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Based on observation, document review, and interview, the facility failed to maintain its fire barriers, as evidenced by the facility's failure to maintain a two hour fire barrier separation as required between the hospital and the Distinct Part Skilled Nursing Facility. This affected all residents and could result in the expedited spread of smoke or fire.

NFPA 101, 2000 Edition
7.2.4.3 Fire Barriers.

7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)

Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:

(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

8.2.3.2.3 Opening Protectives.

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:

(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).

(3) 1/2-hour fire barrier - 20-minute fire protection rating.

Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire barrier separation between the hospital and the distinct part skilled nursing facility was observed. The fire barrier wall by the Skilled Nursing Facility's Nurses Station was a concrete wall. The doors protecting the opening were 20-minute fire rated doors. The Distinct Part Skilled Nursing Facility did not have a 2-hour fire barrier separation at that location with the required 90 minute doors.

When interviewed, the Facilities Project Manager stated that the fire doors were on order. A review of an e-mail communication between the vendor and the Facilities Project Manager dated 7/18/12 revealed that delivery of the fire doors from the manufacturer could be expected at the end of August.

Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations in the walls and ceiling. This could result in the passage of smoke in the event of a fire, and affected two of three smoke compartments.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the walls and ceiling were observed.

1. At 3:44 p.m., there were four approximately 1/4 inch penetrations in the ceiling of the Supply Closet between the Clean Utility Room and Room 25.

2. At 4:10 p.m., there was an approximately 1 1/2 inch penetration in the ceiling at the top of the escutcheon plate in the Pharmacy Manager's Office Store Room and a 2 1/2 inch by 1/4 inch penetration at the top of the outlet at the Pharmacy Manager's desk.

3. At 4:46 p.m., there was an approximately 1 inch penetration near the ceiling in the east wall of the Phone Room.

4. At 5:05 p.m., there was an approximately 2 inch penetration in the ceiling at the Exit Sign above the fire door leading to the Distinct Part Skilled Nursing Facility.

Based on observation, the facility failed to maintain its corridor doors, as evidenced by doors that were obstructed from closing or that failed to latch. This could result in the passage of smoke and flames in the event of a fire, and affected two of three smoke compartments.

Findings:

During a tour of the facility with the Facilities Maintenance Staff on 7/18/12, the corridor doors were observed and tested.

1. At 3:42 p.m., door closure to Room 25 was obstructed by the foot of Bed 25 B.

2. At 3:46 p.m., door closure to Room 21 was obstructed by a chair at the foot of Bed 21 B. The door failed to latch when tested.

3. At 3:50 p.m., the door to the Med Staff Conference Room and Library failed to latch when tested because of a metal plate on the door. The door was held open to its fullest extent and allowed to close.

4. At 4:14 p.m., the right half of the door to the Pharmacy failed to close when tested, which left a 3-inch gap between both halves of the door. The door was held open to its fullest extent and allowed to close.

Based on record review, the facility failed to have pertinent supervisory staff review and acknowledge revisions to its Emergency Plan, as evidenced by a current revision that was not reviewed. This could result in delayed evacuation in the event of an emergency, and affected all staff and patients.

Findings:

During record review at 10:47 a.m., documents revealed that the Safety and Disaster Plan and Policy was updated May 2012. There was no indication that the policy was reviewed and acknowledged by supervisory personnel.

Based on observation, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 25, as evidenced by a missing escutcheon plate and by foreign materials or objects on two sprinklers. This could result in an obstruction to the sprinklers' spray patterns, which could lead to the sprinklers malfunctioning in the event of a fire, and affected one of three smoke compartments.

NFPA 25, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the sprinklers were observed.

1. At 2:55 p.m., the escutcheon plate was missing from the the sprinkler above the tub in the East Wing Patient Bathroom.

2. At 4:50 p.m., there was painter's tape on the sprinkler in the Admin. Break Room.

3. At 4:51 p.m., the pull cord of a light fixture in the Admin Bathroom Storage Closet was wrapped around the sprinkler's deflector located in the closet.

Based on observation, the facility failed to maintain its automatic sprinkler system, as evidenced by a blocked fire department connection (FDC) assembly. This could result in delayed extinguishment by the fire department in the event of a fire, and affected all staff and patients.

NFPA 13, 1999 Edition
3-9.2 Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the automatic sprinkler system was observed.

At 5:15 p.m., access to the fire department connection (FDC) was blocked by a picnic table.

Based on observation, the facility failed to maintain its fire extinguishers, as evidenced by a fire extinguisher that was mounted above the required height. This could result in staff's inability to readily access the fire extinguisher in the event of a fire, and affected one of three smoke compartments.

NFPA 10, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 ½ ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire extinguishers were observed.

At 3:10 p.m., the fire extinguisher located in the CCU was mounted 69 inches from the floor to the top of the nozzle. The extinguisher was mounted in a recessed cabinet.

Based on document review and interview, the facility failed to maintain its building service equipment, as evidenced by the lack of inspection and maintenance on the dampers within the past four years. The absence of proper maintenance could result in the dampers malfunctioning in the event of a fire, and affected all staff and patients in three of three smoke compartments.

NFPA 90 A, 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire and smoke damper maintenance and inspection records were requested.

At 10:53 a.m., a hand-written document titled "Smoke Dampers" indicated the locations of the facility's dampers, but did not indicate if any inspection or maintenance was performed. The first dated entry was in 2008.

When interviewed, the Maintenance Engineer stated that the dampers were serviced but not documented.

Based on record review and interview, the facility failed to maintain its building services, as evidenced by the absence of documentation that indicated the kitchen's hood steam cleaning was performed by properly trained and qualified persons. This could result in damage to the kitchen's hood system, and affected one of three smoke compartments.

NFPA 96, 1998 Edition
8-3 Cleaning.

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 acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Findings:

During a review of records, kitchen hood cleaning documents were requested.

At 10:55 a.m., a document titled "Biweekly Cleaning of the Hood" revealed a checklist of various kitchen staff responsible for cleaning the kitchen hood. The document did not indicate the procedure used to clean the hood or if the kitchen staff was properly trained or qualified to perform the duties required to clean the exhaust system to bare metal.

When interviewed, the Maintenance Engineer stated that the facility does not utilize the services of a certified vendor.

Based on record review and interview, the facility failed to maintain its piped in medical gas system, as evidenced by discrepancies discovered during an annual inspection that were not addressed in a timely manner. This could result in failure of the medical gas system, and affected all patients of the hospital.

Findings:

During record review at 10:37 a.m., the annual medical gas testing and inspection records were requested. A document titled "Discrepancies: Medical Gas System" dated 6/18/12 revealed that the medical air was "outside of NFPA acceptable operating pressure" at 42 psig in OR 1B, OR 2B, CCU/ICU Bed 1, CCU/ICU Bed 2, CCU/ICU Bed 3, and CCU/ICU Bed 4.

When interviewed, the Maintenance Engineer stated the discrepancies were not corrected, and that the vendor suggested disconnection of the system and implementation of the use of single portable oxygen cylinders in the ICU department.

Based on observation, the facility failed to maintain its electrical wiring and equipment, as evidenced by the unauthorized use of power strips and by a missing receptacle faceplate. This could result in the increased risk of fire, and affected one of three smoke compartments.

NFPA 70, 1999 Edition
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the electrical wiring and equipment were observed.

1. At 2:20 p.m., a 1500-watt single-cup coffee brewer in the ER Staff Room was plugged into a wall-mounted power strip.

2. At 3:21 p.m., a small refrigerator in the Med Surg Medication Room was plugged into a power strip.

3. At 4:46 p.m., the faceplate was missing from the outlet located near the ceiling on the east wall of the Phone Room.

Based on record review, the facility failed to provide policies and procedures in the event the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. This could result in the lack of protection of all staff, patients, and visitors in the event of a fire.

Findings:

During record review on 7/18/2012 the facility disaster manual records were reviewed.

At 9:51 a.m., the fire watch policy was requested. The documents provided revealed that the policy did not contain fire watch procedures in case of a failure of the automatic sprinkler system for more than four hours.

Based on observation, document review, and interview, the facility failed to maintain its fire barriers, as evidenced by the facility's failure to maintain a two hour fire barrier separation as required between the hospital and the Distinct Part Skilled Nursing Facility. This affected all residents and could result in the expedited spread of smoke or fire.

NFPA 101, 2000 Edition
7.2.4.3 Fire Barriers.

7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)

Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:

(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

8.2.3.2.3 Opening Protectives.

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:

(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).

(3) 1/2-hour fire barrier - 20-minute fire protection rating.

Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire barrier separation between the hospital and the distinct part skilled nursing facility was observed. The fire barrier wall by the Skilled Nursing Facility's Nurses Station was a concrete wall. The doors protecting the opening were 20-minute fire rated doors. The Distinct Part Skilled Nursing Facility did not have a 2-hour fire barrier separation at that location with the required 90 minute doors.

When interviewed, the Facilities Project Manager stated that the fire doors were on order. A review of an e-mail communication between the vendor and the Facilities Project Manager dated 7/18/12 revealed that delivery of the fire doors from the manufacturer could be expected at the end of August.

Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations in the walls and ceiling. This could result in the passage of smoke in the event of a fire, and affected two of three smoke compartments.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the walls and ceiling were observed.

1. At 3:44 p.m., there were four approximately 1/4 inch penetrations in the ceiling of the Supply Closet between the Clean Utility Room and Room 25.

2. At 4:10 p.m., there was an approximately 1 1/2 inch penetration in the ceiling at the top of the escutcheon plate in the Pharmacy Manager's Office Store Room and a 2 1/2 inch by 1/4 inch penetration at the top of the outlet at the Pharmacy Manager's desk.

3. At 4:46 p.m., there was an approximately 1 inch penetration near the ceiling in the east wall of the Phone Room.

4. At 5:05 p.m., there was an approximately 2 inch penetration in the ceiling at the Exit Sign above the fire door leading to the Distinct Part Skilled Nursing Facility.

Based on observation, the facility failed to maintain its corridor doors, as evidenced by doors that were obstructed from closing or that failed to latch. This could result in the passage of smoke and flames in the event of a fire, and affected two of three smoke compartments.

Findings:

During a tour of the facility with the Facilities Maintenance Staff on 7/18/12, the corridor doors were observed and tested.

1. At 3:42 p.m., door closure to Room 25 was obstructed by the foot of Bed 25 B.

2. At 3:46 p.m., door closure to Room 21 was obstructed by a chair at the foot of Bed 21 B. The door failed to latch when tested.

3. At 3:50 p.m., the door to the Med Staff Conference Room and Library failed to latch when tested because of a metal plate on the door. The door was held open to its fullest extent and allowed to close.

4. At 4:14 p.m., the right half of the door to the Pharmacy failed to close when tested, which left a 3-inch gap between both halves of the door. The door was held open to its fullest extent and allowed to close.

Based on record review, the facility failed to have pertinent supervisory staff review and acknowledge revisions to its Emergency Plan, as evidenced by a current revision that was not reviewed. This could result in delayed evacuation in the event of an emergency, and affected all staff and patients.

Findings:

During record review at 10:47 a.m., documents revealed that the Safety and Disaster Plan and Policy was updated May 2012. There was no indication that the policy was reviewed and acknowledged by supervisory personnel.

Based on observation, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 25, as evidenced by a missing escutcheon plate and by foreign materials or objects on two sprinklers. This could result in an obstruction to the sprinklers' spray patterns, which could lead to the sprinklers malfunctioning in the event of a fire, and affected one of three smoke compartments.

NFPA 25, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the sprinklers were observed.

1. At 2:55 p.m., the escutcheon plate was missing from the the sprinkler above the tub in the East Wing Patient Bathroom.

2. At 4:50 p.m., there was painter's tape on the sprinkler in the Admin. Break Room.

3. At 4:51 p.m., the pull cord of a light fixture in the Admin Bathroom Storage Closet was wrapped around the sprinkler's deflector located in the closet.

Based on observation, the facility failed to maintain its automatic sprinkler system, as evidenced by a blocked fire department connection (FDC) assembly. This could result in delayed extinguishment by the fire department in the event of a fire, and affected all staff and patients.

NFPA 13, 1999 Edition
3-9.2 Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the automatic sprinkler system was observed.

At 5:15 p.m., access to the fire department connection (FDC) was blocked by a picnic table.

Based on observation, the facility failed to maintain its fire extinguishers, as evidenced by a fire extinguisher that was mounted above the required height. This could result in staff's inability to readily access the fire extinguisher in the event of a fire, and affected one of three smoke compartments.

NFPA 10, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 ½ ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire extinguishers were observed.

At 3:10 p.m., the fire extinguisher located in the CCU was mounted 69 inches from the floor to the top of the nozzle. The extinguisher was mounted in a recessed cabinet.

Based on document review and interview, the facility failed to maintain its building service equipment, as evidenced by the lack of inspection and maintenance on the dampers within the past four years. The absence of proper maintenance could result in the dampers malfunctioning in the event of a fire, and affected all staff and patients in three of three smoke compartments.

NFPA 90 A, 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the fire and smoke damper maintenance and inspection records were requested.

At 10:53 a.m., a hand-written document titled "Smoke Dampers" indicated the locations of the facility's dampers, but did not indicate if any inspection or maintenance was performed. The first dated entry was in 2008.

When interviewed, the Maintenance Engineer stated that the dampers were serviced but not documented.

Based on record review and interview, the facility failed to maintain its building services, as evidenced by the absence of documentation that indicated the kitchen's hood steam cleaning was performed by properly trained and qualified persons. This could result in damage to the kitchen's hood system, and affected one of three smoke compartments.

NFPA 96, 1998 Edition
8-3 Cleaning.

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 acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Findings:

During a review of records, kitchen hood cleaning documents were requested.

At 10:55 a.m., a document titled "Biweekly Cleaning of the Hood" revealed a checklist of various kitchen staff responsible for cleaning the kitchen hood. The document did not indicate the procedure used to clean the hood or if the kitchen staff was properly trained or qualified to perform the duties required to clean the exhaust system to bare metal.

When interviewed, the Maintenance Engineer stated that the facility does not utilize the services of a certified vendor.

Based on record review and interview, the facility failed to maintain its piped in medical gas system, as evidenced by discrepancies discovered during an annual inspection that were not addressed in a timely manner. This could result in failure of the medical gas system, and affected all patients of the hospital.

Findings:

During record review at 10:37 a.m., the annual medical gas testing and inspection records were requested. A document titled "Discrepancies: Medical Gas System" dated 6/18/12 revealed that the medical air was "outside of NFPA acceptable operating pressure" at 42 psig in OR 1B, OR 2B, CCU/ICU Bed 1, CCU/ICU Bed 2, CCU/ICU Bed 3, and CCU/ICU Bed 4.

When interviewed, the Maintenance Engineer stated the discrepancies were not corrected, and that the vendor suggested disconnection of the system and implementation of the use of single portable oxygen cylinders in the ICU department.

Based on observation, the facility failed to maintain its electrical wiring and equipment, as evidenced by the unauthorized use of power strips and by a missing receptacle faceplate. This could result in the increased risk of fire, and affected one of three smoke compartments.

NFPA 70, 1999 Edition
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with Facilities Management Staff on 7/18/12, the electrical wiring and equipment were observed.

1. At 2:20 p.m., a 1500-watt single-cup coffee brewer in the ER Staff Room was plugged into a wall-mounted power strip.

2. At 3:21 p.m., a small refrigerator in the Med Surg Medication Room was plugged into a power strip.

3. At 4:46 p.m., the faceplate was missing from the outlet located near the ceiling on the east wall of the Phone Room.

Based on record review, the facility failed to provide policies and procedures in the event the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. This could result in the lack of protection of all staff, patients, and visitors in the event of a fire.

Findings:

During record review on 7/18/2012 the facility disaster manual records were reviewed.

At 9:51 a.m., the fire watch policy was requested. The documents provided revealed that the policy did not contain fire watch procedures in case of a failure of the automatic sprinkler system for more than four hours.