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Based on observation the facility failed to maintain the building construction for 3 of 16 smoke compartments as evidenced by penetrations within the facility walls. These penetrations could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients, visitors and staff due to smoke and fire.

Findings:

During an observation with the facility staff 1,3 and 7 from January 4, 2010 to January 7, 2010

On January 5, 2010

1. At 9:50 a.m., in ICU A, Building 21, there were three 1/4 inch penetrations in the right wall of the ICU Storage. When interviewed on January 5, 2010 at 9:50 a.m., staff 1 stated that the refrigerator had been moved and they had not patched the holes yet.

2. At 10:41 a.m., the Imaging area had two, 1 inch penetrations in the Catscan 1 Room. When interviewed on January 5, 2010 at 10:41 a.m., Staff 1 stated that the magnetic strip for the door was moved.


3. At 11:15 a.m., in the Financial Counselor Office, 1-223, there were two 1/2 inch unsealed penetrations.

4. At 1:40 p.m., Above the door of the inside room of Gift Storage, 1-311, Old ER Basement, there was a 2 inch by 6 inch cut out penetration.

5. At 1:47 p.m., in the Outpatient Surgery Pavilion, Operating Room 2 had 1 penetration approximately 1/2 inch round by the clock and 4 penetrations approximately 1/4 inch round above the telephone.

6. At 1:50 p.m., in the Outpatient Surgery Pavilion, Operating Room 1 had 5 penetrations approximately 1/2 inch round above the phone in the wall.

7. At 1:58 p.m., in the Outpatient Surgery Pavilion, the Janitor room had a 12 inch X 12 inch penetration in the ceiling. Staff 6 stated that they had been working on the air conditioning and probably forgot to patch the hole when finished.

8. At 2:10 p.m., in the Outpatient Surgery Pavilion, the Warming Cabinet Sterilizer room had a 2 inch penetration around the copper pipe in the wall.


On January 6, 2010

1. At 8:50 a.m., in the Housekeeping Closet, 2-108, Labor and Delivery, there were six 1/4 inch penetrations in the center of the right wall and a 1/2 inch by 8 inch penetration on the left bottom of the wall along the sink.

Based on observation the facility failed to maintain the corridor doors for 8 of 16 smoke compartments as evidenced by corridor doors that were held open in an unauthorized manner and corridor doors that failed to positive latch upon closure. These findings could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During an observation with the facility staff 1, 3, and 7 from January 4, 2010 to
January 7, 2010

On January 5, 2010

1. At 10:05 a.m., the corridor door to the Ante-Room to 216-218, failed to positive latch.
2. At 10:14 a.m., in Building 22, Telemetry Unit, the door to Room 215 failed to positive latch.

3. At 1:25 p.m., the corridor door to the Employee Health Office 1-291, Old ER, was held open with a door wedge.

On January 6, 2010

1. At 9:15 a.m., the corridor door to Office 2-182, Labor and Delivery, failed to fully close and positive latch upon self closure.

2. At 10:37 a.m., the self-closing corridor door to the Storage area by Office
1-291, Old ER basement, was held open with a wedge.

On January 7, 2010

1. At 10:20 a.m., in Medical Records, Analyst Room, the door was blocked open by medical records stacked halfway up the door.

2. At 10:35 a.m., the self-closing door to the Trash Room by Pathology Transcription, failed to fully close and positive latch.

3. At 10:45 a.m., the Dietary Storage self-closing door 2-260, failed to fully close and positive latch.

4. At 10:50 a.m., the exit door in the Dietary Service Hallway, failed to fully close and positive latch.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls in 3 of 16 smoke compartments, as evidenced by penetrations in the smoke barrier walls. These penetrations could result in the spread of smoke and fire throughout the facility and increased risk of injury to the patients, visitors and staff due to smoke and fire.

Findings:

During observation with facility staff 1,3 and 7 on January 5, 2010

1. At 10:25 a.m., the smoke barrier wall by X-Ray 5, there was a 2 inch square unsealed penetration in the center right of the wall.
2. At 11:20 a.m., the smoke barrier wall by Office 1-198, there were four 1/2 inch unsealed penetration in the center of the wall.
3. At 2:15 p.m., the smoke barrier wall in the Old ER, N Med-Surg by Room 279, there was a 3 inch circular unsealed penetration in the right center of the wall surrounding a group of cables.

Based on observation the facility failed to maintain a set of smoke barrier double doors in 2 of 16 smoke compartments as evidenced by smoke barrier door leafs that failed to fully close and positive latch. This failure could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to the patients, visitors and staff due to smoke and fire.

Findings:

During the facility tour with the facility staff 3 and 7 on January 6, 2010 the smoke barrier doors were observed.

1.At 10:15 a.m., Med-Surg Unit-C, the smoke barrier double door outside of office 2-507, 2 of 2 door leafs failed to fully close and positive latch.

2. At 10:25 a.m., in the Med Surge Area C, the smoke barrier door by Workroom 2-420 failed to positive latch on on both sides after activation of a smoke detector.

3. At 10:58 a.m., the smoke barrier door in the Telemetry Unit by Room 201 failed to positive latch on the left side after activation of a smoke detector.

4. At 11:08 a.m., in ICU A, the smoke barrier door by Room 2-351 Storage Room and nursing station failed to latch on the left side.

Based on observation, the facility failed to protect hazardous areas with auto-closing doors as required for 3 of 16 smoke compartments. These findings could result in the spread of smoke and fire from the hazardous area and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During observation with facility staff 1, 3 and 7 on January 5, 2010
1. At 11:05 a.m., the door to the storage closet in the Financial Counselor 1-223 area failed to have a self-closing device. The room contained racks of boxes, paper, and supplies and was over 50 sq. feet.


2. At 1:35 p.m., the door to Career Registry Office 1-308, Old ER Basement, measuring over 50 square feet contained an abundant amount of combustible materials such as books, binders, manuals, paper materials,etc. The door was not equipped with a self closing device.

3. At 1:55 p.m., the door to Medical Records Storage 1-317, Old ER Basement, measuring over 50 square feet contained an abundant amount of combustible materials such as medical records and paper materials. The door was not equipped with a self closing device.

4. At 2:15 p.m., the door to the Med-Surg Office 2-543, Old ER, First Floor, measuring over 50 square feet contained an abundant amount of combustible materials such as books, binders, manuals and paper materials. The door was not equipped with a self closing device.

Based on record review and interview, the facility failed to accomplish all of the requirements for conducting fire drills as evidenced by the facility failure to enforce the facility policy and procedures, conduct fire drills at varying times and conduct the required four fire drills per year at the off-site locations. These findings could result in any one facility staff member not accomplishing all of the tasks required of him or her in the event of a fire and the increased risk of injury to the patients, visitors and staff due to a fire.

Findings:

During record review and interview with facility staff 1,10 and 11 from January 4, 2010 thru January 7, 2010

On January 4, 2010

1. At 1:00 p.m., the facility failed to provide four fire drills for 2009, one for each quarter for the off-site locations. The documentation showed that fire drills on off-site locations are conducted a minimum of once a year. The records presented, showed one fire drill for Out Patient Patient Surgery Pavilion on 6-26-2009, one fire drill for 18077 Community Health Center on 5-1-2009, one fire drill for Hesperia Clinic on 3-05-2009 and one fire drill for Adelanto Prenatal Clinic on 1-20-2009.

On January 5, 2010

2. At 1:15 p.m., Fire drills in the Main Hospital showed several fire drills with negative comments-1/23/09 showed low response, 2/19/2009 showed low response and staff refusal to sign-in, 11/13/2009 no employees present, and 2/16/09,12/21/2009, 8/10/2009, 4/23/09 showed issues with PBX and fire alarm system. There was no documentation for follow -up on these drills.

3. At 1:30 p.m., the Night shift fire drills showed 3 of 4 fire drills conducted at approximately the same time-3/11/2009 at 0610, 7/10/2009 at 0620 and 12/21/2009 at 0615.

On January 6, 2010

4. At 2:00 p.m., Staff 1, Staff 10 and Staff 11 confirmed that management for fire drills had changed and documentation and follow-up would improve.

Based on observation and interview the facility failed to provide notification devices in all areas to provide an effective warning of fire in any part of the facility, that would allow staff time to relocate. And to train staff in the location of the nearest activation devices in the event of a fire.
NFPA 101, 2000 EDITION
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conations:
(1) When the individual who discovers a fire must immediately go the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

NFPA 72 section 2-8.2.1
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

On January 5, 2010 during a tour of the facility with staff 1 and 3 the manual fire alarm pull stations were observed.
At 1:42 p.m., the manual pull box by the front door in the Lobby was blocked from access by table with pamphlets on it.
At 2:20 p.m., in the Old ER, 1st Floor, N Med-Surg, the manual fire alarm pull station device located between Patient Rooms 282 and 284 was impeded with a housekeeping cart which was parked in front on the manual alarm activation device. The cart was removed by the housekeeper.

On January 6, 2010 during testing of the fire alarm system from 10:01 a.m. to 2:06 p.m. the fire alarm system was observed.

At 10:07 a.m., During fire alarm testing, the single alarm in the kitchen failed to sound and no other alarm could be heard.

At 12:19 p.m. in the lab there were no audible or visual notification devices. The manual pull station at "4 corners" was activated but the fire alarm system cannot be heard in the lab. During an interview with 2 staff they did not know the location of the nearest manual fire alarm box (pull station). One of two staff pointed out the location of the fire extinguisher in the lab.

Based on observation, interview and document review the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by failure to provide testing records, and annual certification of the fire alarm system. This affected 1 of 1 smoke compartments and may result in the fire alarm system not functioning properly in the event of a fire.

NFPA 72
7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Findings:
On January 5, 2010 during a tour of the facility Healthy Beginnings, Hesperia, the facility staff 1 and 3, was not able to provide access to the fire alarm panel because the aceess was in another suite that was not open at the time. Staff 1 was unable to provide documentation for the testing and maintenance of the fire alarm system, stating he would have to obtain it from the owner of the building.
On January 6, 2009 at 7:59 a.m., Fire Alarm Testing and Maintenance Report dated September 5, 2007, was reviewed.
At 4:54 p.m. The facility staff 1 and 3 provided documentation from the vendor dated September, 2007. This documentation did not include the fire alarm system in the Healthy Beginnings suite 17091. When asked when the last inspection of the system was staff 1 stated that there was no other documentation to provide.
The fire alarm panel was observed in another suite and had two rechargeable batteries with no dates indicating when they were installed. No documentation was provided showing maintenance of the batteries in accordance with NFPA 72. The fire alarm system consists of 2 pull stations and rate of rise heat detectors.

Based on observation and interview the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by failure to provide documentation for the testing and mainteance of the smoke detectors. This affected 1 of 1 smoke compartments and may result in the smoke detectors not functioning properly in the event of a fire.

Findings:
On January 5, 2010, during a tour of the facility with staff 1, at 9:45 a.m. there were 13 battery operated smoke detectors. During an interview, staff 1 stated that they did not have documenation when the batteries were replaced but did confirm the batteries were replaced in December 2009.

Based on observation, the facility failed to ensure that the automatic sprinkler system is maintained in 6 of 16 smoke compartments, as evidenced by escutcheon rings that were not flush to the ceiling and missing escutcheon rings. These findings could result in a malfunction during a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During observation with facility staff 1, 3 and 7, from January 4, 2010 thru January 7, 2010

On January 5, 2010

1. At 11:05 a.m., in the Quality Analyst/Educator Office, there was 1 of 1 sprinkler heads with a missing escutcheon ring.

2. At 2:50 p.m., in the corridor in front of Med-Surg, there was 1 of 9 sprinkler heads with a missing escutcheon ring.

On January 6, 2010

3. At 9:00 a.m., in the Storage Room 2-188, there was 1 of 1 sprinklers with a 1/2 inch gap from the ceiling and the escutcheon ring.

4. At 10:00 a.m., in the Nutrition corridor by room 2-266, there were 2 of 5 sprinklers with a one half inch gap from the ceiling and the escutcheon ring and 2 of 5 sprinklers with missing escutcheon rings.

5. At 10:05 a.m., in the Dietary corridor by room 2-242, there were 2 of 4 sprinklers with a one half inch gap from the ceiling and the escutcheon ring and 2 of 4 sprinklers with missing escutcheon rings.

6. At 1:45 p.m., in the X-Ray Imaging corridor by room 1-102, there was 1 of 5 sprinklers with a missing escutcheon ring.

Based on document review, interview and observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinkler heads that were missing escutcheon rings and, no documentation of quarterly automatic sprinkler test/inspection for 2 of 4 tests/inspections. This could cause potential harm to patients and staff in the event of a fire.

Findings:

During document review with Staff 1 on January 4, 2010 and a tour of the facility with facility Staff 1, Staff 7, Staff 9 and Staff 3 on January 5, 2010 and January 6, 2010, the sprinkler system was observed.

1. On January 4, 2010 at 2:30 p.m., the facility failed to provide documentation that the sprinkler test/inspections were conducted for the 2nd and 4th quarter 2009. When interviewed on January 4, 2010 at 2:30 p.m., Staff 1 stated that they thought they were only required to test and inspect their automatic sprinkler system twice a year.

2. On January 5, 2010 at 10:08 a.m. in Building 22, Telemetry Unit, the Nurse Locker Room 2-362 had a sprinkler head that was missing an escutcheon ring.

3. On January 5, 2010 at 10:36 a.m. in the Imaging Unit room 1-102 had a sprinkler missing an escutcheon ring in the hallway lounge area.

4. On January 6, 2010 at 8:38 a.m. in the Maternity/NICU area there was a sprinkler missing an escutcheon ring in the Nursing Station ceiling.

5. On January 6, 2010 at 10:05 a.m. in the Med Surge area there was a sprinkler missing an escutcheon ring in the ceiling by Room 2-247.

6. On January 6, 2010 at 2:05 p.m. in the Public Safety Office there was a sprinkler missing an escutcheon ring in the ceiling above the refrigerator and microwave.

Based on observation, the facility failed to maintain the portable fire extinguishers in 3 of 16 smoke compartments as evidenced by a fire extinguisher impeded by a housekeeping cart, fire extinguishers sitting on counters and expired fire extinguishers. These findings could result in delayed response to fire emergencies and increase the risk of injury to patients, visitors and staff due to fire.

NFPA 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 observation with facility staff 1, 3 and 7, from January 4, 2010 thru January 7, 2010

On January 5, 2010

1. At 10:35 a.m., in the R & F Room, there was a fire extinguisher blocked from view and impeded by a cart and a table.
2. At 11:00 a.m., the fire extinguisher in the Chapel on the first floor was dated 12/30/08 (expired) and was blocked from access by a large potted plant.

3. At 3:15 p.m., in the ICUN storage, there were two fire extinguishers sitting on the counter. The larger extinguisher had an inspection date of 12-30-08.

On January 6, 2010

1. At 8:55 a.m., in Storage Room 2-188, there was a fire extinguisher sitting on the counter. The last inspection date was 12-30-08.

On January 7, 2010

1. At 11:00 a.m., the ABC fire extinguisher in the Kitchen was blocked from access by a large plastic bag of towels and a plastic tub of aprons.

Based on observation the facility failed to prevent the use of portable space heating devices. This may cause a fire which may cause injury to staff or patients. This affects 1 of 13 smoke compartments.

Findings:
On January 6, 2010 during a tour of the facility with staff 1 and 3 at 4:47 p.m. at the entrance to the Labor and Delivery Department at the security desk there was a floor heater observed in use.

Based on observation the facility failed to maintain the path of egress free of all obstructions or impediments for full instant use in the event of a fire. This was evident by the installation of pull down charting stations in the corridors which extended into the corrdior more than 3 inches. This may cause injury to staff and patients in the event of evacuation from the facility.

Findings:
On January 6, 2010 at 10:59 a.m. during a tour of the telemetry unit with staff 1 there was a wall mounted charting station left in the open position with a 3 ring binder on it. When in the open position the charting station extends into the hallway 22 inches, when closed the charting station extends 3 and 7/8 inches. During an interview with staff 1 at the time he stated that there are approximately 12 wall mounted charting stations located through out the hospital.

Based on observation the facility failed to maintain the oxygen storage free of combustibles and electrical devices that were not stored 5 feet from the oxygen cylinders and electric light switches installed 5 feet above the floor to prevent damage. This may cause the spread of fire. This affected 1 of 13 smoke compartments.

NFPA 99, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction or Both)
# 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.


NFPA 99
4-3.1.1.2 #'s 5 and 7
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2 (a) 7]

7. Combustible materials, such as paper, cardboard, plastics and fabrics shall not be stored or kept near supply sytem cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinders storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Findings:
1. On January 5, 2010 at 2:30 p.m., the Oxygen Storage light switch was approximately 4ft from the floor.

1. On January 7, 2010 during a tour of the emergency room with staff 1 the oxygen storage was observed.
At 10:30 a.m. in the room labeled as oxygen storage there were 13 E tanks stored with ventilators and a supply cart with combustible items such as plastics and paper/cardboard within 5 feet.

Based on document review and interview the facility failed to maintain the operating rooms (OR) humidity levels at a level in accordance with NFPA 99, Health Care Facilities, and to provide evidence that the humidity level had been adjusted to 35% or greater. This could cause an increased risk of fire and injury to patients. This affected 3 of 3 operating rooms.

Findings:
On January 4, 2010 through January 7, 2010, during document review the humidity logs or the ORs at the Outpatient Surgery Pavilion, the Hospital Operating Rooms and the Labor and Delivery Operating Room were reviewed.
On January 4, 2010 the humidity logs for the Labor and Delivery OR were reviewed from January 2009 through December 2009.
Labor and Delivery Operating Room Humidity Levels:
1. January 2009, Humidity Levels:
a. January 1, 2009:
OR 1 = 34%
b. January 2, 2009:
OR 1 = 34%
c. January 3, 2009
OR 1 = 34%
d. January 4, 2009:
OR 1= 33%
e. January 5, 2009:
OR 1 = 32%
f. January 7, 2009:
OR 1 = 34%
g. January 8, 2009:
OR 1 = 34%
h. January 9, 2009:
OR 1 = 34%
i. January 10, 2009:
OR 1 = 33%
j. January 11, 2009:
OR 1 = 34%
k. January 13, 2009:
OR 1 = 34%
l. January 15, 2009:
OR 1 = 32%
m. January 16, 2009:
OR 1 = 34%
n. January 25, 2009:
OR 1 = 34%
o. January 27, 2009:
OR 1 = 32 %
p. January 28, 2009:
OR 1 = 32%
q. January 30, 2009:
OR 1 = 34 %
r. January 31, 2009:
OR 1 = 34%
2. February 2009 Humidity Levels:
a. February 2, 2009:
OR 1 = 32%
b. February 3, 2009:
OR 1 = 23%
c. February 4, 2009:
OR 1 = 23%
d. February 5, 2009:
OR 1 = 34%
e. February 7, 2009:
OR 1 = 34%
f. February 8, 2009:
OR 1 = 33%
g. February 9, 2009:
OR 1 = 33%
h. February 10, 2009:
OR 1 = 32 %
i. February 12, 2009:
OR 1 = 33%
j. February 13, 2009: OR 1 = 33%
k. February 14, 2009:
OR 1 = 31%
l. February 15, 2009:
OR 1 = 32%
m. February 16, 2009:
OR 1 = 32%
n. February 17, 2009:
OR 1 = 32%
o. February 18, 2009:
OR 1 = 32%
p. February 19, 2009:
OR 1 = 33%
q. February 20, 2009:
OR 1 = 33%
r. February 21, 2009:
OR 1 = 32%
s. February 22, 2009:
OR 1 = 34%
t. February 23, 2009:
OR 1 = 34%
u. February 24, 2009:
OR 1 = 32%
v. February 25, 2009:
OR 1 = 33%
w. February 26, 2009:
OR 1 = 31%
x. February 27, 2009:
OR 1 = 32%
y. February 28, 2009:
OR 1 - 32%
3. March 2009 Humidity Levels:
a. March 1, 2009:
OR 1 = 33%
b. March 2, 2009:
OR 1 = 32%
c. March 3, 2009:
OR 1 = 31%
d. March 4, 2009:
OR 1 = 32%
e. March 5, 2009:
OR 1 = 32%
f. March 6, 2009:
OR 1 = 32%
g. March 7, 2009:
OR 1 = 32%
h. March 8, 2009:
OR 1 = 32%
i. March 9, 2009:
OR 1 = 32%
j. March 10, 2009:
OR 1 = 32%
k. March 11, 2009:
OR 1 = 32%
l. March 12, 2009:
OR 1 = 31%
m. March 13, 2009:
OR 1 = 31%
n. March 14, 2009:
OR 1 = 32%
o. March 15, 2009:
OR 1 = 32%
p. March 16, 2009:
OR 1 = 32%
at 1200 humidity level was 29%
at 1330 humidity level was 31%
q. March 23, 2009:
OR 1 = 33%
r. March 24, 2009:
OR 1 = 33%
s. March 25, 2009:
OR 1 = 34%
t. March 27, 2009:
OR 1 = 33%
u. March 29, 2009:
OR 1 = 32%
v. March 31, 2009:
OR 1 = 34%
4. April 2009, Humidity Levels:
a. April 2, 2009:
OR 1 = 33%
b. April 4, 2009:
OR 1 = 34%
c. April 6, 2009:
OR 1 = 33%
d. April 7, 2009:
OR 1 = 33%
e. April 8, 2009:
OR 1 = 34%
f. April 15, 2009:
OR 1 = 34%
g. April 19, 2009:
OR 1 = 33%
h. April 21, 2009:
OR 1 = 34%
i. April 22, 2009:
OR 1 = 34%
j. April 29, 2009:
OR 1 = 33%
k. April 30, 2009:
OR 1 = 33%
5. May 2009, Humidity Levels:
a. May 13, 2009:
OR 1 = 34%
b. May 14, 2009:
OR 1 = 34%
c. May 15, 2009:
OR 1 = 34%
6. September 2009, Humidity Levels:
a. September 22, 2009:
OR 1 = 33%
b. September 23, 2009:
OR 1 = 31%
c. September 24, 2009:
OR 1 = 32%
d. September 25, 2009:
OR 1 = 32%
e. September 26, 2009:
OR 1 = 32%
f. September 27, 2009:
OR 1 = 33%
g. September 28, 2009:
OR 1 = 34%
h. September 29, 2009:
OR 1 = 32%
i. September 30, 2009:
OR 1 = 32%
7. October 2009, Humidity Levels:
a. October 2, 2009:
OR 1 = 32 %
b. October 3, 2009:
OR 1 = 30%
c. October 5, 2009:
OR 1 = 33%
d. October 6, 2009:
OR 1 = 33%
e. October 7, 2009:
OR 1 = 33%
f. October 8, 2009:
OR 1 = 34%
g. October 10, 2009:
OR 1 = 33%
h. October 21, 2009:
OR 1 = 32 %
i. October 22, 2009:
OR 1 = 33%
j. October 23, 2009:
OR 1 = 32%
k. October 24, 2009:
OR 1 = 32%
l. October 25, 2009:
OR 1 = 32%
m. October 26, 2009:
OR 1 = 32%
n. October 27, 2009:
OR 1 = 32%
o. October 28, 2009:
OR 1 = 32%
p. October 29, 2009:
OR 1 = 33 %
q. October 30, 2009:
OR 1 = 32%
r. October 31, 2009:
OR 1 = 32%
8. November 2009, Humidity Levels:
a. November 1, 2009:
OR 1 = 32%
b. November 2, 2009:
OR 1 = 31%
c. November 3, 2009:
OR 1 = 32%
d. November 4, 2009:
OR 1 = 33%
e. November 6, 2009:
OR 1 = 34%
f. November 7, 2009:
OR 1 = 33%
g. November 8, 2009:
OR 1 = 32%
h. November 9, 2009:
OR 1 = 34%
i. November 10, 2009:
OR 1 = 33%
j. November 11, 2009:
OR 1 = 32%
k. November 12, 2009:
OR 1 = 32%
l. November 13, 2009:
OR 1 = 33%
m. November 14, 2009:
OR 1 = 32%
n. November 15, 2009:
OR 1 = 30%
o. November 16, 2009:
OR 1 = 32%
p. November 20, 2009:
OR 1 = 32%
q. November 21, 2009:
OR 1 = 32%
r. November 22, 2009:
OR 1 = 32%
s. November 23, 2009:
OR 1 = 33%
t. November 24, 2009:
OR 1 = 32%
u. November 25, 2009:
OR 1 = 32%
v. November 26, 2009:
OR 1 = 31%
w. November 27, 2009:
OR 1 = 30%
x. November 28, 2009:
OR 1 = 30%
y. November 29, 2009:
OR 1 = 32%
z. November 30, 2009:
OR 1 = 30%
9. December 2009, Humidity Levels:
a. December 1, 2009:
OR 1 = 31%
b. December 2, 2009:
OR 1 = 32%
c. December 3, 2009:
OR 1 = 32%
d. December 4, 2009:
OR 1 = 31%
e. December 5, 2009:
OR 1 = 30%
f. December 6, 2009:
OR 1 = 30%
g. December 7, 2009:
OR 1 = 32%
h. December 8, 2009:
OR 1 = 32%
i. December 9, 2009:
OR 1 = 32%
j. December 10, 2009:
OR 1 = 30%
k. December 11, 2009:
OR 1 = 34%
l. December 12, 2009:
OR 1 = 33%
m. December 13, 2009:
OR 1 = 34%
n. December 14, 2009:
OR 1 = 32%
o. December 16, 2009:
OR 1 = 32%
p. December 17, 2009:
OR 1 = 32%
q. December 18, 2009:
OR 1 = 32%
r. December 19, 2009:
OR 1 = 32%
s. December 20, 2009:
OR 1 = 32%
t. December 21, 2009:
OR 1 = 32%
u. December 22, 2009:
OR 1 = 32%
v. December 23, 2009:
OR 1 = 32%
w. December 24, 2009:
OR 1 = 32%
x. December 25, 2009:
OR 1 = 32%
y. December 26, 2009:
OR 1 = 32%

On January 4, 2009 at 1:47 p.m. during an interview, Staff 2 stated that the OR staff check the humidity, if it is low (below 30%) they call facilities and facilities staff go to the OR and check the humidity level. Documentation of facilities findings and verification that the humidity levels were adjusted in range when reported was requested. Per staff 2 the humidity levels were adjusted into range but the computer system that was installed in March/April 2009 was not able to go back that far. Per staff 6 if humidity levels are low no surgeries are performed in that OR. Per staff 2 no work orders are generated that he is aware of .

Outpatient Surgery Pavilion:
On January 5, 2010 during a tour of the facility from 1:35 p.m. to 3:00 p.m. the humidity level logs for 3 of 3 OR'S were reviewed from January 2009 through January 4, 2010:

1. January 2009 Humidity Levels:
a. January 5, 2009:
OR 1 = 20%
OR 2 = 23 %
b. January 6, 2009:
OR 1 = 31 %
OR 2 = 31 %
c. January 7, 2009:
OR 1 = 28%
OR 2 = 30%
d. January 8, 2009:
OR 1 = 25 %
OR 2 = 31%
e. January 12, 2009:
OR 1 = 21%
OR 2 = 22%
OR 3 = 31%
f. January 13, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 30%
g. January 14, 2009:
OR 1 = 21%
OR 2 = 21%
OR 3 = 30%
h. January 15, 2009:
OR 1 = 19%
OR 2 = 20%
OR 3 = 29%
i. January 16, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 27%
j. January 19, 2009:
OR 1 = 21%
OR 2 = 19%
OR 3 = 27%
k. January 20, 2009:
OR 1 = 21%
OR 2 = 21%
OR 3 = 28%
l. January 21, 2009:
OR 1 = 25%
OR 2 = 28%
m. January 22, 2009:
OR 2 = 30%
n. January 26, 2009:
OR 1 = 26%
OR 2 = 31%
o. January 27, 2009:
OR 1 = 21%
OR 2 = 30 %
p. January 28, 2009:
OR 1 = No humidity levels recorded
OR 2 = No humidity levels recorded
OR 3 = No humidity levels recorded
q. January 29, 2009:
OR 1 = 20 %
OR 2 = 24 %
OR 3 = 34 %

2. February 2009, Humidity Levels:
a. February 2, 2009
OR 1 = 20 %
OR 2 = 19%
OR 3 = 30%
b. February 3, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 28%
c. February 4, 2009:
OR 1 = 21%
OR 2 = 22%
OR 3 = 31%
d. February 5, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 21%
e. February 9, 2009:
OR 1 = 33%
f. February 10, 2009:
OR 1 = 23%
OR 2 = 26%
OR 3 = 34%
g. February 11, 2009:
OR 1 = 21%
OR 2 = 25%
OR 3 = 32%
h. February 12, 2009:
OR 1 = 22%
OR 2 = 24%
i. February 16, 2009:
OR 1 = 26%
OR 2 = 34%
j. February 17, 2009:
OR 1 = 25%
OR 2 = 28%
k. February 18, 2009:
OR 1 = 27%
OR 2 = 25%
l. February 19, 2009:
OR 1 = 25%
OR 2 = 24%
OR 3 = 34%
m. February 20, 2009:
OR 1 = 28%
OR 2 = 28%
n. February 23, 2009:
OR 1 = 29%
OR 2 = 25%
OR 3 = 33%
o. February 24, 2009
OR 1 = 27%
OR 2 = 26%
OR 3 = 32%
p. February 25, 2009:
OR 1 = 27%
OR 2 = 28%
OR 3 = 32%
q. February 26, 2009:
OR 1 = 24%
OR 2 = 23%
OR 3 = 31%
r. February 27, 2009:
OR 1 = 25 %
OR 2 = 24%
OR 3 = 30%
3. March 2009, Humidity Levels:
a. March 2, 2009:
OR 1 = 22%
OR 2 = 19%
OR 3 = 28%
b. March 3, 2009:
OR 1 = 28%
OR 2 = 33%
OR 3 = 30%
c. March 4, 2009:
OR 1 = 23%
OR 2 = 22%
OR 3 = 28%
d. March 5, 2009:
OR 1 = 26%
OR 2 = 26%
OR 3 = 34%
e. March 6, 2009:
OR 1 = 21%
OR 2 = 25%
OR 3 = 33%
f. March 11, 2009:
OR 1 = 21%
OR 2 = 24%
OR 3 = 33%
g. March 12, 2009:
OR 1 = 24%
OR 2 = 30%
h. March 16, 2009:
OR 1 = 25%
OR 2 = 25%
OR 3 = 27%
i. March 17, 2009:
OR 1 = 28%
OR 2 = 30%
OR 3 = 31%
j. March 18, 2009:
OR 1 = 26%
OR 2 = 27%
OR 3 = 31%
k. March 19, 2009:
OR 1 = 25%
OR 2 = 27%
OR 3 = 33%
l. March 20, 2009:
OR 1 = 26%
OR 2 = 27%
OR 3 = 32%
m. March 23, 2009:
OR 1 = 20%
OR 2 = 23%
OR 3 = 28%
n. March 24, 2009:
OR 1 = 28%
OR 2 = 23%
OR 3 = 26%
o. March 25, 2009:
OR 1 = 30%
OR 2 = 23%
OR 3 = 27%
p. March 26, 2009:
OR 1 = 29%
OR 2 = 23%
OR 3 = 28%
q. March 30, 2009:
OR 1 = 19%
OR 2 = 18%
OR 3 = 20%
r. March 31, 2009:
OR 1 = 20%
OR 2 = 21%
OR 3 = 21%
4. April 2009, Humidity Levels:
a. April 1, 2009
OR 1 = 21%
OR 2 = 20%
OR 3 = 22%
b. April 2, 2009:
OR 1 = 28%
OR 2 = 28%
OR 3 = 27%
c. April 3, 2009:
OR 1 = 26%
OR 2 = 28%
OR 3 = 28%
d. April 6, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 20%
e. April 7, 2009:
OR 1 = 21%
OR 2 = 19%
OR 3 = 20%
f. April 8, 2009:
OR 1 = 23%
OR 2 = 20%
OR 3 = 22%
g. April 9, 2009:
OR 1 = 28%
OR 2 = 29%
OR 3 = 31%
h. April 14, 2009:
OR 1 = 22%
OR 2 = 22%
OR 3 = 23%
i. April 15, 2009:
OR 1 = 21%
OR 2 = 20%
OR 3 = 22%
j. April 16, 2009:
OR 1 = 21%
OR 2 = 21%
OR 3 = 21%
k. April 20, 2009:
OR 1 = 19%
OR 2 = 18%
OR 3 = 21%
l. April 21, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 21%
m. April 22, 2009:
OR 1= 20 %
OR 2 = 19%
OR 3 = 22%
n. April 23, 2009:
OR 1 = 21%
OR 2 = 30%
OR 3 = 25%
o. April 27, 2009:
OR 1 = 28%
OR 2 = 30%
OR 3 = 32%
p. April 28, 2009:
OR 1 = 27%
OR 2 = 31%
OR 3 = 33%
q. April 29, 2009: OR 1 = 25%
OR 2 = 24%
OR 3 = 28%
r. April 30, 2009:
OR 1 = 23%
OR 2 = 26%
OR 3 = 21%
5. May 2009, Humidity Levels:
a. May 1, 2009:
OR 1 = 25%
OR 2 = 25%
OR 3 = 23%
b. May 4, 2009:
OR 1 = 26%
OR 2 = 23%
OR 3 = 24%
c. May 5, 2009:
OR 1 = 31%
OR 2 = 28%
OR 3 = 30%
d. May 11, 2009:
OR 1 = 24%
OR 2 = 27%
OR 3 = 24%
e. May 12, 2009:
OR 1 = 29%
OR 2 = 31%
OR 3 = 25%
f. May 13, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 20%
g. May 14, 2009: OR 1 = 21%
OR 2 = 19%
OR 3 = 20%
h. May 15, 2009:
OR 1 = 19%
OR 2 = 23%
OR 3 = 23%
i. May 18, 2009:
OR 1 = 26%
OR 2 = 26%
OR 3 = 18%
j. May 19, 2009:
OR 1 = 19%
OR 2 = 20%
OR 3 = 19%
k. May 20, 2009:
OR 1 = 23%
OR 2 = 26%
OR 3 = 21%
l. May 21, 2009:
OR 1 = 26%
OR 2 = 26%
OR 3 = 20%
m. May 26, 2009: OR 1 = 30%
OR 2 = 30%
OR 3 = 23%
n. May 27, 2009:
OR 1 = 30 %
OR 2 = 30%
OR 3 = 22%
o. May 28, 2009:
OR 1 = 29%
OR 2 = 31%
OR 3 = 24%
6. June 2009, Humidity Levels:
a. June 1, 2009:
OR 1 = 22%
OR 2 = 22%
OR 3 = 20%
b. June 2, 2009:
OR 1 = 22%
OR 2 = 20%
OR 3 = 20%
c. June 3, 2009:
OR 1 = 24%
OR 2 = 20%
OR 3 = 22%
d. June 4, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 21%
e. June 5, 2009:
OR 1 = 21%
OR 2 = 19%
OR 3 = 22%
f. June 15, 2009:
OR 2 = 31%
OR 3 = 30%
g. June 16, 2009:
OR 1 = 34%
OR 2 = 31%
OR 3 = 34%
h. June 17, 2009:
OR 2 = 34%
i. June 18, 2009:
OR 1 = 34%
OR 2 = 34%
j. June 19, 2009:
OR 1 = 32%
k. June 22, 2009:
OR 1 = 31%
OR 2 = 31%
l. June 23, 2009:
OR 1 = 32%
OR 2 = 28%
OR 3 = 34%
7. July 2009, Humidity Levels:
a. July 13, 2009
OR 2 = 32%
b. July 14, 2009:
OR 2 = 30%
c. July 15, 2009:
OR 2 = 32%
d. July 16, 2009:
OR 2 = 34%
8. August 2009, Humidity Levels:
a. August 5, 2009:
OR 1 = 26%
OR 2 = 28%
OR 3 = 25%
b. August 6, 2009:
OR 1 = 23%
OR 2 = 28%
OR 3 = 22%
c. August 7, 2009:
OR 1 = 29%
OR 2 = 32%
OR 3 = 30%
d. August 10, 2009:
OR 1 = 25%
OR 2 = 28%
OR 3 = 21%
e. August 11, 2009:
OR 1 = 34%
OR 2 = 34%
OR 3 = 28%
f. August 13, 2009:
OR 1 = 25%
OR 2 = 26%
OR 3 = 25%
g. August 14, 2009:
OR 3 = 32%
h. August 17, 2009:
OR 1 = 25%
OR 2 = 32%
OR 3 = 19%
i. August 18, 2009:
OR 1 = 26%
OR 2 = 30%
OR 3 = 21%
j. August 19, 2009:
OR 1 = 27%
OR 2 = 31%
OR 3 = 21%
k. August 20, 2009:
OR 1 = 28%
OR 2 = 32%
OR 3 = 22%
l. August 21, 2009:
OR 1 = 29%
OR 2 = 30%
OR 3 = 22%
m. August 24, 2009:
OR 1 = 32%
OR 2 = 31%
OR 3 = 23%
n. August 25, 2009:
OR 1 = 33%
OR 3 = 33%
o. August 26, 2009:
OR 1 = 26%
OR 3 = 33%
p. August 27, 2009:
OR 2 = 34%
OR 3 = 31%
q. August 28, 2009:
OR 1 = 26%
OR 2 = 32%
OR 3 = 32%
r. August 31, 2009:
OR 1 = 27%
OR 2 = 33%
OR 3 = 31%
9. September 2009, Humidity Levels:
a. September 1, 2009:
OR 1 = 28%
OR 2 = 32%
OR 3 = 32%
b. September 2, 2009:
OR 1 = 29%
OR 2 = 33%
OR 3 = 33%
c. September 8, 2009:
OR 1 = 29%
OR 2 = 32%
OR 3 = 30%
d. September 9, 2009: OR 1 = 30%
OR 2 = 31%
OR 3 = 30%
e. September 10, 2009:
OR 1 = 31%
OR 2 = 32%
OR 3 = 30%
f. September 11, 2009:
OR 1 = 30%
OR 2 = 34%
OR 3 = 30%
f. September 16, 2009:
OR 1 = 34%
OR 3 = 34%
g. September 17, 2009:
OR 1 = 33%
OR 3 = 32%
h. September 18, 2009:
OR 1 = 32%
OR 3 = 31%
i. September 21, 2009:
OR 1 = 30%
OR 3 = 32%
j. September 22, 2009:
OR 1 = 21%
OR 3 = 32 %
k. September 23, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 20%
l. September 24, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 19%
m. September 28, 2009:
OR 1 = 23%
OR 2 = 28%
OR 3 = 19%
n. September 29, 2009:
OR 1 = 22%
OR 2 = 27%
OR 3 = 20%
o. September 30, 2009:
OR 1 = 21%
OR 2 = 28%
OR 3 = 21%
10. October 2009, Humidity Levels:
a. October 1, 2009:
OR 1 = 20%
OR 2 = 27%
OR 3 = 22%
b. October 2, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 20%
c. October 6, 2009:
OR 1 = 21%
OR 2 = 20%
OR 3 = 21%
d. October 7, 2009:
OR 1 = 26%
OR 2 = 21%
OR 3 = 28%
e. October 8, 2009:
OR 1 = 26%
OR 2 = 27%
OR 3 = 28%
f. October 12, 2009:
OR 1 = 26%
OR 2 = 26%
OR 3 = 26%
g. October 16, 2009:
OR 3 = 34%
h. October 19, 2009:
OR 1 = 34%
OR 3 = 33%
i. October 20, 2009:
OR 1 = 32%
OR 3 = 32%
j. October 21, 2009:
OR 1 = 30%
OR 3 = 31%
k. October 22, 2009:
OR 1 = 20%
OR 2 = 32%
OR 3 = 24%
l. October 26, 2009:
OR 1 = 19%
OR 2 = 31%
OR 3 = 25%
m. October 27, 2009:
OR 1 = 21%
OR 2 = 30%
OR 3 = 22%
n. October 28, 2009:
OR 1 = 20%
OR 2 = 30%
OR 3 = 21%
o. October 29, 2009:
OR 1 = 19%
OR 2 = 29%
OR 3 = 22%
p. October 30, 2009:
OR 1 = 17%
OR 2 = 19%
OR 3 = 19%
11. November 2009, Humidity Levels:
a. November 2, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 19%
b. November 3, 2009:
OR 1 = 19%
OR 2 = 20%
OR 3 = 19%
c. November 6, 2009:
OR 1 = 21%
OR 2 = 23%
OR 3 = 22%
d. November 9, 2009:
OR 1 = 21%
OR 2 = 22%
OR 3 = 21%
e. November 10, 2009:
OR 1 = 20%
OR 2 = 21%
OR 3 = 20%
f. November 11, 2009:
OR 1 = 20%
OR 2 = 22%
OR 3 = 23%
g. November 12, 2009:
OR 1 = 22%
OR 2 = 21%
OR 3 = 22%
h. November 13, 2009:
OR 1 = 22%
OR 2 = 21%
OR 3 = 21%
i. November 16, 2009:
OR 1 = 20%
OR 2 = 22%
OR 3 = 19%
j. November 17, 2009:
OR 1 = 21%
OR 2 = 21%
OR 3 = 18%
k. November 18, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 19%
l. November 19, 2009:
OR 1 = 19%
OR 2 = 20%
OR 3 = 19%
m. November 20, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 20%
n. November 21, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 19%
m. November 22, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 = 20%
n. November 23, 2009:
OR 1 = 21%
OR 2 = 20%
OR 3 = 19%
o. November 24, 2009:
OR 1 = 19%
OR 2 = 21%
OR 3 = 19%
p. November 30, 2009:
OR 1 = 20%
OR 2 = 24%
OR 3 = 20%
12. December 2009, Humidity Levels:
a. December 1, 2009: OR 1 = 20%
OR 2 = 22%
OR 3 = 20%
b. December 2, 2009:
OR 1 = 19%
OR 2 = 23%
OR 3 = 19%
c. December 3, 2009:
OR 1 = 21%
OR 2 = 21%
OR 3 = 21%
d. December 4, 2009:
OR 1 = 22%
OR 2 = 22%
OR 3 = 22%
e. December 7th through the 11th, 2009 there was no humidity levels recorded.
f. December 14, 2009:
OR 1 = 20%
OR 2 = 22%
OR 3 = 21%
g. December 15, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 21%
h. December 16, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 20%
i. December 17, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 20%
j. December 21, 2009:
OR 1 = 20%
OR 2 = 19%
OR 3 20%
k. December 22, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 19%
l. December 23, 2009:
OR 1 = 20%
OR 2 = 21%
OR 3 = 20%
m. December 28, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 19%
n. December 29, 2009:
OR 1 = 20%
OR 2 = 20%
OR 3 = 19%
o. December 30, 2009:
OR 1 = 20%
OR 2 = 21%
OR 3 = 19%
13. January, 2009, Humidity Levels:
a. January 4, 2009:
OR 1 = 20%
OR 2 = 22%
OR 3 = 19%
b. January 5, 2009:
OR 1 = 19%
OR 2 = 19%
OR 3 = 19%

On January 5, 2009 at 2:21 p.m. during an interview with staff 6, when asked what the policy was when humidity levels were below range, staff 6 stated they were to call engineering and note the time on the form. When asked if they continue with the surgeries if the humidity levels are low staff stated yes, that they continue with the surgeries and take precautions. When asked for a copy of the policy staff 6 stated that there was no written policy. When asked if there was no written policy and procedure, what procedure does staff follow and how do they make sure all staff are following the same procedure, staff 6 stated that staff are trained when they are hired. Surgeries performed at the Outpatient Pavilion are Cataracts, Podiatry, GYN, D&C'S, Endoscopy, Laparoscopy's and Plastic surgeries and Ear, Nose and Throat, some surgeries are done under general anesthesia.
On January 6, 2010, at 10:54 a.m. during an interview with staff 1, when asked if the facilities department generates work orders when the department is notified that the humidity levels are low, staff 1 stated that each engineer has a log book and they log what they do on a daily basis, so if they are sent to check the humidity levels in any of the ORs they would log it in their book. Staff 1 stated that the engineers take a Humidity Sling and measure the humidity levels in the OR when they arrive. But no work orders are generated.
On January 6, 2009 the facility had a vendor adjust the humidity levels in 3 of 3 OR'S at the outpatient surgery pavilion. Staff 1 stated, no surgeries were performed in OR 1 because they were not able to adjust the humidity level to stay within range.

Corridor Separation:
Based on observation, the facility failed to maintain corridor doors in the Outpatient Surgery Pavilion based on corridor doors that failed to positive latch and doors blocked from closure. This would allow for smoke and fire to travel and possible harm to patients and staff in the event of a fire.

Findings:

During a tour of the facility with facility Staff 1 and Staff 6 on January 5, 2010, the corridor doors in the outpatient Surgery Pavilion were observed.

1. At 1:38 p.m., the Minor Treatment room door failed to positive latch upon closure.

2. At 2:00 p.m., the Anesthesia Office door was blocked from closing by a rubber door wedge.

3. At 2:10 p.m., the Anesthesia Work Room door failed to positive latch upon closure.

During a tour of the facility with facility Staff 1, Staff 5 and Staff 6 on January 5, 2010 and January 6, 2010, the electrical system was observed.

Based on observation the facility failed to maintain its electrical equipment and appliances in 4 of 16 smoke compartments and 2 of 4 off site facility clinics, as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets and items being stored within 3 feet of the electrical panels and panels with blank spacers missing. These findings could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

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

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

Findings:

During a tour of the facility with facility Staff 1, Staff 5 and Staff 6 on January 5, 2010 and January 6, 2010, the electrical system was observed.

On January 5, 2010:
1. At 9:37 a.m., in Med Surg Unit A, Building 23, the HHS 2-309 Office had a refrigerator and a microwave plugged into a multi-plug power strip and not directly into the wall.

2. At 10:55 a.m., in Office 2-357, there was a refrigerator plugged into a multi-outlet adapter.

3. At 11:26 a.m. the electrical panel marked X-Ray Room was missing 2 blank spacers at the Community Health Center Apple Valley
4. At 11:47 a.m. the electrical panel in the back hall was missing 3 blank spacers.
At 2:15 p.m., the Outpatient Surgery Pavilion Business Office had an electrical cover plate that had fallen to the floor behind the copy machine.
5. At 1:50 p.m., in the Nutrition and Guest Services Directors Office, Old ER Basement, there was a microwave plugged into a multi-outlet adapter.
6. At 2:15 p.m. electrical panels LIA and LIA 1 had an approximately 6 foot supply cart stored in front of the 2 electrical panels at the outpatient surgery center.
7. At 2:40 p.m., in Medical Surgical South, Room 2504, there was a refrigerator plugged into a multi-outlet adapter.

On January 6, 2010:
1. At 9:53 a.m., the Pathology/Transcription Office where the fire alarm panel is located had a refrigerator and a microwave plugged into a multi-plug power strip and not directly into the wall.
2. At 2:40 p.m., in the DPS Office, there was a microwave plugged into a multi-outlet adapter.












27961

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. This could cause a fire and potential harm to patients and staff in the event of a fire.

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: