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Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls. This has the potential to cause the spread of smoke and flames in the event of a fire. This affected 4 of 6 smoke compartments on the first floor and 1 of 1 compartment in the basement. Smoke compartments are utilized to separate one area from another to prevent the spread of smoke and fire.

Findings:

On a tour of the facility from March 26, 2012 through March 30, 2012, the walls were observed.

March 27, 2012 - 1st Floor
At 1:58 p.m., the phone line cover plate was not attached to the wall, exposing an approximately 4 inch penetration in the back wall, behind the copy machine, of the triage area.
At 2:13 p.m., there was an approximately 4 inch diameter penetration on the wall behind the door, in the physicians' lounge.
At 2:30 p.m., there were three approximately 1/8 inch to 1/2 inch penetrations, in the back wall of the admission managers office.

March 28, 2012 - 1st Floor
Behavioral Health Unit (BHU)
At 10:56 a.m., there were two approximately 1 inch penetrations in Room 8.
At 10:58 a.m., there were two approximately 1/2 inch penetrations on the east wall in the scanning room.

Basement
At 2:43 p.m., there were five approximately 1/4 inch to 1/2 inch penetrations, in the telephone room on the east wall.

Based on observation, the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that failed to latch when closed, and by doors that were blocked or wedged open. This affected 2 of 6 smoke compartments on the first floor and 2 of 2 compartments on the second floor. This has the potential to cause the spread of smoke and flames in the event of a fire.

Findings:

On a tour of the facility from March 26, 2012 through March 30, 2012, the corridor doors were observed.

March 27, 2012 - First Floor
At 3:23 p.m., the MD/Conference room door was obstructed from closing by a table placed in front of the door.

March 28, 2012 - BHU
Pediatrics
At 11:10 a.m., the patient nourishment door failed to close and latch.
At 11:11 a.m., the nurse station door had a piece of cardboard wedged under the door to keep it open. When the cardboard was removed the door failed to close and latch.
At 11:12 a.m., the dirty utility room door failed to close and latch.

Second Floor
At 2:21 p.m., the dialysis supply room door had cardboard taped over the latching plate preventing the door from latching. When the cardboard was removed there was paper inside the latching plate, that prevented the door from latching. When the cardboard and paper were removed the door closed and latched.
At 2:28 p.m., the staff lounge/patient nourishment room door failed to latch upon self closure.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in one smoke barrier wall. This has the potential to allow the spread of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments on the 1st floor.

Findings:

During a tour of the facility on March 27, 2012, with staff, the smoke barrier walls were observed. At 2:26 p.m., the smoke barrier wall by the radiologist office had an approximately 3 inch diameter conduit penetrating the wall, around communication wires. The conduit was unsealed on both sides of the wall.

Based on observation and interview, the facility failed to ensure the smoke barrier doors close and latch during activation of the fire alarm system. This was evidenced by four doors that failed to release and close during fire alarm system testing. This could result in the spread of smoke and flames in the event of a fire. This affected 1 of 1 smoke compartment in the basement and 1 of 6 smoke compartments on the 1st floor.

Findings:

During fire alarm system testing with facilities staff, on March 29, 2012, the smoke barrier doors were observed.

1st Floor
At 2:56 p.m., the right leaf of the smoke barrier doors by the Cath lab failed to latch.
At 3:41 p.m., the horizontal smoke barrier door in front of operating room 4 failed to close upon activation of the the smoke detectors on each side of the door.

During an interview at 3:43 p.m., the vendor stated that the door should close when the smoke detectors were activated.

2nd Floor
At 3:55 p.m., the left door of the smoke barrier failed to latch upon closure, at the smoke barrier doors by Room 204.

At 4:11 p.m., and 4:13 p.m., the horizontal door in the cafeteria failed to close when smoke detectors on each side of the door were activated.

During an interview at 4:14 p.m., the vendor stated that the door has a fusible link but should close upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the doors in hazardous areas. This was evidenced by one door that was not self closing and was obstructed from closing. This affected 1 of 6 smoke compartments on the first floor and had the potential to cause the spread of smoke and flames in the event of a fire.

Findings:

On March 27, 2012, during a tour of the facility with facilities staff, the hazardous areas were observed.

At 1:41 p.m., in the Emergency Room, the biohazard/soiled utility room door was not equipped with a self closing device. The door was obstructed from closing by a chair.

Based on observation, interview and document review, the facility failed to provide and maintain emergency lighting. This was evidenced by no emergency lights or back up power in the GI lab, by one emergency light that failed when tested with the test button, and by no documentation for testing and maintenance of the emergency lights. This affected 6 of 6 smoke compartments on the 1st floor. This had the potential to result in harm to patients in the GI lab, and delay egress from the facility in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
7-.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

1. On March 27, 2012, at 9:30 a.m., the GI Lab was observed. There were no emergency lights visible in the GI Lab. There were no designated emergency outlets in the lab.

During an interview at 9:32 a.m., the GI Lab Nurse was asked if the room had emergency power or lighting. She stated no, if the power goes out it is "pitch black in here." The GI Nurse did not know if the machines had back up batteries except for the vital signs machine which did.

On March 28, 2012 at 8:30 a.m., the facility floor plan was reviewed. The floor plan identified the GI Lab in the area where the Birth Certificate Room currently was located.

At 9:00 a.m., during an interview, GI Lab staff reported they do outpatient GI testing, and when the census is high they do about 5 procedures a day with sedation and conscious sedation. They average approximately 2 to 3 cases a day.

GI Staff was asked if there was a procedure going on and the lights went out what procedure would they follow. GI Staff stated they wait to see if the lights go back on, and if they don't they would take the patient back to the outpatient area. Staff stated the emergency cases are done in the emergency room or the ICU.

At 9:37 a.m., during an interview, Facilities Staff 1 was unaware the room had no emergency lights or power.

At 9:42 a.m., during an interview, the Director of Ancillary Services reported she believed it (the GI Lab) was moved because of outpatients going into inpatient areas.

On March 28, 2012, at 10:09 a.m., an Immediate Jeopardy was identified in the GI Lab. The lab had no emergency lighting or power. The CEO (Chief Executive Officer), Director of Ancillary Services, CNO (Chief Nursing Officer), Director of Quality and Risk Management Compliance Officer, were notified of the immediate jeopardy.

On March 29, 2012, at 8:44 a.m., the Immediate Jeopardy was abated after receiving an acceptable plan of correction. The CEO and Director of Ancillary Services provided a plan to discontinue use of the GI lab until emergency power was provided.


2. During document review on March 26, 2012 , the documentation for the testing and maintenance of the battery operated (bullfrog type) emergency lights was requested.

On March 27, 2012, at 8:35 a.m., the Emergency Exit Lights form was reviewed. During an interview, Facilities Staff 1 was asked if it was for the emergency lights or exit signs. He stated it was for the exit signs.

On March 28, 2012, at 11:43 a.m., the facility policies were reviewed. Policy FM06007 Emergency Lighting Battery Testing, indicated monthly testing for 30 seconds and annual testing for 90 minutes.

On March 29, 2012, at 9:12 a.m., no documentation for testing the battery operated emergency lights was provided. Facilities Staff 1 stated there was no documentation to confirm the emergency lights were tested.

3. On March 28, 2012, during a tour of the facility the emergency lights were observed. At 2:10 p.m., in the old radiology office, the bullfrog emergency light was tested using the test button. The light failed to illuminate. Facilities Staff 1 disconnected the electrical cord and the light failed to illuminate.

Based on observation and document review, the facility failed to maintain and test emergency exit signs in accordance with NFPA 101, Life Safety Code. This was evidenced by broken exit signs, expired exit signs, and exit signs with no continuous illumination. This had the potential to cause delayed evacuation from the building. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor and 1 of 1 smoke compartments in the basement.

NFPA 101, Life Safety Code, 2000 Edition
7.10.5 Illumination of Signs
7.10.5.1* General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.3* Sign Legend. Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.

7.10.4* Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.9 Testing and Maintenance
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During document review and the facility tour, from March 26, 2012 through March 30, 2012, records for testing emergency lights and signs were reviewed and emergency lighting was observed.

1. On March 27, 2012, at 8:35 a.m., records for testing and maintenance of the Emergency Exit Lights (signs) were missing for 12/2011. Records indicated that in the North building 2nd floor, Light #10 failed on 9/2011, 10/2011, and 11/2011. There were no testing records for 12/2011. Records indicated the sign failed on 1/2012, 2/2012 and 3/2012.
Exit signs 13-73 on the 1st floor were not tested/checked in 12/2011.
Exit signs 74-98 lower level were not tested/checked in 12/2011.

2. On March 28, 2012, at 10:35 a.m., the exit sign in the hallway outside the emergency room had no date the sign was installed or when it was to be replaced. Facilities Staff 1 had no information for when the sign was installed or the expiration date.

At 10:38 a.m., the exit sign by AV 42, was a 10 year sign. The replacement date indicated replace before 5/2004.
At 10:45 a.m., the exit sign by Utilization review had no date of install or replacement. Facilities Staff 1 had no information on when the sign was installed or when it expired.

At 3:11 p.m., 3 of 3 exit signs outside the kitchen, in the egress corridor, indicated replacement due by 1/2011.


3. At 10:56 a.m., in BHU (Behavioral Health Unit) the floor level exit sign near the scanning room had a broken face plate. The sign was no longer legible.

Based on document review and interview, the facility failed to maintain the Fire Alarm System in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by alarm devices that failed during testing, and by incomplete records for maintenance and testing for the complete fire alarm system. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor, and 1 of 1 smoke compartment in the basement.

Visual Inspections and Testing Frequencies shall be completed in accordance with NFPA 72, National Fire Alarm Code, 1999 edition, Tables 7-3.1 and 7-3.2.

NFPA 72, National Fire Alarm Code, 1999 Edition

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 affiliation, 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 manufacturers
(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:

On March 26, 2012, maintenance and testing records were reviewed. The "Fire Alarm Inspection Report," dated June 14, 2011, was reviewed from 10:59 a.m. to 11:59 a.m.

1. Page 4 of the report indicated the Control Panel Central Processing Unit, Control Function(s) failed, in Engineering on the first floor.

At 11:04 a.m., during an interview, Facilities Staff 1 stated parts had been ordered to repair the unit. The repairs had not been completed.

2. The report indicated that Lamps/LED test - failed light bulbs are missing, in Labor and Delivery 1st floor, inside telephone room by surgery.
There was no record that the lamps were replaced.

3. Page 8 notes, Alarm Initiating Devices - 54 duct detectors, 51 were tested. Duct detector RF AH1 (D-36) disconnected/bypassed. Duct detector medical floor nurse station (D27) not tested area under construction. Duct detectors activate when exposed to smoke, to close dampers in the event of a fire.

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 missing escutcheon plates. This affected 3 of 6 smoke compartments on the 1st floor, and 1 of 1 smoke compartments in the basement. This had the potential to allow the spread of smoke or fire, in the event of a fire.

Findings:

During a tour of the facility, from March 26, 2012, through March 30, 2012, the sprinkler system was observed. Escutcheon plates cover penetrations around sprinkler pipes and are a part of the listed sprinkler assembly.

On March 27, 2012, at 2:52 p.m., the sprinkler escutcheon plate was missing in the post partum nurses station, by the supply room.
On March 28, 2012, at 2:45 p.m., the sprinkler was missing the escutcheon plate in the elevator machine room (basement).
On March 29, 2012, at 3:28 p.m., the sprinkler escutcheon plate was missing in the operating room hallway, in front of operating room 4.

Based on observation and interview, the facility failed to maintain the fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was evidenced by unsecured fire extinguishers, missing fire extinguishers in one area, obstructed access to fire extinguishers, and missing monthly checks. This could result in a delay to extinguish a fire in the event of fire.

NFPA 10, Standard for Portable Fire Extinguishers 1998 edition.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions.

1.6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed to cope with this problem.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Findings:

During record review, on March 27, 2012, at 11:16 a.m., the Fire Extinguisher Preventative Maintenance log was reviewed.
The log indicated n/a for the monthly check for March 7, 2012.
On February 6, 2012, the log indicated "missing again."
On January 10, 2012, the log indicated "missing again."
On December 3, 2011, the log indicated "missing and replaced."
On October 17, 2011, there was no check for the heliport fire extinguisher on the ramp or in the helicopter parking area.

During an interview on March 28, 2012, Facilities Staff 1 reported that the fire extinguisher is taken on a regular basis. The facility is trying to figure out a way to secure it.

During the facility tour on March 27, 2012, fire extinguishers were observed throughout the facility.

At 2:43 p.m., the access to the fire extinguisher across from the nurses station was obstructed by an infant scale.
At 3:08 p.m., in Labor and Delivery by Room 1 the access to the fire extinguisher was obstructed by an infant scale.
At 3:19 p.m., in the supply room for surgery on the 1st floor the fire extinguisher was unsecured.

Based on document review and interview, the facility failed to maintain, the dampers in accordance with NFPA 90A. This was evidenced by the failure to test all dampers, by no records for repair of dampers that failed, and by no current record for damper testing. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor and the basement. This could result in smoke and flames passing from one smoke compartment to another. Damper activation closes open duct work to stop the spread of smoke during a fire.


NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
2-3.4 Air duct access and Inspection
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum height of ? in. (1.27 cm) to indicate the location of the fire protection device(s) within.

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:

1. On March 29, 2012, at 1:45 p.m., the Fire Damper Report dated June 5, 2007 was reviewed. The report indicated dampers that were not inspected, damper motors that failed, and dampers that were held open with wood.

1st floor:
Damper 1 was not inspected due to no access.
Damper 5 - 24 volt motor failed damper blocked open with wood.
Damper 6 - 24 volt motor failed damper blocked open with wood.
Damper 7 no access to damper could not inspect, same for dampers 8-29.

2nd floor:
Damper 2 - 24 volt motor failed damper blocked open with wood.
Damper 3 - 24 volt motor failed damper blocked open with wood.
Damper 9 room occupied could not inspect damper
Damper 10 - 24 volt motor failed damper blocked open with wood.
Damper 11 - 24 volt motor failed damper blocked open with wood.

Basement:
Damper 1 - 24 volt motor failed damper is closed.
Damper 2 - 24 volt motor failed damper closed.
Damper 3, 4, 5, 6, no access to damper could not inspect
Damper 8 no access to damper could not inspect
Damper 9 no access to damper could not inspect.

2. There was no complete list of dampers and locations of the dampers provided by the facility. Damper locations were not identified in the facility. The facility did not provide documentation showing the dampers above were repaired, wood was removed, or motors were replaced.

During an interview at 1:49 p.m., Facilities Staff 1 stated he did not know how many dampers were in the facility.

On March 30, 2012, at 9:30 a.m., Facilities Staff 1 stated there was no documentation showing repairs had been completed on the dampers that failed.

3. There was no current report for damper inspection in 2011.

Based on observation and interview, the facility failed to maintain the means of egress free from all obstructions at all times, as evidenced by furnishings and equipment stored in hallways and obstructing doorways. This affected 1 of 1 smoke compartment in the basement and 1 of 6 smoke compartments on the 1st floor. This could result in a delay in evacuation in the event of a fire or other emergency.

Findings:

On a tour of the facility from March 26, 2012 through March 28, 2012, with facility staff, the means of egress were observed.

On March 28, 2012, at 3:12 p.m., the exit corridor hall outside of the kitchen was obstructed by eight food carts that were stored in the hallway.
At 3:15 p.m., Facilities Staff 1 stated he spoke to the kitchen supervisor about moving the carts. The kitchen supervisor stated that he has no place else to store the carts. Facilities staff 1 stated he informed the supervisor carts cannot be stored in the hallway.

Based on observation, the facility failed to maintain the oxygen storage area in accordance with NFPA 99, Health Care Facilities. This was evidenced by medical gas cylinders that were unsecured in the outside storage area.

NFPA 99 Health Care Facilities 1999 edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation

Findings:

On a tour of the facility on March 28, 2012, the oxygen storage area was observed.
At 2:54 p.m., the outside oxygen storage contained oxygen and other medical gas cylinders. One cylinder of compressed air, 8 E cylinders of oxygen, 1 carbon dioxide cylinder and 1 H size Helium tank were unsecured in the storage area.

Based on document review and interview, the facility failed to maintain the medical air system in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by the failure to repair identified problems with the medical air system. This affected the Neo Natal Intensive Care Unit, and Post Partum Unit. This failure could result in potential harm to patients.

Findings:

During review of the 2567 for the complaint survey on December 31, 2011, the facility failed to maintain their med gas system. The records failed to indicate repair of identified problems with the medical air system. There were no records for monitoring the dew point, providing a second dryer, and recertification of the medical air system after a breach. The dew point is the temperature at which air becomes saturated and produces moisture. The facility stopped use of the areas affected by the med gas system problems and requested a time limited waiver.

During an interview on March 29, 2012, at 10 a.m., the facility IOR (Inspector of Record), Facilities Staff 1, and the OSHPD (Office of Statewide Health Planning and Development) representative, reported the repairs to the medical air system have not started. The IOR stated they are waiting for the plans to be returned with OSHPD approval. The facility will then obtain permits from the city to perform the required work to the medical air system.

The facility has requested and was granted a waiver for time to complete all repairs identified during the previous complaint visit in January 2012. They reported the system should be repaired and updated by September 2012.

Based on document review and interview, the facility failed to maintain the humidity levels in 6 of 6 operating rooms in accordance with NFPA 99, Health Care Facilities. This was evidenced by humidity levels below 35 percent and by incomplete records for humidity levels. This has the potential to create an increased risk of fire, and injury to patients and staff.

Findings:

From March 26, 2012, through March 30, 2012, the Temperature and Humidity Logs were reviewed for the operating rooms.

On March 26, 2012, at 12:16 p.m., logs indicated the following:
March 2012
Operating Room 1 - 17 of 23 days had humidity levels below 35%.
Operating Room 2 - 13 of 23 days had humidity levels below 35%. There were no humidity levels recorded on 4 of 23 days.
Operating Room 3 - 2 of 23 days had humidity levels below 35%.
There were no humidity levels recorded on 12 of 23 days.
Operating Room 4 - 9 of 23 days had humidity levels below 35%.
Operating Room 5 - 7 of 23 days had humidity levels below 35%.
Operating Room 6 - 4 of 23 days had humidity levels below 35 %.
There were no humidity levels recorded on 2 of 23 days.

February 2012
Operating Room 1 -21 of 29 days had humidity levels below 35%.
Operating Room 2 -21 of 29 days had humidity levels below 35%.
Operating Room 3 - 15 of 29 days had humidity levels below 35%.
Operating Room 4 - 6 of 31 days had humidity levels below 35%.
Operating Room 5 - 17 of 31 days had humidity levels below 35%.
Operating Room 6 - 2 of 31 days had humidity levels below 35%.

January 2012
Operating Room 1 -29 of 31 days had humidity levels below 35%.
Operating Room 2 -25 of 31 days had humidity levels below 35%.
Operating Room 3 -14 of 31 days had humidity levels below 35%.
Operating Room 4 -23 of 31 days had humidity levels below 35%.
Operating Room 5 -26 of 31 days had humidity levels below 35%.
Operating Room 6 -16 of 31 days had humidity levels below 35%.


December 2011
Operating Room 1 -27 of 31 days had humidity levels below 35%.
Operating Room 2 -20 of 31 days had humidity levels below 35%.
Operating Room 3 -16 of 31 days had humidity levels below 35%.
There were no humidity levels recorded on 4 of 31 days.
Operating Room 4 -18 of 31 days had humidity levels below 35%.
Operating Room 5 -22 of 31 days had humidity levels below 35%.
Operating Room 6- 19 of 31 days had humidity levels below 35%.


July 2011
Operating Rooms 1, 2, 3, 4, 5, 6
No humidity levels were recorded on the 1st, 2nd, 3rd, 6th, 7th, and 19th.

June 2011
Operating Rooms 1, 2, 3, 4, 5, 6
No humidity levels were recorded on the 24th, 28th, 29th, and 30th.

February 2011:
Operating Room 1- 17 of 28 days had humidity levels below 35%.
Operating Room 2- 17 of 28 days had humidity levels below 35%.
Operating Room 3- 9 of 28 days had humidity levels below 35%.
Operating Room 4- 12 of 28 days had humidity levels below 35%.
Operating Room 5- 20 of 28 days had humidity levels below 35%.
Operating Room 6- 9 of 28 days had humidity levels below 35%.

At 11:25 a.m., during an interview, OR Nurse 1 was asked what the range was for the humidity level. OR Nurse 1 stated the range was from 30 to 60 percent. She stated that the humidity level is monitored by the staff in facilities (maintenance).

On March 27, 2012, at 11:35 a.m., Facilities Staff 1 was asked how they monitored the humidity ranges and what actions were taken when the humidity was below 35%. Facilities Staff 1 stated he does "research" before he makes adjustments, and has to get approval before he can make adjustments.

Humidity levels from 3/10/12 through 3/17/12 were below 35 percent, in OR 1, 2, 4, 5, and 6. No adjustments were made to the HVAC system until 3/23/2012. Facilities Staff 1 stated that the humidity level is not adjusted on the day it is below 35 percent. He has to research which HVAC unit needs adjustment and then it is adjusted.

The Policy and Procedure Humidity Control, indicates humidity will be maintained between 30 and 60 percent by facilities management department. The facilities management department will notify the unit director with any deviation from the norm or the unit director will notify the facilities management of any deviation from the norm. Daily log of humidity is done and kept by facilities management department.

The policy did not indicate the procedure to follow when the humidity is out of range.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.

Chapter 12 System Inspection, Testing, and Maintenance
12.1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 Edition.

5-2.2.2 Pump System Conditions.
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is normal.
(d) System line pressure gauge reading is normal.
(e) Suction reservoir is full.
5-3.2. Weekly Tests
Qualified operating personnel shall be in attendance during the weekly pump operation.
5-3-2-1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.

Based on observation, document review and interview the facility failed to maintain the Fire Pump in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition. This was evidenced by ongoing leaks at the fire pump, and by no records for weekly testing. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

Findings:

During document review on March 26, 2012 and March 27, 2012, testing and maintenance records were reviewed for the Fire Pump.

March 26, 2012
At 11:48 a.m., the vendor Service Request form, dated December 7, 2011, was reviewed. The report noted "Fire Pump Leaking, took apart gland and cleaned corrosion reinstalled OS&Y still leaking but not overflowing on outside drive. Pump needs a repack."

March 27, 2012
At 8:49 a.m., during review of Inspection, Testing, and Maintenance cover sheet dated April 19, 2011, the Fire Performance Test indicates system failed, parts on order.

At 9:15 a.m., during an interview, Facilities Staff 1 stated he thought there was other paper work regarding the system failure noted on April 19, 2011.

One weekly report "Fire Pump Preventative Maintenance" was dated 6/24/2011. There were no other weekly testing records provided during 2011 and no current testing records in 2012.

At 9:56 a.m., the Policy and Procedure Fire Pump (FM05024) was reviewed. The procedure stated that (1) Valves will be exercised weekly, (2) pump will be tested and serviced by a licensed contractor.

At 11:07 a.m., documentation was provided for a Service Request dated 2/1/12, from the vendor regarding the fire pump. The report indicated that the vendor "Took apart and repacked."
A Service Request report dated 2/22/12, noted fire pump leaking - ovulation relief valve on the fire pump is leaking, tried to adjust it on my last visit but I found that it is just broken and needs to be replaced.

At 11:32 a.m., documentation was provided from the vendor dated 3/27/12. The report indicated materials and pump will be ordered today or tomorrow 4-6 week delivery.

On March 28, 2012, at 2:55 p.m., the fire pump area was observed. There was water leaking/dripping in one area.

Based on observation, document review and interview, the facility failed to maintain the emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by no current load bank test, by missing monthly load tests and by no remote annunciator for the generator. The generator provided secondary power to the fire alarm system, emergency lights, emergency outlets and exit signs. This could result in a failure to monitor the generator during a power outage and the potential failure of the emergency generator to supply emergency power. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

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 March 26, 2012, at 3:40 p.m., documentation was provided for a load bank test that was done on June 23, 2010. During an interview, Facilities Staff 1 stated there was no documentation for a current load bank test.

There were no records for 30 minute load testing in November 2011 and February 2012.

During the facility tour from March 26, 2012 through March 29, 2012, there was no remote alarm annunciator located in an area that is constantly manned by staff. During an interview on March 30, 2012, at 9:17 a.m., Facilities Staff 1 reported that there was no remote annunciator for the emergency generator.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Fire Alarm Code and NFPA 99, Health Care Facilities. This was evidenced by no emergency power in a critical patient care area, by the use of extension cords, by equipment plugged into surge protectors, and by broken light switches and outlet cover plates. This had the potential to cause harm to patients or staff, and increased the risk of a fire. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

NFPA 99, Health Care Facilities, 1999 Edition
3-2.4 Interruption of Power.
3-2.4.1 General. Medical and nursing sciences are becoming progressively more dependent on electrical apparatus for the preservation of life of hospitalized patients. For example year by year more cardiac operations are performed, in some of which the patient ' s life depends on artificial circulation of the blood. In other operations, life is sustained by means of electrical impulses that stimulate and regulate heart action. In still others, suction developed by electrical means is routinely relied on to remove body fluids and mucus that might otherwise cause suffocation. In another sense, lighting is needed in strategic areas in order that precise procedures can be carried out, and power is needed to safeguard such vital services as refrigerated stores held in tissue, bone, and blood banks. Interruption of normal electrical service in health care facilities can be caused by catastrophes such as storms, floods, fires, earthquakes, or explosions; by failures of the systems supplying electrical power; or by incidents within the facility.

For all such situations, electrical systems should be planned
to limit internal disruption and to provide for continuity of
vital services at all times. Outages might be corrected in seconds
or might require hours for correction. This indicates that the system or protection needs to be designed to cope with the longest probable outage. Selecting vital areas and functions considered to be essential, designing safeguards to ensure continuity in these circuits, and maintaining the electrical and mechanical components of such essential services so that they will work when called on are complex problems that warrant standardized guidance for regulating agencies, governing boards, and administrators of health care facilities and architects and engineers concerned with their construction. Such guidance is offered in this chapter.

This chapter is predicated on the basic principle of achieving dependability. It is intended to recognize the different degrees of reliability that can result from varying approaches to electrical design. Therefore, its requirements have been developed to allow the designer the flexibility needed to achieve a reliable electrical system.

3-2.4.2 Need to Maintain Power. Interruption of the supply of electric power in a facility can be a hazard. Implementation of the requirements of this chapter serves to maintain the required level of continuity and quality of electrical power for patient care electrical appliances.

3-4.2.2.4 Wiring Requirements.
(a) * Separation from other circuits. The life Safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment.
(b) Receptacles.
1. The number of receptacles on a single branch circuit for areas described in 3-4.2.2.2 (c) (8) shall be minimized to limit the effects of a branch circuit outage. Branch circuit overcurrent devices shall be readily accessible to nursing and other authorized personnel.
2. * The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.
(c) Switches. Switches installed in the lighting circuits connected to the essential electrical system shall comply with Article 700, Section E.

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:

From March 26, through March 30, 2012, during a tour of the facility, the electrical wiring and equipment was observed.

On March 27, 2012, at 9:30 a.m., the GI Lab was observed. There were no red outlets, backed up by the generator, in the GI Lab. There were no emergency lights visible in the room.

During an interview at 9:32 a.m., the GI Lab Nurse was asked if the room had emergency power or lighting. She stated that if the power goes out it is "pitch black in here." The GI Lab Nurse stated she did not know if the equipment had back up batteries or not except for the vital signs machine which does.

During an interview on March 28, 2012 at 9 a.m., GI Lab Staff reported they do the outpatient GI testing, and when the census is high they do about 5 procedures a day with sedation and conscious sedation. Staff stated right now they average approximately 2 to 3 cases a day. Staff was asked if there was a procedure going on and the lights and power went out what would they do. Staff stated they wait to see if the lights or power go back on, and if they don't they would take the patient back to the outpatient area. Staff stated the emergency cases are done in the emergency room or the ICU. None of the equipment in the room is equipped with backup batteries.

On the floor plan the Birth Certificate room is identified as the GI Lab. Facilities Staff 1 reported the GI Lab was moved to the current location approximately 10 years ago.

At 9:42 a.m., during an interview, the Director of Ancillary Services reported he believed the GI Lab was moved because of outpatients going into inpatient areas.

On March 28, 2012, at 10:09 a.m., an Immediate Jeopardy was identified in the GI Lab. The lab had no emergency lighting or power. The CEO (Chief Executive Officer), Director of Ancillary Services, CNO (Chief Nursing Officer), Director of Quality and Risk Management Compliance Officer, were notified of the immediate jeopardy. On March 29, 2012, at 8:44 a.m., the Immediate Jeopardy was abated after receiving an acceptable plan of correction. The CEO and Director of Ancillary Services provided a plan to discontinue use of the GI lab until emergency power was provided.


March 27, 2012 -
At 1:52 p.m., the electrical outlet cover plate was broken in Triage.
At 1:56 p.m., a refrigerator and microwave were plugged into a surge protector in the fast track break room.
At 2:18 p.m., the refrigerator in the lab employee break room was plugged into a surge protector.
At 2:20 p.m., the refrigerator was plugged into a surge protector in the radiologist office.
At 2:39 p.m., 2 of 3 outlet cover plates on the right wall were not flush with the wall, in the clean utility room.
At 3:26 p.m., the microwave was plugged into a surge protector in the surgery break room.

March 28, 2012 -
At 10:40 a.m., the light switch and light switch cover plate were broken in the soiled linen room in the BHU.
At 10:52 a.m., a surge protector was plugged into a surge protector and a refrigerator was plugged into surge protector, in an office in the BHU.

On March 28, 2012, during a tour of the facility the emergency lights were observed. At 2:10 p.m., in the old radiology office, the bullfrog emergency light was tested using the test button. The light failed to illuminate. Facility staff disconnected the electrical cord. The light failed to illuminate.

Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls. This has the potential to cause the spread of smoke and flames in the event of a fire. This affected 4 of 6 smoke compartments on the first floor and 1 of 1 compartment in the basement. Smoke compartments are utilized to separate one area from another to prevent the spread of smoke and fire.

Findings:

On a tour of the facility from March 26, 2012 through March 30, 2012, the walls were observed.

March 27, 2012 - 1st Floor
At 1:58 p.m., the phone line cover plate was not attached to the wall, exposing an approximately 4 inch penetration in the back wall, behind the copy machine, of the triage area.
At 2:13 p.m., there was an approximately 4 inch diameter penetration on the wall behind the door, in the physicians' lounge.
At 2:30 p.m., there were three approximately 1/8 inch to 1/2 inch penetrations, in the back wall of the admission managers office.

March 28, 2012 - 1st Floor
Behavioral Health Unit (BHU)
At 10:56 a.m., there were two approximately 1 inch penetrations in Room 8.
At 10:58 a.m., there were two approximately 1/2 inch penetrations on the east wall in the scanning room.

Basement
At 2:43 p.m., there were five approximately 1/4 inch to 1/2 inch penetrations, in the telephone room on the east wall.

Based on observation, the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that failed to latch when closed, and by doors that were blocked or wedged open. This affected 2 of 6 smoke compartments on the first floor and 2 of 2 compartments on the second floor. This has the potential to cause the spread of smoke and flames in the event of a fire.

Findings:

On a tour of the facility from March 26, 2012 through March 30, 2012, the corridor doors were observed.

March 27, 2012 - First Floor
At 3:23 p.m., the MD/Conference room door was obstructed from closing by a table placed in front of the door.

March 28, 2012 - BHU
Pediatrics
At 11:10 a.m., the patient nourishment door failed to close and latch.
At 11:11 a.m., the nurse station door had a piece of cardboard wedged under the door to keep it open. When the cardboard was removed the door failed to close and latch.
At 11:12 a.m., the dirty utility room door failed to close and latch.

Second Floor
At 2:21 p.m., the dialysis supply room door had cardboard taped over the latching plate preventing the door from latching. When the cardboard was removed there was paper inside the latching plate, that prevented the door from latching. When the cardboard and paper were removed the door closed and latched.
At 2:28 p.m., the staff lounge/patient nourishment room door failed to latch upon self closure.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in one smoke barrier wall. This has the potential to allow the spread of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments on the 1st floor.

Findings:

During a tour of the facility on March 27, 2012, with staff, the smoke barrier walls were observed. At 2:26 p.m., the smoke barrier wall by the radiologist office had an approximately 3 inch diameter conduit penetrating the wall, around communication wires. The conduit was unsealed on both sides of the wall.

Based on observation and interview, the facility failed to ensure the smoke barrier doors close and latch during activation of the fire alarm system. This was evidenced by four doors that failed to release and close during fire alarm system testing. This could result in the spread of smoke and flames in the event of a fire. This affected 1 of 1 smoke compartment in the basement and 1 of 6 smoke compartments on the 1st floor.

Findings:

During fire alarm system testing with facilities staff, on March 29, 2012, the smoke barrier doors were observed.

1st Floor
At 2:56 p.m., the right leaf of the smoke barrier doors by the Cath lab failed to latch.
At 3:41 p.m., the horizontal smoke barrier door in front of operating room 4 failed to close upon activation of the the smoke detectors on each side of the door.

During an interview at 3:43 p.m., the vendor stated that the door should close when the smoke detectors were activated.

2nd Floor
At 3:55 p.m., the left door of the smoke barrier failed to latch upon closure, at the smoke barrier doors by Room 204.

At 4:11 p.m., and 4:13 p.m., the horizontal door in the cafeteria failed to close when smoke detectors on each side of the door were activated.

During an interview at 4:14 p.m., the vendor stated that the door has a fusible link but should close upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the doors in hazardous areas. This was evidenced by one door that was not self closing and was obstructed from closing. This affected 1 of 6 smoke compartments on the first floor and had the potential to cause the spread of smoke and flames in the event of a fire.

Findings:

On March 27, 2012, during a tour of the facility with facilities staff, the hazardous areas were observed.

At 1:41 p.m., in the Emergency Room, the biohazard/soiled utility room door was not equipped with a self closing device. The door was obstructed from closing by a chair.

Based on observation, interview and document review, the facility failed to provide and maintain emergency lighting. This was evidenced by no emergency lights or back up power in the GI lab, by one emergency light that failed when tested with the test button, and by no documentation for testing and maintenance of the emergency lights. This affected 6 of 6 smoke compartments on the 1st floor. This had the potential to result in harm to patients in the GI lab, and delay egress from the facility in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
7-.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

1. On March 27, 2012, at 9:30 a.m., the GI Lab was observed. There were no emergency lights visible in the GI Lab. There were no designated emergency outlets in the lab.

During an interview at 9:32 a.m., the GI Lab Nurse was asked if the room had emergency power or lighting. She stated no, if the power goes out it is "pitch black in here." The GI Nurse did not know if the machines had back up batteries except for the vital signs machine which did.

On March 28, 2012 at 8:30 a.m., the facility floor plan was reviewed. The floor plan identified the GI Lab in the area where the Birth Certificate Room currently was located.

At 9:00 a.m., during an interview, GI Lab staff reported they do outpatient GI testing, and when the census is high they do about 5 procedures a day with sedation and conscious sedation. They average approximately 2 to 3 cases a day.

GI Staff was asked if there was a procedure going on and the lights went out what procedure would they follow. GI Staff stated they wait to see if the lights go back on, and if they don't they would take the patient back to the outpatient area. Staff stated the emergency cases are done in the emergency room or the ICU.

At 9:37 a.m., during an interview, Facilities Staff 1 was unaware the room had no emergency lights or power.

At 9:42 a.m., during an interview, the Director of Ancillary Services reported she believed it (the GI Lab) was moved because of outpatients going into inpatient areas.

On March 28, 2012, at 10:09 a.m., an Immediate Jeopardy was identified in the GI Lab. The lab had no emergency lighting or power. The CEO (Chief Executive Officer), Director of Ancillary Services, CNO (Chief Nursing Officer), Director of Quality and Risk Management Compliance Officer, were notified of the immediate jeopardy.

On March 29, 2012, at 8:44 a.m., the Immediate Jeopardy was abated after receiving an acceptable plan of correction. The CEO and Director of Ancillary Services provided a plan to discontinue use of the GI lab until emergency power was provided.


2. During document review on March 26, 2012 , the documentation for the testing and maintenance of the battery operated (bullfrog type) emergency lights was requested.

On March 27, 2012, at 8:35 a.m., the Emergency Exit Lights form was reviewed. During an interview, Facilities Staff 1 was asked if it was for the emergency lights or exit signs. He stated it was for the exit signs.

On March 28, 2012, at 11:43 a.m., the facility policies were reviewed. Policy FM06007 Emergency Lighting Battery Testing, indicated monthly testing for 30 seconds and annual testing for 90 minutes.

On March 29, 2012, at 9:12 a.m., no documentation for testing the battery operated emergency lights was provided. Facilities Staff 1 stated there was no documentation to confirm the emergency lights were tested.

3. On March 28, 2012, during a tour of the facility the emergency lights were observed. At 2:10 p.m., in the old radiology office, the bullfrog emergency light was tested using the test button. The light failed to illuminate. Facilities Staff 1 disconnected the electrical cord and the light failed to illuminate.

Based on observation and document review, the facility failed to maintain and test emergency exit signs in accordance with NFPA 101, Life Safety Code. This was evidenced by broken exit signs, expired exit signs, and exit signs with no continuous illumination. This had the potential to cause delayed evacuation from the building. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor and 1 of 1 smoke compartments in the basement.

NFPA 101, Life Safety Code, 2000 Edition
7.10.5 Illumination of Signs
7.10.5.1* General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.3* Sign Legend. Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.

7.10.4* Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.9 Testing and Maintenance
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During document review and the facility tour, from March 26, 2012 through March 30, 2012, records for testing emergency lights and signs were reviewed and emergency lighting was observed.

1. On March 27, 2012, at 8:35 a.m., records for testing and maintenance of the Emergency Exit Lights (signs) were missing for 12/2011. Records indicated that in the North building 2nd floor, Light #10 failed on 9/2011, 10/2011, and 11/2011. There were no testing records for 12/2011. Records indicated the sign failed on 1/2012, 2/2012 and 3/2012.
Exit signs 13-73 on the 1st floor were not tested/checked in 12/2011.
Exit signs 74-98 lower level were not tested/checked in 12/2011.

2. On March 28, 2012, at 10:35 a.m., the exit sign in the hallway outside the emergency room had no date the sign was installed or when it was to be replaced. Facilities Staff 1 had no information for when the sign was installed or the expiration date.

At 10:38 a.m., the exit sign by AV 42, was a 10 year sign. The replacement date indicated replace before 5/2004.
At 10:45 a.m., the exit sign by Utilization review had no date of install or replacement. Facilities Staff 1 had no information on when the sign was installed or when it expired.

At 3:11 p.m., 3 of 3 exit signs outside the kitchen, in the egress corridor, indicated replacement due by 1/2011.


3. At 10:56 a.m., in BHU (Behavioral Health Unit) the floor level exit sign near the scanning room had a broken face plate. The sign was no longer legible.

Based on document review and interview, the facility failed to maintain the Fire Alarm System in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by alarm devices that failed during testing, and by incomplete records for maintenance and testing for the complete fire alarm system. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor, and 1 of 1 smoke compartment in the basement.

Visual Inspections and Testing Frequencies shall be completed in accordance with NFPA 72, National Fire Alarm Code, 1999 edition, Tables 7-3.1 and 7-3.2.

NFPA 72, National Fire Alarm Code, 1999 Edition

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 affiliation, 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 manufacturers
(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:

On March 26, 2012, maintenance and testing records were reviewed. The "Fire Alarm Inspection Report," dated June 14, 2011, was reviewed from 10:59 a.m. to 11:59 a.m.

1. Page 4 of the report indicated the Control Panel Central Processing Unit, Control Function(s) failed, in Engineering on the first floor.

At 11:04 a.m., during an interview, Facilities Staff 1 stated parts had been ordered to repair the unit. The repairs had not been completed.

2. The report indicated that Lamps/LED test - failed light bulbs are missing, in Labor and Delivery 1st floor, inside telephone room by surgery.
There was no record that the lamps were replaced.

3. Page 8 notes, Alarm Initiating Devices - 54 duct detectors, 51 were tested. Duct detector RF AH1 (D-36) disconnected/bypassed. Duct detector medical floor nurse station (D27) not tested area under construction. Duct detectors activate when exposed to smoke, to close dampers in the event of a fire.

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 missing escutcheon plates. This affected 3 of 6 smoke compartments on the 1st floor, and 1 of 1 smoke compartments in the basement. This had the potential to allow the spread of smoke or fire, in the event of a fire.

Findings:

During a tour of the facility, from March 26, 2012, through March 30, 2012, the sprinkler system was observed. Escutcheon plates cover penetrations around sprinkler pipes and are a part of the listed sprinkler assembly.

On March 27, 2012, at 2:52 p.m., the sprinkler escutcheon plate was missing in the post partum nurses station, by the supply room.
On March 28, 2012, at 2:45 p.m., the sprinkler was missing the escutcheon plate in the elevator machine room (basement).
On March 29, 2012, at 3:28 p.m., the sprinkler escutcheon plate was missing in the operating room hallway, in front of operating room 4.

Based on observation and interview, the facility failed to maintain the fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was evidenced by unsecured fire extinguishers, missing fire extinguishers in one area, obstructed access to fire extinguishers, and missing monthly checks. This could result in a delay to extinguish a fire in the event of fire.

NFPA 10, Standard for Portable Fire Extinguishers 1998 edition.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions.

1.6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed to cope with this problem.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Findings:

During record review, on March 27, 2012, at 11:16 a.m., the Fire Extinguisher Preventative Maintenance log was reviewed.
The log indicated n/a for the monthly check for March 7, 2012.
On February 6, 2012, the log indicated "missing again."
On January 10, 2012, the log indicated "missing again."
On December 3, 2011, the log indicated "missing and replaced."
On October 17, 2011, there was no check for the heliport fire extinguisher on the ramp or in the helicopter parking area.

During an interview on March 28, 2012, Facilities Staff 1 reported that the fire extinguisher is taken on a regular basis. The facility is trying to figure out a way to secure it.

During the facility tour on March 27, 2012, fire extinguishers were observed throughout the facility.

At 2:43 p.m., the access to the fire extinguisher across from the nurses station was obstructed by an infant scale.
At 3:08 p.m., in Labor and Delivery by Room 1 the access to the fire extinguisher was obstructed by an infant scale.
At 3:19 p.m., in the supply room for surgery on the 1st floor the fire extinguisher was unsecured.

Based on document review and interview, the facility failed to maintain, the dampers in accordance with NFPA 90A. This was evidenced by the failure to test all dampers, by no records for repair of dampers that failed, and by no current record for damper testing. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor and the basement. This could result in smoke and flames passing from one smoke compartment to another. Damper activation closes open duct work to stop the spread of smoke during a fire.


NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
2-3.4 Air duct access and Inspection
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum height of ? in. (1.27 cm) to indicate the location of the fire protection device(s) within.

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:

1. On March 29, 2012, at 1:45 p.m., the Fire Damper Report dated June 5, 2007 was reviewed. The report indicated dampers that were not inspected, damper motors that failed, and dampers that were held open with wood.

1st floor:
Damper 1 was not inspected due to no access.
Damper 5 - 24 volt motor failed damper blocked open with wood.
Damper 6 - 24 volt motor failed damper blocked open with wood.
Damper 7 no access to damper could not inspect, same for dampers 8-29.

2nd floor:
Damper 2 - 24 volt motor failed damper blocked open with wood.
Damper 3 - 24 volt motor failed damper blocked open with wood.
Damper 9 room occupied could not inspect damper
Damper 10 - 24 volt motor failed damper blocked open with wood.
Damper 11 - 24 volt motor failed damper blocked open with wood.

Basement:
Damper 1 - 24 volt motor failed damper is closed.
Damper 2 - 24 volt motor failed damper closed.
Damper 3, 4, 5, 6, no access to damper could not inspect
Damper 8 no access to damper could not inspect
Damper 9 no access to damper could not inspect.

2. There was no complete list of dampers and locations of the dampers provided by the facility. Damper locations were not identified in the facility. The facility did not provide documentation showing the dampers above were repaired, wood was removed, or motors were replaced.

During an interview at 1:49 p.m., Facilities Staff 1 stated he did not know how many dampers were in the facility.

On March 30, 2012, at 9:30 a.m., Facilities Staff 1 stated there was no documentation showing repairs had been completed on the dampers that failed.

3. There was no current report for damper inspection in 2011.

Based on observation and interview, the facility failed to maintain the means of egress free from all obstructions at all times, as evidenced by furnishings and equipment stored in hallways and obstructing doorways. This affected 1 of 1 smoke compartment in the basement and 1 of 6 smoke compartments on the 1st floor. This could result in a delay in evacuation in the event of a fire or other emergency.

Findings:

On a tour of the facility from March 26, 2012 through March 28, 2012, with facility staff, the means of egress were observed.

On March 28, 2012, at 3:12 p.m., the exit corridor hall outside of the kitchen was obstructed by eight food carts that were stored in the hallway.
At 3:15 p.m., Facilities Staff 1 stated he spoke to the kitchen supervisor about moving the carts. The kitchen supervisor stated that he has no place else to store the carts. Facilities staff 1 stated he informed the supervisor carts cannot be stored in the hallway.

Based on observation, the facility failed to maintain the oxygen storage area in accordance with NFPA 99, Health Care Facilities. This was evidenced by medical gas cylinders that were unsecured in the outside storage area.

NFPA 99 Health Care Facilities 1999 edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation

Findings:

On a tour of the facility on March 28, 2012, the oxygen storage area was observed.
At 2:54 p.m., the outside oxygen storage contained oxygen and other medical gas cylinders. One cylinder of compressed air, 8 E cylinders of oxygen, 1 carbon dioxide cylinder and 1 H size Helium tank were unsecured in the storage area.

Based on document review and interview, the facility failed to maintain the medical air system in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by the failure to repair identified problems with the medical air system. This affected the Neo Natal Intensive Care Unit, and Post Partum Unit. This failure could result in potential harm to patients.

Findings:

During review of the 2567 for the complaint survey on December 31, 2011, the facility failed to maintain their med gas system. The records failed to indicate repair of identified problems with the medical air system. There were no records for monitoring the dew point, providing a second dryer, and recertification of the medical air system after a breach. The dew point is the temperature at which air becomes saturated and produces moisture. The facility stopped use of the areas affected by the med gas system problems and requested a time limited waiver.

During an interview on March 29, 2012, at 10 a.m., the facility IOR (Inspector of Record), Facilities Staff 1, and the OSHPD (Office of Statewide Health Planning and Development) representative, reported the repairs to the medical air system have not started. The IOR stated they are waiting for the plans to be returned with OSHPD approval. The facility will then obtain permits from the city to perform the required work to the medical air system.

The facility has requested and was granted a waiver for time to complete all repairs identified during the previous complaint visit in January 2012. They reported the system should be repaired and updated by September 2012.

Based on document review and interview, the facility failed to maintain the humidity levels in 6 of 6 operating rooms in accordance with NFPA 99, Health Care Facilities. This was evidenced by humidity levels below 35 percent and by incomplete records for humidity levels. This has the potential to create an increased risk of fire, and injury to patients and staff.

Findings:

From March 26, 2012, through March 30, 2012, the Temperature and Humidity Logs were reviewed for the operating rooms.

On March 26, 2012, at 12:16 p.m., logs indicated the following:
March 2012
Operating Room 1 - 17 of 23 days had humidity levels below 35%.
Operating Room 2 - 13 of 23 days had humidity levels below 35%. There were no humidity levels recorded on 4 of 23 days.
Operating Room 3 - 2 of 23 days had humidity levels below 35%.
There were no humidity levels recorded on 12 of 23 days.
Operating Room 4 - 9 of 23 days had humidity levels below 35%.
Operating Room 5 - 7 of 23 days had humidity levels below 35%.
Operating Room 6 - 4 of 23 days had humidity levels below 35 %.
There were no humidity levels recorded on 2 of 23 days.

February 2012
Operating Room 1 -21 of 29 days had humidity levels below 35%.
Operating Room 2 -21 of 29 days had humidity levels below 35%.
Operating Room 3 - 15 of 29 days had humidity levels below 35%.
Operating Room 4 - 6 of 31 days had humidity levels below 35%.
Operating Room 5 - 17 of 31 days had humidity levels below 35%.
Operating Room 6 - 2 of 31 days had humidity levels below 35%.

January 2012
Operating Room 1 -29 of 31 days had humidity levels below 35%.
Operating Room 2 -25 of 31 days had humidity levels below 35%.
Operating Room 3 -14 of 31 days had humidity levels below 35%.
Operating Room 4 -23 of 31 days had humidity levels below 35%.
Operating Room 5 -26 of 31 days had humidity levels below 35%.
Operating Room 6 -16 of 31 days had humidity levels below 35%.


December 2011
Operating Room 1 -27 of 31 days had humidity levels below 35%.
Operating Room 2 -20 of 31 days had humidity levels below 35%.
Operating Room 3 -16 of 31 days had humidity levels below 35%.
There were no humidity levels recorded on 4 of 31 days.
Operating Room 4 -18 of 31 days had humidity levels below 35%.
Operating Room 5 -22 of 31 days had humidity levels below 35%.
Operating Room 6- 19 of 31 days had humidity levels below 35%.


July 2011
Operating Rooms 1, 2, 3, 4, 5, 6
No humidity levels were recorded on the 1st, 2nd, 3rd, 6th, 7th, and 19th.

June 2011
Operating Rooms 1, 2, 3, 4, 5, 6
No humidity levels were recorded on the 24th, 28th, 29th, and 30th.

February 2011:
Operating Room 1- 17 of 28 days had humidity levels below 35%.
Operating Room 2- 17 of 28 days had humidity levels below 35%.
Operating Room 3- 9 of 28 days had humidity levels below 35%.
Operating Room 4- 12 of 28 days had humidity levels below 35%.
Operating Room 5- 20 of 28 days had humidity levels below 35%.
Operating Room 6- 9 of 28 days had humidity levels below 35%.

At 11:25 a.m., during an interview, OR Nurse 1 was asked what the range was for the humidity level. OR Nurse 1 stated the range was from 30 to 60 percent. She stated that the humidity level is monitored by the staff in facilities (maintenance).

On March 27, 2012, at 11:35 a.m., Facilities Staff 1 was asked how they monitored the humidity ranges and what actions were taken when the humidity was below 35%. Facilities Staff 1 stated he does "research" before he makes adjustments, and has to get approval before he can make adjustments.

Humidity levels from 3/10/12 through 3/17/12 were below 35 percent, in OR 1, 2, 4, 5, and 6. No adjustments were made to the HVAC system until 3/23/2012. Facilities Staff 1 stated that the humidity level is not adjusted on the day it is below 35 percent. He has to research which HVAC unit needs adjustment and then it is adjusted.

The Policy and Procedure Humidity Control, indicates humidity will be maintained between 30 and 60 percent by facilities management department. The facilities management department will notify the unit director with any deviation from the norm or the unit director will notify the facilities management of any deviation from the norm. Daily log of humidity is done and kept by facilities management department.

The policy did not indicate the procedure to follow when the humidity is out of range.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.

Chapter 12 System Inspection, Testing, and Maintenance
12.1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 Edition.

5-2.2.2 Pump System Conditions.
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is normal.
(d) System line pressure gauge reading is normal.
(e) Suction reservoir is full.
5-3.2. Weekly Tests
Qualified operating personnel shall be in attendance during the weekly pump operation.
5-3-2-1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.

Based on observation, document review and interview the facility failed to maintain the Fire Pump in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition. This was evidenced by ongoing leaks at the fire pump, and by no records for weekly testing. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

Findings:

During document review on March 26, 2012 and March 27, 2012, testing and maintenance records were reviewed for the Fire Pump.

March 26, 2012
At 11:48 a.m., the vendor Service Request form, dated December 7, 2011, was reviewed. The report noted "Fire Pump Leaking, took apart gland and cleaned corrosion reinstalled OS&Y still leaking but not overflowing on outside drive. Pump needs a repack."

March 27, 2012
At 8:49 a.m., during review of Inspection, Testing, and Maintenance cover sheet dated April 19, 2011, the Fire Performance Test indicates system failed, parts on order.

At 9:15 a.m., during an interview, Facilities Staff 1 stated he thought there was other paper work regarding the system failure noted on April 19, 2011.

One weekly report "Fire Pump Preventative Maintenance" was dated 6/24/2011. There were no other weekly testing records provided during 2011 and no current testing records in 2012.

At 9:56 a.m., the Policy and Procedure Fire Pump (FM05024) was reviewed. The procedure stated that (1) Valves will be exercised weekly, (2) pump will be tested and serviced by a licensed contractor.

At 11:07 a.m., documentation was provided for a Service Request dated 2/1/12, from the vendor regarding the fire pump. The report indicated that the vendor "Took apart and repacked."
A Service Request report dated 2/22/12, noted fire pump leaking - ovulation relief valve on the fire pump is leaking, tried to adjust it on my last visit but I found that it is just broken and needs to be replaced.

At 11:32 a.m., documentation was provided from the vendor dated 3/27/12. The report indicated materials and pump will be ordered today or tomorrow 4-6 week delivery.

On March 28, 2012, at 2:55 p.m., the fire pump area was observed. There was water leaking/dripping in one area.

Based on observation, document review and interview, the facility failed to maintain the emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by no current load bank test, by missing monthly load tests and by no remote annunciator for the generator. The generator provided secondary power to the fire alarm system, emergency lights, emergency outlets and exit signs. This could result in a failure to monitor the generator during a power outage and the potential failure of the emergency generator to supply emergency power. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

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 March 26, 2012, at 3:40 p.m., documentation was provided for a load bank test that was done on June 23, 2010. During an interview, Facilities Staff 1 stated there was no documentation for a current load bank test.

There were no records for 30 minute load testing in November 2011 and February 2012.

During the facility tour from March 26, 2012 through March 29, 2012, there was no remote alarm annunciator located in an area that is constantly manned by staff. During an interview on March 30, 2012, at 9:17 a.m., Facilities Staff 1 reported that there was no remote annunciator for the emergency generator.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Fire Alarm Code and NFPA 99, Health Care Facilities. This was evidenced by no emergency power in a critical patient care area, by the use of extension cords, by equipment plugged into surge protectors, and by broken light switches and outlet cover plates. This had the potential to cause harm to patients or staff, and increased the risk of a fire. This affected 6 of 6 smoke compartments on the first floor, 2 of 2 smoke compartments on the second floor and the basement.

NFPA 99, Health Care Facilities, 1999 Edition
3-2.4 Interruption of Power.
3-2.4.1 General. Medical and nursing sciences are becoming progressively more dependent on electrical apparatus for the preservation of life of hospitalized patients. For example year by year more cardiac operations are performed, in some of which the patient ' s life depends on artificial circulation of the blood. In other operations, life is sustained by means of electrical impulses that stimulate and regulate heart action. In still others, suction developed by electrical means is routinely relied on to remove body fluids and mucus that might otherwise cause suffocation. In another sense, lighting is needed in strategic areas in order that precise procedures can be carried out, and power is needed to safeguard such vital services as refrigerated stores held in tissue, bone, and blood banks. Interruption of normal electrical service in health care facilities can be caused by catastrophes such as storms, floods, fires, earthquakes, or explosions; by failures of the systems supplying electrical power; or by incidents within the facility.

For all such situations, electrical systems should be planned
to limit internal disruption and to provide for continuity of
vital services at all times. Outages might be corrected in seconds
or might require hours for correction. This indicates that the system or protection needs to be designed to cope with the longest probable outage. Selecting vital areas and functions considered to be essential, designing safeguards to ensure continuity in these circuits, and maintaining the electrical and mechanical components of such essential services so that they will work when called on are complex problems that warrant standardized guidance for regulating agencies, governing boards, and administrators of health care facilities and architects and engineers concerned with their construction. Such guidance is offered in this chapter.

This chapter is predicated on the basic principle of achieving dependability. It is intended to recognize the different degrees of reliability that can result from varying approaches to electrical design. Therefore, its requirements have been developed to allow the designer the flexibility needed to achieve a reliable electrical system.

3-2.4.2 Need to Maintain Power. Interruption of the supply of electric power in a facility can be a hazard. Implementation of the requirements of this chapter serves to maintain the required level of continuity and quality of electrical power for patient care electrical appliances.

3-4.2.2.4 Wiring Requirements.
(a) * Separation from other circuits. The life Safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment.
(b) Receptacles.
1. The number of receptacles on a single branch circuit for areas described in 3-4.2.2.2 (c) (8) shall be minimized to limit the effects of a branch circuit outage. Branch circuit overcurrent devices shall be readily accessible to nursing and other authorized personnel.
2. * The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.
(c) Switches. Switches installed in the lighting circuits connected to the essential electrical system shall comply with Article 700, Section E.

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:

From March 26, through March 30, 2012, during a tour of the facility, the electrical wiring and equipment was observed.

On March 27, 2012, at 9:30 a.m., the GI Lab was observed. There were no red outlets, backed up by the generator, in the GI Lab. There were no emergency lights visible in the room.

During an interview at 9:32 a.m., the GI Lab Nurse was asked if the room had emergency power or lighting. She stated that if the power goes out it is "pitch black in here." The GI Lab Nurse stated she did not know if the equipment had back up batteries or not except for the vital signs machine which does.

During an interview on March 28, 2012 at 9 a.m., GI Lab Staff reported they do the outpatient GI testing, and when the census is high they do about 5 procedures a day with sedation and conscious sedation. Staff stated right now they average approximately 2 to 3 cases a day. Staff was asked if there was a procedure going on and the lights and power went out what would they do. Staff stated they wait to see if the lights or power go back on, and if they don't they would take the patient back to the outpatient area. Staff stated the emergency cases are done in the emergency room or the ICU. None of the equipment in the room is equipped with backup batteries.

On the floor plan the Birth Certificate room is identified as the GI Lab. Facilities Staff 1 reported the GI Lab was moved to the current location approximately 10 years ago.

At 9:42 a.m., during an interview, the Director of Ancillary Services reported he believed the GI Lab was moved because of outpatients going into inpatient areas.

On March 28, 2012, at 10:09 a.m., an Immediate Jeopardy was identified in the GI Lab. The lab had no emergency lighting or power. The CEO (Chief Executive Officer), Director of Ancillary Services, CNO (Chief Nursing Officer), Director of Quality and Risk Management Compliance Officer, were notified of the immediate jeopardy. On March 29, 2012, at 8:44 a.m., the Immediate Jeopardy was abated after receiving an acceptable plan of correction. The CEO and Director of Ancillary Services provided a plan to discontinue use of the GI lab until emergency power was provided.


March 27, 2012 -
At 1:52 p.m., the electrical outlet cover plate was broken in Triage.
At 1:56 p.m., a refrigerator and microwave were plugged into a surge protector in the fast track break room.
At 2:18 p.m., the refrigerator in the lab employee break room was plugged into a surge protector.
At 2:20 p.m., the refrigerator was plugged into a surge protector in the radiologist office.
At 2:39 p.m., 2 of 3 outlet cover plates on the right wall were not flush with the wall, in the clean utility room.
At 3:26 p.m., the microwave was plugged into a surge protector in the surgery break room.

March 28, 2012 -
At 10:40 a.m., the light switch and light switch cover plate were broken in the soiled linen room in the BHU.
At 10:52 a.m., a surge protector was plugged into a surge protector and a refrigerator was plugged into surge protector, in an office in the BHU.

On March 28, 2012, during a tour of the facility the emergency lights were observed. At 2:10 p.m., in the old radiology office, the bullfrog emergency light was tested using the test button. The light failed to illuminate. Facility staff disconnected the electrical cord. The light failed to illuminate.