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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by three wall penetrations in the utility rooms of the Outpatient Surgery Center. This could result in the spread of smoke in the event of a fire. This affected one of six smoke compartments on the 1st Floor in the Outpatient Surgery area.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1, on 4/2/13, the facility walls and ceilings were observed.

1. At 4:57 p.m., there was an approximately 18 by 18 inch penetration in the wall above the door inside the main electrical room for the Outpatient Surgery Center.

2. At 5:01 p.m., there was an approximately 12 by 12 inch penetration in the wall above the door in the fire riser closet for the Outpatient Surgery Center.

3. At 5:03 p.m., there was an approximately 8 by 14 inch penetration in the wall of the the medical gas closet for the Outpatient Surgery Center.

Based on observation, the facility failed to maintain one hazardous area. This was evidenced by a kitchen dry goods storage door that was obstructed from closing. This could result in the spread of smoke and fire, in a fire emergency, affecting one of six smoke compartments.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1, on 4/3/13, the hazardous areas of the facility were observed. Combustible storage areas, greater than 50 square feet in size, are considered hazardous areas.

At 4:07 p.m., the kitchen dry goods storage room door failed to self close. The door was held open by a cord that was looped around the door handle and wall shelf support.

Based on observation, the facility failed to prevent the unsafe use of a portable space heater. This was evidenced by a portable space heater that was plugged into a wall outlet and in close proximity to combustible materials. This could result in the increased risk of fire, affecting one of six smoke compartments on the first floor.

NFPA 70 National Electrical Code, 1999 Edition
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1 on 4/3/13, electrical equipment and wiring connections were observed.

Inpatient Surgery Hospital
First Floor

At 4:20 p.m., there was a Holmes portable electric space heater that was plugged into a wall outlet under a desk in Room 1440. A wooden desk support was located approximately three inches to the left of the space heater. A plastic bin, full of discarded paper, was located approximately ten inches to the right of the space heater.

The space heater was labeled with a warning to "keep combustible materials 3 feet away from the front, the back and the sides," of the heater.

Based on record review and interview, the facility failed to inspect the generator for the Outpatient Surgery area on a weekly basis. This was evidenced by incomplete documentation of weekly inspections for 11 of 52 weeks. This could result in a delay in identifying leaks, battery deficiencies, low fuel, or activation of the generator during a power outage.

Findings:

During document review and interview with Maintenance Staff 1, on 4/2/13, the emergency generator testing and inspection logs were requested.

At 10:30 a.m., there were no "weekly generator inspection" logs completed for the first three months of 2013 for the Outpatient Surgery Center generator.

At 10:40 a.m., Maintenance Staff 1 confirmed that inspections were only performed prior to the monthly load test for the Outpatient Surgery Center generator.

Based on observation, interview and plan review, the facility failed to provide a Type I EES (Emergency Electrical System) divided into three branches of emergency power for the Outpatient Surgery Center. This was evidenced by one line diagrams provided by the facility and statements from staff confirming the emergency electrical system has a single transfer switch. This affected one of six smoke compartments and could result in a failure to back up the required essential electrical systems.

Findings:

During a facility tour and interview with Maintenance Staff 1 and QA Staff 1, on 4/2/13, the emergency electrical system was observed.
At 4 p.m., the Type I EES was not divided into three branches (Critical Care, Life Safety, and Emergency system,) as required when general anesthesia is used. The use of anesthesia at the Out Patient surgery center was confirmed by QA Staff 1.

During plan review with Maintenance Staff 1 on 4/3/13, from 4:20 p.m. to 5 p.m., the emergency electrical one line diagrams were reviewed. The plans confirmed that Outpatient Surgery Center did not have a Type I EES. The emergency electrical system was not divided into the critical branch, life safety branch, and the emergency system branch.

Based on observation, the facility failed to maintain their electrical wiring and equipment. This was evidenced by a surgery table plugged into a surge protected extension cord in Operating Room 8 (OR). This could increase the risk of electrical shock or fire and affected one of six smoke compartments.

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

Finding:

During a facility tour with Maintenance Staff 1 and QA Staff 1 on 4/3/13, the electrical devices and wiring connections were observed.

At 1:33 p.m., the surgery table in OR 8 was plugged into a surge protected extension cord. The surge protected extension cord was plugged into a four-way electrical drop from a ceiling electrical outlet.

Based on observation, interview and record review, the facility failed to conduct a continuous fire watch when the fire alarm system was disabled. This was evidenced by disabled smoke detectors, in two construction areas, without a continuous fire watch during non-construction hours. This could result in a delay in notification and evacuation during a fire emergency. This increased the risk of exposure to fire and smoke affecting two of six smoke compartments on the first floor.

Findings:

During a tour of the facility and interview with QA Staff 1 and Maintenance Staff 1, on 4/2/13, two construction/remodel areas were observed. Between 3 p.m. and 3:30 p.m., there were three smoke detectors missing from their bases in the PACU Step-Down remodel area and two smoke detectors that were covered by a red plastic cap in the OR 9 remodel area.

During an interview, QA Staff 1 stated the facility was conducting a fire watch as part of their interim life safety measures. He reported that the fire watch ended each day after the construction crew was gone.

There were no logs documenting a fire watch after the time the construction crew left the facility. Maintenance Staff 1 explained that the smoke detectors should have been placed back in service at the end of each day, but they were not.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by three wall penetrations in the utility rooms of the Outpatient Surgery Center. This could result in the spread of smoke in the event of a fire. This affected one of six smoke compartments on the 1st Floor in the Outpatient Surgery area.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1, on 4/2/13, the facility walls and ceilings were observed.

1. At 4:57 p.m., there was an approximately 18 by 18 inch penetration in the wall above the door inside the main electrical room for the Outpatient Surgery Center.

2. At 5:01 p.m., there was an approximately 12 by 12 inch penetration in the wall above the door in the fire riser closet for the Outpatient Surgery Center.

3. At 5:03 p.m., there was an approximately 8 by 14 inch penetration in the wall of the the medical gas closet for the Outpatient Surgery Center.

Based on observation, the facility failed to maintain one hazardous area. This was evidenced by a kitchen dry goods storage door that was obstructed from closing. This could result in the spread of smoke and fire, in a fire emergency, affecting one of six smoke compartments.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1, on 4/3/13, the hazardous areas of the facility were observed. Combustible storage areas, greater than 50 square feet in size, are considered hazardous areas.

At 4:07 p.m., the kitchen dry goods storage room door failed to self close. The door was held open by a cord that was looped around the door handle and wall shelf support.

Based on observation, the facility failed to prevent the unsafe use of a portable space heater. This was evidenced by a portable space heater that was plugged into a wall outlet and in close proximity to combustible materials. This could result in the increased risk of fire, affecting one of six smoke compartments on the first floor.

NFPA 70 National Electrical Code, 1999 Edition
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During the facility tour with Maintenance Staff 1 and QA Staff 1 on 4/3/13, electrical equipment and wiring connections were observed.

Inpatient Surgery Hospital
First Floor

At 4:20 p.m., there was a Holmes portable electric space heater that was plugged into a wall outlet under a desk in Room 1440. A wooden desk support was located approximately three inches to the left of the space heater. A plastic bin, full of discarded paper, was located approximately ten inches to the right of the space heater.

The space heater was labeled with a warning to "keep combustible materials 3 feet away from the front, the back and the sides," of the heater.

Based on record review and interview, the facility failed to inspect the generator for the Outpatient Surgery area on a weekly basis. This was evidenced by incomplete documentation of weekly inspections for 11 of 52 weeks. This could result in a delay in identifying leaks, battery deficiencies, low fuel, or activation of the generator during a power outage.

Findings:

During document review and interview with Maintenance Staff 1, on 4/2/13, the emergency generator testing and inspection logs were requested.

At 10:30 a.m., there were no "weekly generator inspection" logs completed for the first three months of 2013 for the Outpatient Surgery Center generator.

At 10:40 a.m., Maintenance Staff 1 confirmed that inspections were only performed prior to the monthly load test for the Outpatient Surgery Center generator.

Based on observation, interview and plan review, the facility failed to provide a Type I EES (Emergency Electrical System) divided into three branches of emergency power for the Outpatient Surgery Center. This was evidenced by one line diagrams provided by the facility and statements from staff confirming the emergency electrical system has a single transfer switch. This affected one of six smoke compartments and could result in a failure to back up the required essential electrical systems.

Findings:

During a facility tour and interview with Maintenance Staff 1 and QA Staff 1, on 4/2/13, the emergency electrical system was observed.
At 4 p.m., the Type I EES was not divided into three branches (Critical Care, Life Safety, and Emergency system,) as required when general anesthesia is used. The use of anesthesia at the Out Patient surgery center was confirmed by QA Staff 1.

During plan review with Maintenance Staff 1 on 4/3/13, from 4:20 p.m. to 5 p.m., the emergency electrical one line diagrams were reviewed. The plans confirmed that Outpatient Surgery Center did not have a Type I EES. The emergency electrical system was not divided into the critical branch, life safety branch, and the emergency system branch.

Based on observation, the facility failed to maintain their electrical wiring and equipment. This was evidenced by a surgery table plugged into a surge protected extension cord in Operating Room 8 (OR). This could increase the risk of electrical shock or fire and affected one of six smoke compartments.

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

Finding:

During a facility tour with Maintenance Staff 1 and QA Staff 1 on 4/3/13, the electrical devices and wiring connections were observed.

At 1:33 p.m., the surgery table in OR 8 was plugged into a surge protected extension cord. The surge protected extension cord was plugged into a four-way electrical drop from a ceiling electrical outlet.

Based on observation, interview and record review, the facility failed to conduct a continuous fire watch when the fire alarm system was disabled. This was evidenced by disabled smoke detectors, in two construction areas, without a continuous fire watch during non-construction hours. This could result in a delay in notification and evacuation during a fire emergency. This increased the risk of exposure to fire and smoke affecting two of six smoke compartments on the first floor.

Findings:

During a tour of the facility and interview with QA Staff 1 and Maintenance Staff 1, on 4/2/13, two construction/remodel areas were observed. Between 3 p.m. and 3:30 p.m., there were three smoke detectors missing from their bases in the PACU Step-Down remodel area and two smoke detectors that were covered by a red plastic cap in the OR 9 remodel area.

During an interview, QA Staff 1 stated the facility was conducting a fire watch as part of their interim life safety measures. He reported that the fire watch ended each day after the construction crew was gone.

There were no logs documenting a fire watch after the time the construction crew left the facility. Maintenance Staff 1 explained that the smoke detectors should have been placed back in service at the end of each day, but they were not.