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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by failing to repair and seal penetrations in the wall and ceiling in the facility to prevent the spread of fire and or smoke. This failure could result in potential harm to patients, staff and visitors from burns and smoke inhalation.

Findings:

During a tour of the facility with the facility staff from January 25, 2010 to January 27, 2010, the facility walls and ceiling were observed.

On 1/25/10 - Third Floor:
1. At 10:30 a.m., in the Clean Linen room there were three approximately 3/4 inch round penetrations in the left wall.

2. At 10:31 a.m., in the Dialysis room there were two approximately 3/4 inch round penetrations in the front wall.

On 1/25/10 - Second floor:
3. At 10:50 a.m., there were three unsealed penetrations in the left wall and one unsealed penetration in the back wall ranging from 1/2 inch to 1 inch each.

1/25/10 - Basement:
4. At 10:44 a.m., in the Medical Records Storage room there were two approximately three-quarter inch round penetrations in the left wall.

5. At 10:56 a.m., in the Waiting room within the Medical Records Department there was an approximately two inch round penetration in the left wall where the door knob makes contact with the wall.

6. At 11:04 a.m., in the Janitor's closet next to the Medical Records Department there were two approximately two inch round penetrations in the left wall.

7. At 11:07 a.m., in the Equipment/Fan room there were four approximately two inch round penetrations in the front wall.

On 1/25/10 - First Floor:
8. At 1:30 p.m., in the Housekeeping closet next to the NICU Employee Lounge, first floor, there were two approximately one inch round penetrations in the right wall.

9. At 1:45 p.m., in the Radiologist Office there was an approximately 4" x 5" unsealed penetration in the wall where the communication box had slipped down the electrical wire and was laying on the floor.

10. At 1:50 p.m., in Room 136, first floor, there was an approximately one inch round penetration in the right wall.

11. At 1:51 p.m., in the Nourishment room across from Room 136, first floor, there was an approximately three inch by six inch rectangular penetration in the front wall.

12. At 1:52 p.m., in the Exam room across from Room 136, first floor, there was an approximately one inch round penetrations in the right wall.

13. At 1:56 p.m., in the Nurse Station within the Pediatrics Department, first floor, there was an approximately four inch by six inch rectangular penetration surrounding communication wires in the right wall.

14. At 2:24 p.m., in the Father's Waiting room, first floor, there was an approximately one inch round penetration in the front wall.

15. At 2:26 p.m., in the EVS Linen room within the Environmental Services corridor, first floor, there was an approximately four inch round penetration in the ceiling.

16. At 2:29 p.m., in the EVS office, first floor, there was an approximately two inch round penetration surrounding communication wires in the back wall. There was an approximately three inch by six inch rectangular penetration in the left wall.

17. At 2:40 p.m., in the Dietary Director office, first floor, there were seven approximately one-quarter inch round penetrations in the front wall.

18. At 3:15 p.m., in the recovery storage room there was a 1 inch by 4 inch unsealed penetration in the ceiling next to the light fixture.

19. At 3:28 p.m., in the office across from the Nurse Station within the C-wing, first floor, there was an approximately three inch oval penetration in the ceiling.

20. At 3:31 p.m., in the C-wing Supply room, first floor, there were two approximately one inch round penetrations in the front wall.

Based on observation, the facility failed to maintain the 1/2 hour fire resistance rating for its corridors as evidenced by unsealed penetrations in the corridor walls and ceilings. This failure could result in the spread of fire and smoke through corridor walls in the event of a fire and result in potential harm to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the facilities corridor walls and ceilings were observed.

On 1/25/10 - Second Floor:
At 11:08 a.m., in the Surgical Unit patient room 215 had a nurse call light on the corridor wall above the door with an approximately 1" x 1" unsealed penetration on the top and an approximately 1 inch x 1 inch unsealed penetration on the left side of the nurse call light.

Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure could result in the spread of fire and smoke resulting in potential harm to patients, staff and visitors from smoke inhalation and burns.

NFPA (National Fire Protection Association) 101 Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the corridor doors were observed.

On 1/25/10 - Second Floor:
1. At 10:53 a.m., the corridor door to patient room 201 failed to latch shut upon closure.

2. At 11:10 a.m., the storage closet across from patient room 209 on the 2nd floor failed to latch on the right side.


3. On 1/25/2010 - First Floor:
At 1:12 p.m., the corridor door to the ENT room was impeded from closure by a large trash can.

4. At 1:18 p.m., the corridor door in the emergency departments Fast track room failed to latch shut upon closure.

5. At 1:25 p.m., on the first floor Orthopedics corridor door failed to latch shut upon closure.

6. At 1:28 p.m., in the OB/GYN Department the exam room door failed to latch shut upon closure.

7. At 1:28 p.m., in the Employee Lounge within the NICU Department, first floor, the corridor door failed to positive latch upon self closure.

8. At 1:30 p.m., in the Housekeeping closet next to the NICU Employee Lounge, first floor, the corridor door failed to positive latch upon self closure.

9. At 1:31 p.m., in Room 103, first floor, the corridor door failed to positive latch upon self closure.

10. At 1:45 p.m., in Room 4 within the Labor and Delivery Department, first floor, the corridor door failed to positive latch upon self closure.

11. At 1:46 p.m., in Room 1 within the Labor and Delivery Department, first floor, the corridor door failed to positive latch upon self closure.

12. At 2:00 p.m., in the Shower room within the Pediatrics Department, first floor, the corridor door failed to positive latch upon self closure.

13. At 2:01 p.m., in the Tub room within the Pediatrics Department, first floor, the corridor door failed to positive latch upon self closure.

14. At 2:15 p.m., in Disaster PPE Equipment room within the Labor and Delivery Department Break room hallway, first floor, the corridor door failed to positive latch upon self closure.

15. At 2:17 p.m., in the Laundry room within the Labor and Delivery Department Break room hallway, first floor, the corridor door had a disassembled self closing device.

16. At 2:20 p.m., in the Code Orange Cart room, first floor, the corridor door failed to positive latch upon self closure.

17. At 2:25 p.m., in the Storage room across from the Father's Waiting room, first floor, the corridor door failed to positive latch upon self closure.

18. At 2:26 p.m., in the EVS Linen room within the Environmental Services corridor, first floor, the corridor door had a disassembled self closing device.

19. At 2:45 p.m., in the Newborn Treatment room within the B-wing, first floor, the corridor door was held open with a door wedge.

20. At 3:06 p.m., in the SPD, first floor, the corridor door separating the processing and Steris machine areas of the clean room failed to positive latch upon self closure.

21. At 3:07 p.m., in the SPD decontamination area, first floor, the two corridor doors to the Surgery Department hallway failed to positive latch upon self closure.

22. At 3:26 p.m., in the Security closet next to Room 193 within the C-wing, first floor, the corridor door had a disassembled self closing device.

23. At 3:28 p.m., in the office across from the Nurse Station within the C-wing, first floor, the corridor door failed to positive latch upon self closure.

24. At 3:43 p.m., in the Nutrition room within the C-wing, first floor, the corridor door failed to positive latch upon self closure.

25. At 3:45 p.m., in the Clean Linen closet across from Room 183, first floor, the corridor door failed to positive latch upon self closure.

Basement
26. At 11:04 a.m., in the Janitor closet next to the Materials Department, basement, the corridor door had a disassembled self closing device.

Based on observation, the facility failed to maintain the integrity of doors on hold open magnetic devices to automatically release and close upon activation of the fire alarm system as evidenced by doors failing to release from its magnetic device and a disassemble door device. This failure could result in the spread of fire and or smoke from compartment to another, resulting in the potential harm to the patients, staff and visitors.

Findings:

During a tour of the facility and during the testing of the fire alarm system with facility Staff on January 25, 2010, through January 27, 2010, the doors on magnetic devices were observed.

On 1/25/10 - First Floor:
1. At 3:24 p.m., in Room 196 the door hold open magnetic device was disassembled.

On 1/26/10 - Third Floor:
2. At 2:58 p.m., the smoke barrier door labeled #500995 by the Nurses Station on the 3rd floor failed to release from the magnet and positive latch on the right side after activation of a smoke detector and manual pull.

Based on observation, the facility failed to maintain the integrity of its smoke barrier walls to provide an effective smoke/fire barrier and to resist the passage of smoke in the event of a fire, as evidenced by failing to seal penetration within smoke barrier walls. This failure could result in the potential spread of smoke from one compartment to another and could result in potential harm to patient , staff and visitors through out the facility..

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

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the smoke barrier walls were observed.

On 1/25/10 - Second Floor:
1. At 10:58 a.m., in the smoke barrier wall next to patient room 218 there was a 1 inch unsealed penetration around a conduit in the center of the wall.

On 1/25/10 - First Floor:
2. At 1:38 p.m., in the smoke barrier wall above the main entrance to Triage there was a 3/4 inch unsealed penetration around blue and grey communication wires.

3. At 1:40 p.m., the smoke barrier wall next to the ER Staff Lounge on the 1st floor had a 1 1/2 inch unsealed penetration around the blue and gray communication wires in the wall.

4. At 2:45 p.m., the smoke barrier wall over the entrance to the Intensive & Coronary Care wing on the 1st floor had an approximately 1" unsealed penetration around the metal pipe in the wall and an approximately 1" unsealed penetration around three white wires in the wall.

5. At 3:18 p.m., the smoke barrier wall above the entrance to the SPD hallway, first floor, there was an approximately two inch round penetration on the left wall.

6. At 3:27 p.m., the smoke barrier wall above the G.I. Lab entrance, first floor, there was a 1/2 inch unsealed penetration around blue communication wires in the left side of the wall.

Based on observation, the facility failed to maintain their smoke barrier double doors as evidenced by smoke barrier doors that failed to positive latch upon closure. This failure could result in the spread of smoke and fire from one compartment to the adjacent compartment which would result in the potential harm to patients, staff and visitors.

Findings:

During a tour of the facility tour with the facility Staff from January 25, 2010 to January 27, 2010, the smoke barrier doors were observed.


On 1/26/10 - First Floor:
1. At 2:37 p.m., the smoke barrier double doors outside of the ICU Waiting room, first floor, 1 of 2 door leafs (west door leaf) failed to positive latch upon self closure.

Based on document review and interview, the facility failed to hold fire drills at least quarterly and disaster drills at least semi-annually for each shift as evidenced by the facility failure to provide complete records for fire and disaster drills. This could result in any one staff member not being able to complete all of the tasks expected of him or her in the event of a fire and/or disaster and the increased risk of injury to the patients in the event of a fire or a disaster.

Findings:

During record review with the facility Staff from January 25, 2010 to January 27, 2010, the fire drill and disaster drill records were reviewed.

1. On January 26, 2010, at 10:05 a.m., the facility provided two disaster drill records. The disaster drill record dated January 2009 to March 2009 was not an actual disaster drill record. This was a record of minutes for safety meetings conducted in the first quarter of 2009.

On January 26, 2010, at 10:06 a.m., during an interview, Staff 1 stated that the record dated January 2009 to March 2009 was considered a table top disaster drill. During these meetings, the results of the County wide disaster drill conducted on June 2008 were discussed. No other records were provided by the facility.

2. On January 27, 2010, at 11:30 a.m., the facility failed to provide documentation of conducting quarterly fire drills for it's Outpatient services clinic. During interview, Staff 1 provided a report dated 7/22/09, the report indicated its was a in service (fire extinguisher) and not a drill.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by obstructions to the access to the fire alarm system devices and the failure of a fire alarm system device. This failure could result in the delay in the announcement of a fire within the facility and increase the risk of potential harm to patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the fire alarm system was observed.


On 1/26/10 - First Floor:
1. At 1:36 p.m., in the Surgery Department, first floor, the access to the pull station outside of OR 2 was obstructed by three waste receptacles.

2. At 2:05 p.m., in the Lounge within the Labor and Delivery procedure hallway, first floor, the access to the pull station was obstructed by a couch.

3. At 2:40 p.m., in the Main Lobby, first floor, the access to the pull station was obstructed by a chair.

4. At 3:24 p.m., in the Mechanical room next to the Emergency Department, the strobe/annunciator device failed to annunciate upon the activation of the fire alarm system.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by 1 of 2 Post Indicator Valves that was not supervised so that at least a local alarm would sound in the event of the valve being closed. This could result in the interruption of the water supply to the automatic sprinkler system without staff notification, the failure of the automatic sprinkler system in the event of a facility fire and the increased risk of harm to the patients, staff and visitors.

Findings:

During fire alarm system testing with the facility staff from January 26, 2010 to January 27, 2010, the facility automatic sprinkler system tamper alarm was tested.

1. On January 26, 2010, at 3:28 p.m., the closing of the Post Indicator Valve outside of the Surgery Department failed to activate an audible alarm within the facility and failed to send a signal to the fire alarm panel. The facility contacted the vendor to rectify the situation.
On January 27, 2010, at 1:11 p.m., the Post Indicator Valve was re-tested once the vendor completed the repairs to the valve. An audible alarm was heard and a signal was sent to the fire alarm panel once the valve was closed.

Based on observation, document review and interview, the facility failed to ensure that the automatic sprinkler system was inspected periodically and maintained in accordance with NFPA 25, Standards for Inspection, Testing and Maintenance as evidenced by no documentation for 2 of 4 required sprinkler quarterly inspections and by sprinkler escutcheon rings that were missing or were not flush with the ceiling. This failure could result in the sprinkler system not functioning as designed and could result in potential harm to patient, staff and visitors in the event of a sprinkler failure.

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the sprinkler system was observed, documents were reviewed and staff interviewed.

On 1/25/10 - Third Floor:
1. At 10:20 a.m., in the Orthopedics/Recovery Department the sprinkler escutcheon ring located in the Infection Control Storage room was not flush with the ceiling.

2. At 10:22 a.m., in the Janitors closet next to the Infection Control Storage room the sprinkler escutcheon was not flush with the ceiling.

3. At 10:30 a.m., in the supply room next to patient room 320 the sprinkler escutcheon ring was not flush with the ceiling.

On 1/25/10 - First Floor:
4. At 3:10 p.m., the sprinkler escutcheon ring was missing in the corridor outside of the Anesthesia work room.

5. At 3:32 p.m., 1 of 4 sprinkler escutcheon rings were missing in the G I Laboratory Cystoscopy room.

6. At 3:35 p.m., 2 of 5 sprinkler escutcheon rings were missing in the corridor outside of the Sterile Processing Department (SPD).

7. On January 26, 2010, at 10:26 a.m., during record review, the facility failed to provide quarterly testing records for 1.) three water flow devices, there was no record for a first quarter 2009 test, 2.) for one tamper device, there was no record for a first and fourth quarter 2009 test and 3.) for the two Post Indicator Valves, there was record for a fourth quarter 2009 test.

On 1/26/10 - First Floor:
8. At 1:30 p.m., in the 1st floor Surgery area there was a sprinkler escutcheon ring missing in the ceiling outside of Operating Room #1.

9. At 1:40 p.m., in the 1st floor Surgery area there was a sprinkler escutcheon ring missing in the ceiling above the row of sinks on the wall next to Operating Room #4.

Based on observation, the facility failed to maintain ready access to their portable fire extinguishers as evidenced by obstructions to the access to fire extinguishers within the facility. This could result in the delay in the use of the fire extinguishers in the event of a fire and the increased risk of harm to the patients, staff and visitors in the event of
a fire.

NFPA (National Fire Protection Association) 10 Standard for Portable Fire Extinguishers, 2002 Edition

1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.

Findings:
During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the fire extinguishers were observed.

On 1/25/10 - Third Floor:
1. At 10:25 a.m., in the corridor outside of Room 312, third floor, the access to the fire extinguisher was obstructed by a wheel chair.

On 1/25/10 - Basement:
2. At 11:00 a.m., in the Materials Department, basement, the access to the fire extinguisher was obstructed by a mobile metal cart.

On 1/25/10 - First Floor:
3. At 2:35 p.m., in the Kitchen, first floor, the access to the K-type fire extinguisher was obstructed by a metal table.

4. At 2:38 p.m., in the Kitchen, first floor, the access to the K-type and ABC fire extinguishers was obstructed by a industrial sized mixer.

Based on observation, the facility failed to enforce it's "No Smoking" on grounds, policy adopted by the facility as evidenced by cigarette butts on the hospital grounds. This failure could result in the potential increased risk of a fire.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the facility grounds were observed.

On 1/25/10
At 2:00 p.m., in the area outside the door to the Radiology Employee Lounge there were 9 cigarette butts on the ground approximately 2 -3 feet from the Employee Lounge exit door. During interview, Staff 1 acknowledged and stated sometimes visitors are in the area waiting for patients in Radiology.

Based on observation and record review, the facility failed to maintain the cooking facilities as evidenced by grease laden kitchen hardware. This could result in the increased risk of a grease fire originating in the Kitchen and the increased risk of harm to the patients, staff and visitors.

NFPA (National Fire Protection Association) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition

8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or persons(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Findings:

During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the cooking facilities were observed


On 1/26/10 - First Floor:
At 3:50 p.m., in the Kitchen, first floor, the hardware above the kitchen hood, in the vent system, was laden with a thick layer of grease. The records provided by the facility indicated that the Kitchen hood was last cleaned by a licensed vendor on December 8, 2009.

Based on observation, the facility failed to ensure portable heating devices were not used in patient care areas, as evidenced by portable heaters observed in two patient care areas. This failure could result in an increase risk of fire and could cause in potential harm to patients.

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the portable heating devices were observed.

On 1/25/10 - First Floor:
1. At 105 p.m., a potable heater was observed in the Emergency Department Triage room. The heater was not in use and there were no patients in the room during the observation.

2. At 2:50 p.m., a portable heater was observed in the Same Day surgery Pre-Admissions room. The heater was not in use and there were no patients in the room during the observation.

Based on observation, the facility failed to ensure that the storage of medical gas was in accordance with NFPA 99, as evidenced by oxygen tanks stored with combustible material, no signs indicating the room was used for oxygen cylinder storage and an electrical light switch installed less than 5 feet from the floor.

NFPA (National Fire Protection Association) 99, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 1307F (547C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2.*Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the oxygen cylinder storage areas were observed.

On 1/25/10 - Third Floor:
1. At 10:33 a.m., in the clean utility room across from patient room 20 there were 7 "E" oxygen tanks that were stored within 5 feet of flammable material, there was no sign on the door stating oxygen storage room, the light switch was less than 60 inches from the floor and the door failed to latch upon self closure.

On 1/25/10 - Second Floor:
2. At 10:51 a.m., in the storage room next to the treadmill room there were 7 "E" oxygen tanks stored within 2-3 feet of a patient bed mattress, there was no sign on the door stating oxygen storage and the light switch was less than 60 inches from the floor.

3. At 11:05 a.m., in the Patient Supply storage room located next to patient room 215, there were 8 "E" oxygen tanks stored with in 2 feet of card board boxes, shelves filled with plastic supplies and also new patient equipment in plastic wrap, there was no sign stating oxygen storage and the light switch was less than 60 inches from the floor.

On 1/25/10 - First Floor:
4. At 2:20 p.m., in the Respiratory Therapy Department on the 1st floor, the room labeled "Dirty Utility Room" had 27 E-Tanks and 1 H-Tank stored next to a metal rack containing 12 cardboard boxes, a box of manilla envelopes and a second metal shelf containing 8 cardboard boxes as well as medical equipment stored within approximately 8 inches of the oxygen tanks. The room did not have a sign indicating that it was used for oxygen storage. The light switch was mounted approximately 4 feet from the ground.

Based on document review, the facility failed to maintain 2 of 8 anesthetizing locations as evidenced by the facility failure to maintain the relative humidity equal to or greater than 35%. This could result in the increased risk of a facility fire originating in the anesthetizing locations and the increased risk of harm to patients in the event of a fire.

Findings:

During record review with the facility Staff on January 25, 2010 through January 27, 2010, the humidity records were reviewed.

On January 26, 2010, at 1:59 p.m., the facility provided records titled "OR Temperature/Humidity, January 2010" for the Labor and Delivery Procedure room 1 and Procedure room 2. These records indicated that the normal humidity range was 30% to 60%.


1. Procedure room 1 had the following humidity levels less than 35%:

On January 2, 2010 at 11:00 a.m. the humidity was 25%, at 11:00 p.m., the humidity was 30%.

On January 3, 2010 at 11:00 a.m. the humidity was 32%.

On January 4, 2010 at 11:00 p.m., the humidity was 33%.

On January 5, 2010 at 11:00 p.m., the humidity was 28%.

On January 7, 2010 at 11:00 a.m. the humidity was 30%.

On January 8, 2010 at 11:00 p.m. the humidity was 28%.

On January 9, 2010 at 11:00 p.m., the humidity was 31%.

On January 10, 2010 at 11:00 a.m. the humidity was 33%.

On January 11, 2010 at 11:00 a.m. the humidity was 32%, at 11:00 p.m., the humidity was 31%.

On January 12, 2010 at 11:00 p.m., the humidity was 31%.

On January 14, 2010 at 11:00 p.m., the humidity was 22%.

On January 15, 2010 at 11:00 a.m. the humidity was 34%.

On January 25, 2010 at 11:00 a.m. the humidity was 27%.


2. Procedure Room 2 had the following humidity levels less than 35%:

On January 2, 2010 at 11:00 a.m. the humidity was 34%, at 11:00 p.m., the humidity was 32%.

On January 4, 2010 at 11:00 a.m. the humidity was 30%, at 11:00 p.m., the humidity was 30%.

On January 8, 2010 at 11:00 p.m., the humidity was 31%.

On January 9, 2010 at 11:00 a.m. the humidity was 30%, at 11:00 p.m., the humidity was 30%.

On January 12, 2010 at 11:00 p.m., the humidity was 31%.

On January 14, 2010 at 11:00 p.m., the humidity was 31%.

On January 15, 2010 at 11:00 p.m., the humidity was 32%.

On January 16, 2010 at 11:00 a.m. the humidity was 32%.

On January 21, 2010 at 11:00 p.m., the humidity was 34%.

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets.

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 a tour of the facility with facility Staff 1 on January 25, 2010 through January 27, 2010, the electrical system was observed.

On 1/25/10 - Second Floor:
1. At 10:45 a.m., in the Surgical Unit on the 2nd floor, the Case Management office had a refrigerator plugged into a multi-plug power strip and not directly into the wall.

2. At 10:52 a.m., in the Surgical Unit on the 2nd floor, the Nurses Lounge across from patient room 212 had an electrical wall outlet missing a cover plate.

1/25/10 - First Floor:
3. At 1:42 p.m., in the ER Staff Lounge on the 1st floor there was a microwave plugged into a multi-plug power strip and not directly into the wall.

4. At 1:58 p.m., in the Radiologist area on the 1st floor, the Radiology Employee Lounge had a refrigerator plugged into a 6 plug adapter.

5. At 2:28 p.m., the electrical panel box labeled "E-P9" in the Intensive Care Coronary Central Storage Room on the 1st floor of the ICU area had 1 missing blank cover for 1 empty breaker.

6. At 2:45 p.m., in the first floor Same Day Surgery supply room there was a white extension cord with no overcurrent protection plugged into a server.

7. At 3:17 p.m., in the Day Surgery OR "Frozen Section Room" on the 1st floor there was a refrigerator plugged into a multi-plug power strip and not directly into the wall.

8. At 3:18 a.m., on the first floor there was a broken electrical receptacle in the corridor out side the Anesthesia work room.





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On 1/25/10 - Basement:
9. At 10:55 a.m., in the Break room within the Medical Records Department, basement, there was a surge protector that connected a microwave oven to the electrical outlet.

10. At 11:00 a.m., in the Materials Department, basement, there was a surge protector that connected a mini-refrigerator and microwave oven to the electrical outlet.

11. At 11:20 a.m., in the Transcript room, basement, there was a surge protector that connected a microwave oven to the electrical outlet.



On 1/26/10 - First Floor:
12. At 2:00 p.m., in the Labor and Delivery Procedure room 1, first floor, there was an extension cord that connected a surge protector to the electrical outlet.

13. At 2:09 p.m., in the Conference room within Administration, first floor, there was a surge protector that connected a microwave oven to the electrical outlet

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by failing to repair and seal penetrations in the wall and ceiling in the facility to prevent the spread of fire and or smoke. This failure could result in potential harm to patients, staff and visitors from burns and smoke inhalation.

Findings:

During a tour of the facility with the facility staff from January 25, 2010 to January 27, 2010, the facility walls and ceiling were observed.

On 1/25/10 - Third Floor:
1. At 10:30 a.m., in the Clean Linen room there were three approximately 3/4 inch round penetrations in the left wall.

2. At 10:31 a.m., in the Dialysis room there were two approximately 3/4 inch round penetrations in the front wall.

On 1/25/10 - Second floor:
3. At 10:50 a.m., there were three unsealed penetrations in the left wall and one unsealed penetration in the back wall ranging from 1/2 inch to 1 inch each.

1/25/10 - Basement:
4. At 10:44 a.m., in the Medical Records Storage room there were two approximately three-quarter inch round penetrations in the left wall.

5. At 10:56 a.m., in the Waiting room within the Medical Records Department there was an approximately two inch round penetration in the left wall where the door knob makes contact with the wall.

6. At 11:04 a.m., in the Janitor's closet next to the Medical Records Department there were two approximately two inch round penetrations in the left wall.

7. At 11:07 a.m., in the Equipment/Fan room there were four approximately two inch round penetrations in the front wall.

On 1/25/10 - First Floor:
8. At 1:30 p.m., in the Housekeeping closet next to the NICU Employee Lounge, first floor, there were two approximately one inch round penetrations in the right wall.

9. At 1:45 p.m., in the Radiologist Office there was an approximately 4" x 5" unsealed penetration in the wall where the communication box had slipped down the electrical wire and was laying on the floor.

10. At 1:50 p.m., in Room 136, first floor, there was an approximately one inch round penetration in the right wall.

11. At 1:51 p.m., in the Nourishment room across from Room 136, first floor, there was an approximately three inch by six inch rectangular penetration in the front wall.

12. At 1:52 p.m., in the Exam room across from Room 136, first floor, there was an approximately one inch round penetrations in the right wall.

13. At 1:56 p.m., in the Nurse Station within the Pediatrics Department, first floor, there was an approximately four inch by six inch rectangular penetration surrounding communication wires in the right wall.

14. At 2:24 p.m., in the Father's Waiting room, first floor, there was an approximately one inch round penetration in the front wall.

15. At 2:26 p.m., in the EVS Linen room within the Environmental Services corridor, first floor, there was an approximately four inch round penetration in the ceiling.

16. At 2:29 p.m., in the EVS office, first floor, there was an approximately two inch round penetration surrounding communication wires in the back wall. There was an approximately three inch by six inch rectangular penetration in the left wall.

17. At 2:40 p.m., in the Dietary Director office, first floor, there were seven approximately one-quarter inch round penetrations in the front wall.

18. At 3:15 p.m., in the recovery storage room there was a 1 inch by 4 inch unsealed penetration in the ceiling next to the light fixture.

19. At 3:28 p.m., in the office across from the Nurse Station within the C-wing, first floor, there was an approximately three inch oval penetration in the ceiling.

20. At 3:31 p.m., in the C-wing Supply room, first floor, there were two approximately one inch round penetrations in the front wall.

Based on observation, the facility failed to maintain the 1/2 hour fire resistance rating for its corridors as evidenced by unsealed penetrations in the corridor walls and ceilings. This failure could result in the spread of fire and smoke through corridor walls in the event of a fire and result in potential harm to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the facilities corridor walls and ceilings were observed.

On 1/25/10 - Second Floor:
At 11:08 a.m., in the Surgical Unit patient room 215 had a nurse call light on the corridor wall above the door with an approximately 1" x 1" unsealed penetration on the top and an approximately 1 inch x 1 inch unsealed penetration on the left side of the nurse call light.

Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure could result in the spread of fire and smoke resulting in potential harm to patients, staff and visitors from smoke inhalation and burns.

NFPA (National Fire Protection Association) 101 Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the corridor doors were observed.

On 1/25/10 - Second Floor:
1. At 10:53 a.m., the corridor door to patient room 201 failed to latch shut upon closure.

2. At 11:10 a.m., the storage closet across from patient room 209 on the 2nd floor failed to latch on the right side.


3. On 1/25/2010 - First Floor:
At 1:12 p.m., the corridor door to the ENT room was impeded from closure by a large trash can.

4. At 1:18 p.m., the corridor door in the emergency departments Fast track room failed to latch shut upon closure.

5. At 1:25 p.m., on the first floor Orthopedics corridor door failed to latch shut upon closure.

6. At 1:28 p.m., in the OB/GYN Department the exam room door failed to latch shut upon closure.

7. At 1:28 p.m., in the Employee Lounge within the NICU Department, first floor, the corridor door failed to positive latch upon self closure.

8. At 1:30 p.m., in the Housekeeping closet next to the NICU Employee Lounge, first floor, the corridor door failed to positive latch upon self closure.

9. At 1:31 p.m., in Room 103, first floor, the corridor door failed to positive latch upon self closure.

10. At 1:45 p.m., in Room 4 within the Labor and Delivery Department, first floor, the corridor door failed to positive latch upon self closure.

11. At 1:46 p.m., in Room 1 within the Labor and Delivery Department, first floor, the corridor door failed to positive latch upon self closure.

12. At 2:00 p.m., in the Shower room within the Pediatrics Department, first floor, the corridor door failed to positive latch upon self closure.

13. At 2:01 p.m., in the Tub room within the Pediatrics Department, first floor, the corridor door failed to positive latch upon self closure.

14. At 2:15 p.m., in Disaster PPE Equipment room within the Labor and Delivery Department Break room hallway, first floor, the corridor door failed to positive latch upon self closure.

15. At 2:17 p.m., in the Laundry room within the Labor and Delivery Department Break room hallway, first floor, the corridor door had a disassembled self closing device.

16. At 2:20 p.m., in the Code Orange Cart room, first floor, the corridor door failed to positive latch upon self closure.

17. At 2:25 p.m., in the Storage room across from the Father's Waiting room, first floor, the corridor door failed to positive latch upon self closure.

18. At 2:26 p.m., in the EVS Linen room within the Environmental Services corridor, first floor, the corridor door had a disassembled self closing device.

19. At 2:45 p.m., in the Newborn Treatment room within the B-wing, first floor, the corridor door was held open with a door wedge.

20. At 3:06 p.m., in the SPD, first floor, the corridor door separating the processing and Steris machine areas of the clean room failed to positive latch upon self closure.

21. At 3:07 p.m., in the SPD decontamination area, first floor, the two corridor doors to the Surgery Department hallway failed to positive latch upon self closure.

22. At 3:26 p.m., in the Security closet next to Room 193 within the C-wing, first floor, the corridor door had a disassembled self closing device.

23. At 3:28 p.m., in the office across from the Nurse Station within the C-wing, first floor, the corridor door failed to positive latch upon self closure.

24. At 3:43 p.m., in the Nutrition room within the C-wing, first floor, the corridor door failed to positive latch upon self closure.

25. At 3:45 p.m., in the Clean Linen closet across from Room 183, first floor, the corridor door failed to positive latch upon self closure.

Basement
26. At 11:04 a.m., in the Janitor closet next to the Materials Department, basement, the corridor door had a disassembled self closing device.

Based on observation, the facility failed to maintain the integrity of doors on hold open magnetic devices to automatically release and close upon activation of the fire alarm system as evidenced by doors failing to release from its magnetic device and a disassemble door device. This failure could result in the spread of fire and or smoke from compartment to another, resulting in the potential harm to the patients, staff and visitors.

Findings:

During a tour of the facility and during the testing of the fire alarm system with facility Staff on January 25, 2010, through January 27, 2010, the doors on magnetic devices were observed.

On 1/25/10 - First Floor:
1. At 3:24 p.m., in Room 196 the door hold open magnetic device was disassembled.

On 1/26/10 - Third Floor:
2. At 2:58 p.m., the smoke barrier door labeled #500995 by the Nurses Station on the 3rd floor failed to release from the magnet and positive latch on the right side after activation of a smoke detector and manual pull.

Based on observation, the facility failed to maintain the integrity of its smoke barrier walls to provide an effective smoke/fire barrier and to resist the passage of smoke in the event of a fire, as evidenced by failing to seal penetration within smoke barrier walls. This failure could result in the potential spread of smoke from one compartment to another and could result in potential harm to patient , staff and visitors through out the facility..

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

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the smoke barrier walls were observed.

On 1/25/10 - Second Floor:
1. At 10:58 a.m., in the smoke barrier wall next to patient room 218 there was a 1 inch unsealed penetration around a conduit in the center of the wall.

On 1/25/10 - First Floor:
2. At 1:38 p.m., in the smoke barrier wall above the main entrance to Triage there was a 3/4 inch unsealed penetration around blue and grey communication wires.

3. At 1:40 p.m., the smoke barrier wall next to the ER Staff Lounge on the 1st floor had a 1 1/2 inch unsealed penetration around the blue and gray communication wires in the wall.

4. At 2:45 p.m., the smoke barrier wall over the entrance to the Intensive & Coronary Care wing on the 1st floor had an approximately 1" unsealed penetration around the metal pipe in the wall and an approximately 1" unsealed penetration around three white wires in the wall.

5. At 3:18 p.m., the smoke barrier wall above the entrance to the SPD hallway, first floor, there was an approximately two inch round penetration on the left wall.

6. At 3:27 p.m., the smoke barrier wall above the G.I. Lab entrance, first floor, there was a 1/2 inch unsealed penetration around blue communication wires in the left side of the wall.

Based on observation, the facility failed to maintain their smoke barrier double doors as evidenced by smoke barrier doors that failed to positive latch upon closure. This failure could result in the spread of smoke and fire from one compartment to the adjacent compartment which would result in the potential harm to patients, staff and visitors.

Findings:

During a tour of the facility tour with the facility Staff from January 25, 2010 to January 27, 2010, the smoke barrier doors were observed.


On 1/26/10 - First Floor:
1. At 2:37 p.m., the smoke barrier double doors outside of the ICU Waiting room, first floor, 1 of 2 door leafs (west door leaf) failed to positive latch upon self closure.

Based on document review and interview, the facility failed to hold fire drills at least quarterly and disaster drills at least semi-annually for each shift as evidenced by the facility failure to provide complete records for fire and disaster drills. This could result in any one staff member not being able to complete all of the tasks expected of him or her in the event of a fire and/or disaster and the increased risk of injury to the patients in the event of a fire or a disaster.

Findings:

During record review with the facility Staff from January 25, 2010 to January 27, 2010, the fire drill and disaster drill records were reviewed.

1. On January 26, 2010, at 10:05 a.m., the facility provided two disaster drill records. The disaster drill record dated January 2009 to March 2009 was not an actual disaster drill record. This was a record of minutes for safety meetings conducted in the first quarter of 2009.

On January 26, 2010, at 10:06 a.m., during an interview, Staff 1 stated that the record dated January 2009 to March 2009 was considered a table top disaster drill. During these meetings, the results of the County wide disaster drill conducted on June 2008 were discussed. No other records were provided by the facility.

2. On January 27, 2010, at 11:30 a.m., the facility failed to provide documentation of conducting quarterly fire drills for it's Outpatient services clinic. During interview, Staff 1 provided a report dated 7/22/09, the report indicated its was a in service (fire extinguisher) and not a drill.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by obstructions to the access to the fire alarm system devices and the failure of a fire alarm system device. This failure could result in the delay in the announcement of a fire within the facility and increase the risk of potential harm to patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the fire alarm system was observed.


On 1/26/10 - First Floor:
1. At 1:36 p.m., in the Surgery Department, first floor, the access to the pull station outside of OR 2 was obstructed by three waste receptacles.

2. At 2:05 p.m., in the Lounge within the Labor and Delivery procedure hallway, first floor, the access to the pull station was obstructed by a couch.

3. At 2:40 p.m., in the Main Lobby, first floor, the access to the pull station was obstructed by a chair.

4. At 3:24 p.m., in the Mechanical room next to the Emergency Department, the strobe/annunciator device failed to annunciate upon the activation of the fire alarm system.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by 1 of 2 Post Indicator Valves that was not supervised so that at least a local alarm would sound in the event of the valve being closed. This could result in the interruption of the water supply to the automatic sprinkler system without staff notification, the failure of the automatic sprinkler system in the event of a facility fire and the increased risk of harm to the patients, staff and visitors.

Findings:

During fire alarm system testing with the facility staff from January 26, 2010 to January 27, 2010, the facility automatic sprinkler system tamper alarm was tested.

1. On January 26, 2010, at 3:28 p.m., the closing of the Post Indicator Valve outside of the Surgery Department failed to activate an audible alarm within the facility and failed to send a signal to the fire alarm panel. The facility contacted the vendor to rectify the situation.
On January 27, 2010, at 1:11 p.m., the Post Indicator Valve was re-tested once the vendor completed the repairs to the valve. An audible alarm was heard and a signal was sent to the fire alarm panel once the valve was closed.

Based on observation, document review and interview, the facility failed to ensure that the automatic sprinkler system was inspected periodically and maintained in accordance with NFPA 25, Standards for Inspection, Testing and Maintenance as evidenced by no documentation for 2 of 4 required sprinkler quarterly inspections and by sprinkler escutcheon rings that were missing or were not flush with the ceiling. This failure could result in the sprinkler system not functioning as designed and could result in potential harm to patient, staff and visitors in the event of a sprinkler failure.

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the sprinkler system was observed, documents were reviewed and staff interviewed.

On 1/25/10 - Third Floor:
1. At 10:20 a.m., in the Orthopedics/Recovery Department the sprinkler escutcheon ring located in the Infection Control Storage room was not flush with the ceiling.

2. At 10:22 a.m., in the Janitors closet next to the Infection Control Storage room the sprinkler escutcheon was not flush with the ceiling.

3. At 10:30 a.m., in the supply room next to patient room 320 the sprinkler escutcheon ring was not flush with the ceiling.

On 1/25/10 - First Floor:
4. At 3:10 p.m., the sprinkler escutcheon ring was missing in the corridor outside of the Anesthesia work room.

5. At 3:32 p.m., 1 of 4 sprinkler escutcheon rings were missing in the G I Laboratory Cystoscopy room.

6. At 3:35 p.m., 2 of 5 sprinkler escutcheon rings were missing in the corridor outside of the Sterile Processing Department (SPD).

7. On January 26, 2010, at 10:26 a.m., during record review, the facility failed to provide quarterly testing records for 1.) three water flow devices, there was no record for a first quarter 2009 test, 2.) for one tamper device, there was no record for a first and fourth quarter 2009 test and 3.) for the two Post Indicator Valves, there was record for a fourth quarter 2009 test.

On 1/26/10 - First Floor:
8. At 1:30 p.m., in the 1st floor Surgery area there was a sprinkler escutcheon ring missing in the ceiling outside of Operating Room #1.

9. At 1:40 p.m., in the 1st floor Surgery area there was a sprinkler escutcheon ring missing in the ceiling above the row of sinks on the wall next to Operating Room #4.

Based on observation, the facility failed to maintain ready access to their portable fire extinguishers as evidenced by obstructions to the access to fire extinguishers within the facility. This could result in the delay in the use of the fire extinguishers in the event of a fire and the increased risk of harm to the patients, staff and visitors in the event of
a fire.

NFPA (National Fire Protection Association) 10 Standard for Portable Fire Extinguishers, 2002 Edition

1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.

Findings:
During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the fire extinguishers were observed.

On 1/25/10 - Third Floor:
1. At 10:25 a.m., in the corridor outside of Room 312, third floor, the access to the fire extinguisher was obstructed by a wheel chair.

On 1/25/10 - Basement:
2. At 11:00 a.m., in the Materials Department, basement, the access to the fire extinguisher was obstructed by a mobile metal cart.

On 1/25/10 - First Floor:
3. At 2:35 p.m., in the Kitchen, first floor, the access to the K-type fire extinguisher was obstructed by a metal table.

4. At 2:38 p.m., in the Kitchen, first floor, the access to the K-type and ABC fire extinguishers was obstructed by a industrial sized mixer.

Based on observation, the facility failed to enforce it's "No Smoking" on grounds, policy adopted by the facility as evidenced by cigarette butts on the hospital grounds. This failure could result in the potential increased risk of a fire.

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the facility grounds were observed.

On 1/25/10
At 2:00 p.m., in the area outside the door to the Radiology Employee Lounge there were 9 cigarette butts on the ground approximately 2 -3 feet from the Employee Lounge exit door. During interview, Staff 1 acknowledged and stated sometimes visitors are in the area waiting for patients in Radiology.

Based on observation and record review, the facility failed to maintain the cooking facilities as evidenced by grease laden kitchen hardware. This could result in the increased risk of a grease fire originating in the Kitchen and the increased risk of harm to the patients, staff and visitors.

NFPA (National Fire Protection Association) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition

8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or persons(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Findings:

During a tour of the facility with the facility Staff from January 25, 2010 to January 27, 2010, the cooking facilities were observed


On 1/26/10 - First Floor:
At 3:50 p.m., in the Kitchen, first floor, the hardware above the kitchen hood, in the vent system, was laden with a thick layer of grease. The records provided by the facility indicated that the Kitchen hood was last cleaned by a licensed vendor on December 8, 2009.

Based on observation, the facility failed to ensure portable heating devices were not used in patient care areas, as evidenced by portable heaters observed in two patient care areas. This failure could result in an increase risk of fire and could cause in potential harm to patients.

Findings:

During a tour of the facility with Staff on January 25, 2010 through January 27, 2010, the portable heating devices were observed.

On 1/25/10 - First Floor:
1. At 105 p.m., a potable heater was observed in the Emergency Department Triage room. The heater was not in use and there were no patients in the room during the observation.

2. At 2:50 p.m., a portable heater was observed in the Same Day surgery Pre-Admissions room. The heater was not in use and there were no patients in the room during the observation.

Based on observation, the facility failed to ensure that the storage of medical gas was in accordance with NFPA 99, as evidenced by oxygen tanks stored with combustible material, no signs indicating the room was used for oxygen cylinder storage and an electrical light switch installed less than 5 feet from the floor.

NFPA (National Fire Protection Association) 99, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 1307F (547C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2.*Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with facility Staff on January 25, 2010 through January 27, 2010, the oxygen cylinder storage areas were observed.

On 1/25/10 - Third Floor:
1. At 10:33 a.m., in the clean utility room across from patient room 20 there were 7 "E" oxygen tanks that were stored within 5 feet of flammable material, there was no sign on the door stating oxygen storage room, the light switch was less than 60 inches from the floor and the door failed to latch upon self closure.

On 1/25/10 - Second Floor:
2. At 10:51 a.m., in the storage room next to the treadmill room there were 7 "E" oxygen tanks stored within 2-3 feet of a patient bed mattress, there was no sign on the door stating oxygen storage and the light switch was less than 60 inches from the floor.

3. At 11:05 a.m., in the Patient Supply storage room located next to patient room 215, there were 8 "E" oxygen tanks stored with in 2 feet of card board boxes, shelves filled with plastic supplies and also new patient equipment in plastic wrap, there was no sign stating oxygen storage and the light switch was less than 60 inches from the floor.

On 1/25/10 - First Floor:
4. At 2:20 p.m., in the Respiratory Therapy Department on the 1st floor, the room labeled "Dirty Utility Room" had 27 E-Tanks and 1 H-Tank stored next to a metal rack containing 12 cardboard boxes, a box of manilla envelopes and a second metal shelf containing 8 cardboard boxes as well as medical equipment stored within approximately 8 inches of the oxygen tanks. The room did not have a sign indicating that it was used for oxygen storage. The light switch was mounted approximately 4 feet from the ground.

Based on document review, the facility failed to maintain 2 of 8 anesthetizing locations as evidenced by the facility failure to maintain the relative humidity equal to or greater than 35%. This could result in the increased risk of a facility fire originating in the anesthetizing locations and the increased risk of harm to patients in the event of a fire.

Findings:

During record review with the facility Staff on January 25, 2010 through January 27, 2010, the humidity records were reviewed.

On January 26, 2010, at 1:59 p.m., the facility provided records titled "OR Temperature/Humidity, January 2010" for the Labor and Delivery Procedure room 1 and Procedure room 2. These records indicated that the normal humidity range was 30% to 60%.


1. Procedure room 1 had the following humidity levels less than 35%:

On January 2, 2010 at 11:00 a.m. the humidity was 25%, at 11:00 p.m., the humidity was 30%.

On January 3, 2010 at 11:00 a.m. the humidity was 32%.

On January 4, 2010 at 11:00 p.m., the humidity was 33%.

On January 5, 2010 at 11:00 p.m., the humidity was 28%.

On January 7, 2010 at 11:00 a.m. the humidity was 30%.

On January 8, 2010 at 11:00 p.m. the humidity was 28%.

On January 9, 2010 at 11:00 p.m., the humidity was 31%.

On January 10, 2010 at 11:00 a.m. the humidity was 33%.

On January 11, 2010 at 11:00 a.m. the humidity was 32%, at 11:00 p.m., the humidity was 31%.

On January 12, 2010 at 11:00 p.m., the humidity was 31%.

On January 14, 2010 at 11:00 p.m., the humidity was 22%.

On January 15, 2010 at 11:00 a.m. the humidity was 34%.

On January 25, 2010 at 11:00 a.m. the humidity was 27%.


2. Procedure Room 2 had the following humidity levels less than 35%:

On January 2, 2010 at 11:00 a.m. the humidity was 34%, at 11:00 p.m., the humidity was 32%.

On January 4, 2010 at 11:00 a.m. the humidity was 30%, at 11:00 p.m., the humidity was 30%.

On January 8, 2010 at 11:00 p.m., the humidity was 31%.

On January 9, 2010 at 11:00 a.m. the humidity was 30%, at 11:00 p.m., the humidity was 30%.

On January 12, 2010 at 11:00 p.m., the humidity was 31%.

On January 14, 2010 at 11:00 p.m., the humidity was 31%.

On January 15, 2010 at 11:00 p.m., the humidity was 32%.

On January 16, 2010 at 11:00 a.m. the humidity was 32%.

On January 21, 2010 at 11:00 p.m., the humidity was 34%.

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets.

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 a tour of the facility with facility Staff 1 on January 25, 2010 through January 27, 2010, the electrical system was observed.

On 1/25/10 - Second Floor:
1. At 10:45 a.m., in the Surgical Unit on the 2nd floor, the Case Management office had a refrigerator plugged into a multi-plug power strip and not directly into the wall.

2. At 10:52 a.m., in the Surgical Unit on the 2nd floor, the Nurses Lounge across from patient room 212 had an electrical wall outlet missing a cover plate.

1/25/10 - First Floor:
3. At 1:42 p.m., in the ER Staff Lounge on the 1st floor there was a microwave plugged into a multi-plug power strip and not directly into the wall.

4. At 1:58 p.m., in the Radiologist area on the 1st floor, the Radiology Employee Lounge had a refrigerator plugged into a 6 plug adapter.

5. At 2:28 p.m., the electrical panel box labeled "E-P9" in the Intensive Care Coronary Central Storage Room on the 1st floor of the ICU area had 1 missing blank cover for 1 empty breaker.

6. At 2:45 p.m., in the first floor Same Day Surgery supply room there was a white extension cord with no overcurrent protection plugged into a server.

7. At 3:17 p.m., in the Day Surgery OR "Frozen Section Room" on the 1st floor there was a refrigerator plugged into a multi-plug power strip and not directly into the wall.

8. At 3:18 a.m., on the first floor there was a broken electrical receptacle in the corridor out side the Anesthesia work room.





23108

On 1/25/10 - Basement:
9. At 10:55 a.m., in the Break room within the Medical Records Department, basement, there was a surge protector that connected a microwave oven to the electrical outlet.

10. At 11:00 a.m., in the Materials Department, basement, there was a surge protector that connected a mini-refrigerator and microwave oven to the electrical outlet.

11. At 11:20 a.m., in the Transcript room, basement, there was a surge protector that connected a microwave oven to the electrical outlet.



On 1/26/10 - First Floor:
12. At 2:00 p.m., in the Labor and Delivery Procedure room 1, first floor, there was an extension cord that connected a surge protector to the electrical outlet.

13. At 2:09 p.m., in the Conference room within Administration, first floor, there was a surge protector that connected a microwave oven to the electrical outlet