitchen hood fire suppression equipment over the cooking area of the kitchen. This was evidenced by failing to provide the semi annual certification of the kitchen suppression system. This affected the first floor of the Main Hospital and could result in a failure of the kitchen suppression system and an increased risk of fire.

NFPA 96 11.2 Inspection of Fire-Extinguishing Systems.
11.2.1* An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant of fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During record review with Staff 3 on 2/27/12, the kitchen suppression system's certification records were requested.

Main Hospital

At 3:25 p.m., there were no records available for review. The facility was missing two of two 6 month semi annual inspection reports for the kitchen hood fire suppression system.

On 3/5/12, a report titled "Fire Suppression Systems Report", dated 2/29/12 was received via fax.

On 3/8/12, the facility sent, via e-mail, a semi-annual report, titled "Fire Suppression System Service" dated 5/12/11. There was no report available for review within 6 months of the 5/12/11 inspection date.

During an interview, facility staff stated that previous staff were under the impression that the Fire Department could certify the kitchen suppression system and that is the reason no certification is available for November of 2011. Facility staff reported that the Fire Department was out to inspect the kitchen hood suppression system last November.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions, as evidenced by garbage containers, bio-hazard containers, an X-Ray machine, and a cart holding X-ray films placed in the exit corridors. This failure could lead to an obstruction of the corridor and the exit path, during a fire or other emergency. This could result in harm to patients and staff who would be delayed in exiting. This affected one of nineteen smoke compartments in the Main Hospital.

Findings:

During the facility tour and interview with facility staff on 2/29/12, the corridors in the facility were observed.

Main Hospital

1. At 8:47 a.m., there were one 70 gallon garbage container, one 40 gallon Bio-hazard container, one 40 gallon grey garbage container and 5 cardboard boxes against the corridor wall by Room 36.
At 8:56 a.m., during an interview, housekeeping staff revealed this area is usually used for storing these items.

2. At 2:20 p.m., there were one x-ray machine, a cart holding x-ray films, and a 30 gallon garbage container outside Room 23 (1509). The items were against the corridor wall.
During an interview, direct care staff revealed this area is usually used for storing these items.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles is not exceeded within any 64 square foot area. This was evidenced by multiple receptacles placed in three areas in the facility. The facility also failed to ensure that these receptacles when not attended are located in a room protected as a hazardous area. This failure could result in an increase risk fire, affecting two of nineteen compartments in the Main Hospital.

Findings:

During the facility tour with facility staff on 2/28 to 2/29/12, soiled linen and trash receptacles (containers) were observed in the facility.

Main Hospital

2/28 - 1st Floor - Lab
1. At 3:47 p.m., there were two Biohazard bins lined up, side by side, against the wall in the lab, in Room 1428. The carts were approximately 30 gallons in size. The bins were within one 64 foot area.

2. 2/29 - 1st floor - Emergency Department
At 9:47 a.m., there was one Biohazard bin and one grey trash bin, side by side, against the wall inside the Cath Lab Room 1578.

3. At 2:16 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 9. The containers were lined, side by side, up against the privacy curtains.

4. At 2:18 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 8. The containers were lined up, side by side, against the privacy curtain.

5. At 2:18 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 7. The containers were lined up, side by side, against the privacy curtain.

6. At 2:18 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 6. The containers were lined up, side by side, against the privacy curtain.

7. At 2:19 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 5. The containers were lined up against the privacy curtains. The containers were within one 64 square foot area.

8. At 2:19 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 4. The containers were lined up, side by side, against the privacy curtain.

9. At 2:19 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 3. The containers were lined up, side by side, against the privacy curtain.

10. At 2:20 p.m., there was one white approximately 30 gallon soiled linen container and one approximately red 30 gallon Biohazard container in the ER area, Room 1. The containers were lined up against the privacy curtains. The containers were within one 64 square foot area.

11. At 2:48 p.m., there were two white 40 gallon Biohazard containers, one approximately blue 30 gallon soiled linen container in Room 1509. The containers were within one 64 square foot area.

12. At 3:40 p.m., Trauma 1 area Rooms 18, 19 and 20, each had a 44 gallon Biohazard containers in the room.

Based on observations, record review and interview, the facility failed to maintain their electrical equipment and utilities in accordance with NFPA 70 and NFPA 99. This was evidenced by electrical panels that were not labeled properly, surge protected multi-outlet extension cords connected to other surge protected multi-outlet extension cords and by high amp machines that were plugged into a surge protected multi-outlet extension cord, missing electrical cover plates, unlabeled breakers and a damaged outlet . This could result in an increased risk of an electrical fire to occur and affected three of nineteen compartments in the Main Hospital and 1 of 2 Outpatient Buildings.

NFPA 99 Health Care Facilities 1999 edition
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

400.8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or
floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

NFPA 99
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During record the facility tour with Staff 3 and 4 on 2/28 to 3/2/12, the electrical equipment and wiring were observed.

Main Hospital

2/28 - 1st Floor - D Wing
1. At 2:24 p.m., there was a surge protector connecting a router, connected to another surge protector connecting computer equipment in Room 1451 A. The surge protectors were underneath the "staffing desk".

2. At 2:26 p.m., the cover plate to an electrical wall outlet was missing in Room 1451 A. The electrical wall outlet was located behind the "House Supervisor Desk."

3. At 2:29 p.m., there was a surge protector connecting a mid size refrigerator and a door bell transformer in Staff Ref 244.

4. At 2:40 p.m., there was a surge protector connecting a mid size refrigerator, and a microwave in the Gift Shop. The surge protector was connected to the electrical wall outlet.

5. At 3:10 p.m., there was a surge protector connecting a microscope and lens, connected to another surge protector that was connecting computer equipment in Room 1412.

6. At 3:42 p.m., there was a surge protector connecting a printer, connected to another surge protector connecting computer equipment behind the "Vitek 2" machine in Room 1428.

2/29 - 1st Floor - D Wing
7. At 8:29 a.m., Electrical Panel ILA, in D Wing, Lab area, there was no breaker in space 50. The label indicates breaker 50 was assigned to "Women's Room D 101".
During an interview, Staff 4 stated that facility staff was assigned to go through all electrical panels and update the labels approximately a year and a half ago.

E Wing -
8. At 8:40 a.m., Electrical Panel IEA had a breaker in space 35 that was not labeled to identify the function.
During an interview, Staff 4 was asked the function of breaker in space 35 and he was unable to answer.

9. At 9:56 a.m., Electrical Panel IECA had breakers in spaces 32, 33 and 39 that were not labeled to identify the function.

10. At 11:40 a.m., there was a surge protector connecting a mid size refrigerator, in the CAT Scan Room 1.

11. At 12:00 p.m., the cover plate to an electrical wall outlet was missing in Room 1572, Supervisors Office, inside registration. The electrical wall outlet was used to connect computer equipment.

12. At 2:39 p.m., there was a surge protector connecting a mid size refrigerator and a microwave, connected to another surge protector connecting computer equipment and a coffee pot in the Doctors Office in E Wing.

13. At 4:04 p.m., the cover plate to the x-ray machine electrical cords was missing in Room 1530. The missing cover plate was approximately 1 x 2 square ft.
During an interview, facility staff reported that the metal plate covers the electrical cords that go to the generator.

14. At 4:17 p.m., there was a surge protector connecting computer equipment, connected to another surge protector connecting medical equipment and a camera in the Triage waiting area.

3/2/12 -
15. At 9:24 a.m., the cover plate to an electrical wall outlet in trailer 15, in the HS Supervisors Office was missing.

16. At 9:26 a.m., there was a surge protector connecting computer equipment connected to another surge protector, also connecting computer equipment in trailer 15.

PT and In-Home Service Care Staff Outpatient Building

3/1/12 -
17. At 9:35 a.m., there was no label in electrical Panel A to identify the function of each breaker nor were the breakers labeled.

18. At 9:42 a.m., there was a surge protector connecting computer equipment, connected to another surge protector connecting a radio, fish tank, telephone and a scanner in the OSA Office.




29751


2/28/2012
19. At 12:30 p.m., electrical panel 41C had a breaker in space 32 that did not have identification of it's function.

20. At 2:22 p.m., Room 4230, Bed B, there was a cracked faceplate cover on the red emergency outlet.

Based on record review and interview, the facility failed to provide documentation of a fire watch policy during failures of the fire alarm or sprinkler system. This could result in the spread of fire if the fire alarm or sprinkler system was disabled and staff failed to monitor the building. This affected the Main Hospital.

Findings:

During record review and interview with Staff 1 on 2/28/12, a fire watch policy was requested.

At 11:17 a.m., there was no fire watch policy available for review.

At 11:18 a.m., during an interview, Staff 1 reported there was no written fire watch policy for the facility. Staff 1 stated that there is a verbal procedure in case of a fire alarm or sprinkler failure. Staff 1 reported security will conduct hourly patrols inside and outside the facility and an overhead announcement would be made so that all staff will be on the lookout.

Based on observation and interview, the facility failed to comply with the installation requirements for Alcohol Based Hand Rub (ABHR) dispensers, as evidenced by mounting one ABHR dispenser next to and above an ignition source. Staff and residents could potentially be harmed from a static discharge and a fire. This affected three of nineteen smoke compartments in the Main Hospital and 1 of 2 Outpatient Buildings.

Findings:

During the facility tour with Staff 3 on 2/28 to 3/1/12, the ABHR dispensers were observed.

Main Hospital

2/28 - 1st Floor (D Wing) -
1. At 3:04 p.m., there was an (ABHR) Alcohol Based Hand Rub dispenser in Room 1400 mounted directly over a surge protector. The ABHR dispenser was mounted on the "sorting, holding case desk."

2. At 4:32 p.m., there was an ABHR dispenser in Room 1436 mounted directly over an electrical receptacle outlet by the "extra area".

2/29 - 1st Floor (E Wing) -
3. At 1:54 p.m., there was an ABHR dispenser in Room 1535, the supply room, mounted directly above an electrical receptacle outlet and next an electrical ignition source, within 3 inches. The ABHR was mounted on the right side of the entrance door.

4. At 3:37 p.m., there was an ABHR dispenser in Trauma Area 1, next to Bed A, mounted directly over an electrical receptacle outlet.

5. At 3:59 p.m., there was an ABHR dispenser in Room 1528 mounted next to an electrical ignition source, within 5 inches.

4 th Floor -
6. At 2:40 p.m., Room 4113, there was a ABHR mounted above three light switches.

7. At 2:43 p.m., Room 4103, there was an ABHR mounted above a light switch with visible signs of splash across the faceplate.


PT and In-Home Service Care Staff Outpatient Building

3/1/12 -
8. At 9:13 a.m., there was an ABHR dispenser on the left wall in the Physical Therapy Room, directly over an electrical receptacle outlet and over the carpet. The building is not sprinklered.