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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in some walls. This could result in the spread of smoke and flames in the event of a fire. This affected 2 of 5 smoke compartments.

Findings:

On a tour of the facility from April 23, 2012 through April 25, 2012, the walls were observed.

April 24, 2012-
1. At 11:16 a.m., there was an approximately 3 inch diameter penetration in the back wall of the emergency water supply room.

2. At 11:21 a.m., there was an approximately 1 foot by 1 foot cut out in the wall behind Washer 2. During an interview, Maintenance Staff 1 stated they had been doing some repairs but had not repaired the wall.

3. At 2:01 p.m., there was an approximately 2 inch penetration on the right side, of the back wall, of the x-ray room around the data/electrical cover plate.

4. At 2:11 p.m., there was an approximately 2 inch diameter penetration, around a pipe, in the dark room back wall.

Based on observation, the facility failed to maintain the doors in corridor openings free from impediments and failed to maintain the smoke resistance of the doors. This was evidenced by one door that was obstructed from closing and by one door with penetrations in the door. This could result in the spread of smoke and fire, in the event of a fire and affected 2 of 5 smoke compartments.

Findings:

During a tour of the facility from April 23, 2012, through April 25, 2012, the doors were observed.

April 24, 2012-
1. At 11:22 a.m. and 1:48 p.m., the lobby/receptionist office door was held in the open position by boxes placed between the door and the door frame. The door was equipped with a self closing device.

April 25, 2012-
2. At 1:46 p.m., the door knob had been removed from the B-Wing medication room door, leaving 4 holes in the door. This compromised the 30 minute rating of the door.

Based on observation, the facility failed to maintain the smoke barrier walls in 4 of 5 smoke compartments. This had the potential to allow the passage of smoke and flames in the event of a fire.

Findings:

On a tour of the facility from April 23, 2012 through April 25, 2012, the smoke barrier walls were observed.
April 24, 2012 -
1. At 10:34 a.m., there was an approximately 6 inch diameter penetration in the wall of the smoke barrier, above the exit door, to the lobby.

2. At 10:45 a.m., there was an approximately 3 inch diameter conduit penetrating the smoke barrier wall above the operating room suite. The conduit was unsealed.

3. At 10:47 a.m., there was an approximately 2 inch penetration and an approximately 8 inch diameter conduit, around bundles of wires, in the smoke barrier wall by medical records coding. It was not sealed on either side of the smoke barrier wall. There was an approximately 3 inch gap between the smoke barrier and the corridor wall, in the left hand corner, above the ceiling.

Based on observation, the facility failed to maintain the exit signs in accordance with NFPA 101, Life Safety Code. This was evidenced by an exit sign that was not illuminated. The sign contained 2 light bulbs.
This could cause a delay in exiting from one area in the event of an emergency. This affected 1 of 5 smoke compartments.

Findings:

On April 24, 2012, during a tour of the facility with staff, the exit signs were observed.

At 2:23 p.m., the exit signs were observed in the kitchen. The exit sign by the dry storage room had 1 of 2 light bulbs burnt out.

Based on document review and interview, the facility failed to provide documentation for 1 of 2 required disaster drills. This affected 5 of 5 smoke compartments and could result in a delay in staff response in the event of a fire or other emergency.

NFPA 99, Health Care Facilities, 1999 Edition
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

On April 23, 2012, at 11:45 a.m., the disaster drills were requested from Maintenance Staff 1.

At 2:05 p.m., the facility provided 1 disaster drill record, dated February 2, 2011, for downed power lines.

At 3:58 p.m., during review of Policy Environment of Care Program, page 8 of 14, notes Emergency Preparedness semi annual drills are conducted (at least four months apart) and evaluated.

During an interview on April 25, 2012, at 11:00 a.m., the maintenance supervisor confirmed that there were no other documents for disaster drills.

Based on document review and interview, the facility failed to provide documentation for 5 of 8 required fire drills, in accordance with NFPA 101, Life Safety Code. This affected the entire facility and could result in a delay in staff response in the event of a fire and could delay evacuation.

Findings:

On April 23, 2012, at 2:00 p.m., during an interview with the maintenance supervisor, he stated they were out of compliance in regards to the fire drills.

At 2:09 p.m., during review of the Fire Drill Evaluation Form no documentation was provided five fire drills.
1. There were no records for a drill in the second quarter 2011, 1st shift (7:00 a.m., to 7:00 p.m.).
2. There were no records for drills in the third quarter 2011, 1st shift and
2nd shift (7:00 p.m. to 7:00 a.m.).
3. There were no records for drills in the fourth quarter 2011, 1st shift or
2nd shift.

Based on document review and interview the facility failed to provide documentation of annual testing of the complete fire alarm system, in accordance with NFPA 72, National Fire Alarm Code, 1999 edition.
This may result in the failure of the fire alarm panel in the event of an emergency. This has the potential to affect 5 of 5 smoke compartments.

Findings:
During document review on April 23, 2012, through April 25, 2012, the quarterly fire alarm tests were reviewed for the 2nd quarter, 3rd quarter, and 4th quarter of 2011, and the 1st quarter 2012. The fire alarm test reports provided gave no indication that the testing and maintenance of the fire alarm panel was completed. Maintenance and testing of the fire alarm panel should be completed in accordance with NFPA 72, table 7-3.2.
On April 25, 2012, at 11:00 p.m., during an interview with the maintenance supervisor, he stated that when they are testing the smoke detectors and pull stations they are at the panel resetting it.

Based on document review, the facility failed to provide documentation of annual testing of the complete fire alarm system, in accordance with NFPA 72, National Fire Alarm Code. This could result in the failure of the fire alarm panel in the event of a fire. This could potentially affect 5 of 5 smoke compartments and delay notification to patients and staff.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-5.2., Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During document review from April 23, 2012, through April 25, 2012, the quarterly fire alarm tests were reviewed for the the last three quarters in 2011, and the 1st quarter 2012. The fire alarm test reports failed to indicate that testing and maintenance of the fire alarm panel was completed. Maintenance and testing of the fire alarm panel should be completed in accordance with NFPA 72, table 7-3.2.

Based on document review and interview, the facility failed to maintain all smoke detectors in the facility. This was evidenced by no records for smoke detector sensitivity testing and weekly testing on battery operated smoke detectors. This affected 5 of 5 smoke compartments and the CT Scan trailer. This has the potential for smoke detector failure in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: The requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using an device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review on April 23, 2012, the quarterly fire alarm tests were reviewed. There was no documentation provided for smoke detector sensitivity testing.
At 2:25 p.m., during an interview, the maintenance supervisor stated that the sensitivity testing had not been completed.

On April 25, 2012, at 2:55 p.m., the smoke detectors were observed in the CAT Scan mobile trailer. There were 4 hardwired smoke detectors and 3 battery operated smoke detectors in the trailer.

During review of the preventative maintenance book, provided by the facility, no notation was made regarding testing of the hardwired smoke detectors or the battery operated smoke detectors in the CAT Scan trailer. The manufacturer's recommendation is to test weekly. There was no indication as to when the batteries were last changed in the battery operated smoke detectors.

During an interview, the maintenance supervisor stated he does not test these detectors and neither does the vendor. He stated all testing and maintenance is done by the vendor who owns the trailer.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. This was evidenced by the failure to repair the exterior sprinkler gong for 3 of 3 months. This could result in a delay of notification to the facility, in the event the sprinkler system was activated.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Base Fire Protection Systems, 1998 Edition
1-4.4 The owner or occupant promptly shall correct or repair
deficiencies, damaged parts, or impairments found while performing
the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

Findings:

During document review on April 23, 2012, at 12: 19 p.m., the Inspection, Testing and Maintenance of Water Based Fire Protection Systems form, dated January 17, 2012, was reviewed. The record indicated that the electrical alarm gong, had no power and no alarm.

On April 25, 2012, at 1:50 p.m., during an interview, the maintenance supervisor stated the gong had not been repaired.

Based on observation, the facility failed to maintain the fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was evidenced by the failure to conduct monthly inspections for 3 of 3 fire extinguishers in the CT Scan trailer. This could result in the potential failure of the fire extinguishers in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers 1998 edition.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

On April 25, 2012, during a tour of the CT Scan mobile trailer, the fire extinguishers were observed.
At 3:00 p.m., 3 of 3 fire extinguishers had no monthly inspections since the annual service in January 2012.

Based on interview and document review, the facility failed to provide documentation for the inspection and testing of the facility dampers. This affected 5 of 5 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
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:

On April 23, 2012, at 2:18 p.m., the maintenance supervisor was interviewed and asked if the facility dampers were operated by fusible links or smoke detectors. The maintenance supervisor reported he thought the dampers were operated by fusible links. Documentation for damper testing was requested. The maintenance supervisor stated it had not been done.

On April 24, 2012, at 9:45 a.m., the maintenance supervisor stated the dampers were mechanical. When asked how many dampers he stated he did not know. The facility has no drawings or map showing the location of the dampers in the facility. No damper locations were identified in the corridors or attic access areas.

Based on document review and interview, the facility failed to provide documentation for the service of the kitchen hood suppression system every 6 months as required. This affected 1 of 5 smoke compartments and could result in the failure of the suppression system in the event of a fire.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition
8-2 Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.

Findings:

On April 23, 2012, during document review, the facility provided documentation for one kitchen hood fire suppression system service and inspection, dated March 23, 2012. Records for the previous inspection on or around September 2011, were requested.

On April 25, 2012, at 11:15 a.m., during an interview, the facility maintenance supervisor stated he had no further documentation for inspection of the kitchen hood suppression system. He was not sure if the system had been inspected.

Based on document review and interview, the facility failed to maintain the humidity levels in 2 of 2 operating rooms in accordance with NFPA 99, Health Care Facilities. This was evidenced by humidity levels below 35 percent, by the failure to report out of range levels to the maintenance supervisor, and by the failure to adjust humidity levels when needed. This affected 2 of 2 operating rooms and had the potential to increase the risk of fire.

Findings:

On April 23, 2012, at 3:16 p.m., the policy and procedure for monitoring humidity levels in the operating rooms was reviewed. The policy notes the range will be maintained between 40 percent and 60 percent.
The operating rooms logs for humidity levels indicated the range should be maintained between 30 percent and 60 percent.

On April 25, 2012, at 11:33 a.m., the humidity logs were reviewed.
Records indicated humidity levels were out of range as follows:
Operating Room 1 -
1. In January 2012, humidity levels were out of range on 4 of 18 days the OR was used.
2. In February 2012, humidity levels were out of range on 15 of 15 days the OR was used.
3. In March 2012, humidity levels were out of range on 10 of 15 days the OR was used.

Operating Room 2 -
1. January 2012, humidity levels were out of range on 8 of 18 days the OR was used.
2. February 2012, humidity levels were out of range on 15 of 15 days the OR was used.
3. March 2012, humidity levels were out of range on 11 of 16 days the OR was used.

The humidity logs for 2 of 2 operating rooms for April 2012, were reviewed. The only date humidity was recorded was April 2, 2012. Other surgeries were performed in April. 10 procedures were performed on April 20, 2012, 6 procedures were performed on April 19, 2012, and one procedure was performed on April 18, 2012. No documentation was made for humidity levels on these dates. During an interview, Nursing Staff 1 stated that the operating room nurse forgot to record humidity levels on these dates.

At 1:42 p.m., during an interview, the maintenance supervisor was asked if the operating room staff report to maintenance when the humidity levels were out of range. He stated no. He stated there is no way to adjust the humidity levels in the operating rooms, and that he is looking into ways to correct this so they can adjust the humidity levels.

Based on observation and interview, the facility failed to maintain the remote annunciator for the emergency generator and to provide documentation for the maintenance and testing of the generator for the CT Scan mobile trailer. This could result in a delay in notifying staff if the emergency generator malfunctions. This affected the entire hospital.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS (Emergency Power Supply) service room at a work site readily observable by personnel.

Findings:

On April 23, 2012, at 1:34 p.m., the Emergency Generator Log and Generator Testing Log were reviewed. No documentation was provided for a 30 minute load test for May 2011.

During a tour of the facility with the maintenance supervisor, on April 24, 2012, at 11:05 a.m., the remote annunciator was observed at the nurses station on the medical/surgical unit. During an interview at 11:06 a.m., the maintenance supervisor stated it was not working. There were no lights illuminated on the annunciator panel. Maintenance Staff 1 pushed the test button and no lights illuminated.

On April 25, 2012, at 3:28 p.m., there was a generator installed for the mobile CT trailer. The maintenance supervisor stated he does not test this generator and does not even have a key to access the generator. The generator is located at the back of the trailer in a locked compartment.

At 3:40 p.m., during review of the preventive maintenance logs for the unit, no documentation was provided to indicate the generator is tested or maintained in accordance with NFPA 110.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code and NFPA 99 Health Care Facilities. This was evidenced by medical equipment plugged into surge protectors and by the use of extension cords. This could result in an increased risk of fire. This affected the entire facility.

NFPA 99, Health Care Facilities, 1999 Edition
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
3-3.4.2.3 Maintenance and Testing of Electrical System.
(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital grade shall be tested at intervals not exceeding 12 months.

3-3.4.3 Recordkeeping.
3-3.4.3.1* General. A record shall be maintained of the tests required by this chapter and associated repairs or modifications. At a minimum, this record shall contain the date, the rooms or areas tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

NEC 70, National Electrical Code, 1999 Edition
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:

On April 24, 2012, during a tour of the facility with maintenance supervisor the electrical wiring and equipment was observed.
1. At 2:19 p.m., in the lab storage room, the refrigerator and freezer were plugged into a surge protector and not directly into the wall.
2. At 2:07 p.m., in the radiologist office there was an extension cord in use.