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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations within the facility walls and ceilings in 2 of 5 floors. This failure had the potential to allow the spread of smoke during a fire and could result in harm to patients, staff and visitors.

Findings:

During a tour of the facility with Facility Director on March 7, 2011 through March 9, 2011, the walls and ceilings were observed.

Main Hospital - Fifth Floor on 3/7/11:
At 10:34 a.m., the sprinkler escutcheon ring was missing in the Treatment room restroom revealing a penetration in the ceiling.
At 10:38 a.m., in Patient room 5418 the sprinkler escutcheon ring was missing and revelaed an unsealed penetration in the ceiling of the restroom.
At 10:42 a.m., in Patient room 5410 the sprinkler escutcheon ring was missing revealing an unsealed penetration in the ceiling above bed 3.

Second Floor:
At 2:10 p.m., the Electrical room located next to the Laboratory elevator had two one inch penetrations in the ceiling.





29626

During a tour of the facility with the Safety/Risk Analyst, the facility's walls and ceilings were observed.

On 03/07/2011, at 2:23 p.m., there was an unsealed penetration on the wall inside the Biohazard Room in the Emergency Department. The penetration was located adjacent to the door's handle, measuring approximately 2-inches by 6-inches.

On 03/07/2011, at 3:20 p.m., there was an unsealed penetration on the ceiling to CT Room 1 in the Radiology Department. The penetration surrounded a sprinkler head that was caused by an escutcheon ring not being flushed to the ceiling.

On 03/07/2011, at 3:36 p.m., there was an unsealed penetration on the ceiling to corridor in GI Laboratory 1. The penetration measured approximately 1/2 inch and it surrounded a sprinkler head that was caused by a missing skirt above the escutcheon ring.

On 03/07/2011, at 3:40 p.m., there was an unsealed penetration on the ceiling to corridor by the Medical Gas Storage Room and the GI Laboratory. The penetration measured approximately 1-inch and it surrounded a sprinkler head that was caused by an escutcheon ring not being flushed to the ceiling.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls to provide at least a one-half hour fire resistance rating. This was evidenced by penetrations in 5 smoke barrier walls on the 1st floor of the Main Hospital Building, affecting 5 of 10 smoke compartments. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, resulting in injury to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with the Safety/Risk Analyst, smoke barrier walls were observed.

On 03/07/2011, at 2:10 p.m., the smoke barrier wall, located on the 1st floor and above a single fire door that was between the Cardiopulmonary corridor and the main lobby, had a penetration that measured approximately 1/4-inch by 2-inches. The door was next to the Cardiopulmonary Office and the penetration was located above the door's opening mechanism.

On 03/07/2011, at 2:14 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Cardiopulmonary Department's corridor and the main lobby, had 3 penetrations. The first penetration measured approximately 4-inches and was located in the attic space above the doors. The second penetration measured approximately 1/4-inch and was located above the door's opening mechanism. The third penetration measured approximately 1/2-inch and was located above the door's opening mechanism.

On 03/07/2011, at 2:35 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Emergency Department's corridor and the main lobby, had a penetration that measured approximately 1/4-inch. The penetration was located in the attic space above the doors.

On 03/07/2011, at 2:37 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Emergency Department's corridor and the waiting area, had a penetration that measured approximately 1/2-inch. The penetration was located in the attic space above the doors and it surrounded a green electrical conduit.

On 03/07/2011, at 3:56 p.m., the smoke barrier wall, located on the 1st floor corridor that was next to the GI Laboratory and the Open Courtyard, had an opening that measured approximately 8-feet by 1-foot. The open penetration was located in the attic space above the doors. The smoke barrier wall also had multiple penetrations surrounding conduits.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on magnetic device to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by the failure of two smoke barrier doors to latch upon closure on 2 of 5 floors. This could result in the potential spread of fire and smoke from one compartment to another resulting in potential harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with Staff I, 2, 3, 4, 5 and the fire alarm Technician on March 8, 2011 and March 9, 2011, the smoke barrier doors were observed.

Main Hospital - Third Floor on 3/8/11:
At 11:40 a.m., the right leaf to the double doors entering Telemetry failed to latch upon release of its hold open magnetic device during the activation of the fire alarm system.


29626

During a tour of the facility with the Safety/Risk Analyst, smoke barrier doors were observed.

On 03/08/2011, at 9:40 a.m., the smoke barrier doors, located on the 1st floor corridor to Information Systems and next to Volunteer Services, had a 1/2-inch opening between the left and right leaf doors.

On 03/08/2011, at 9:50 a.m., the smoke barrier doors, located on the 1st floor corridor to the Operating Room and next to the Director's Office, had a 1/4-inch opening between the left and right leaf doors.

On 03/08/2011, at 1:59 p.m., 1 of 2 leaf smoke barrier doors on the 1st floor corridor to the Radiology Department and next to the Radiology Reception Area, failed to positively latch upon closure.

Based on observation, the facility failed to ensure that the design of exit components provide at least a one-hour rating and protection against fire and smoke. This was evidenced by a non-rated fire door with no latching mechanism installed on the 2-story stairwell that opens into the 1st floor corridor, affecting the 1st Floor and 2nd Floor of the Main Hospital Building. This had the potential of rapidly spreading smoke and fire from one compartment to the next, resulting in injury to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with the Safety/Risk Analyst, exit components in stairwells were observed.

On 03/07/2011, at 3:25 p.m., the 39-inch door located on the 1st floor corridor, that opens into a stairwell that leads up to the laboratory on the 2nd floor, was vertically split in half into two leafs doors with no latching mechanism installed. No fire rating listed on door or door frame.

The Vice President (VP) of General Services stated that the door had been in place since 1971. The VP stated that a waiver was requested from the state agency when it was written during a validation survey done in 2007, but no documentation was provided that a waiver was granted from the state agency or CMS.

The Facilities Director provided a signed letter, dated 09/03/2004, from the Joint Commission on Accreditation of Healthcare Organizations that granted the facility equivalency for the stairwell door, but the Fire Safety Evaluation System documentation was not provided.

Based on staff interviews, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff who did not know how to activate the fire alarm system. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to patients and staff.

Findings:

On 03/08/2011, facility staff were interviewed to determine their knowledge of their fire emergency procedures. At 12:09 p.m., Housekeeping Staff 1 was asked to explain fire emergency procedures and to explain how to activate the fire alarm system. The staff member did not know how to activate the fire alarm manual pull station and could not explain a method of alerting the facility of a fire.

Based on observation, the facility failed to maintain its fire extinguishers in accordance with NFPA 10, as evidenced by a fire extinguisher that was not secured and a fire extinguisher with an expired annual inspection tag. This failure could result in the fire extinguisher not functioning as required in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
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. Wheeled typed fire extinguishers shall be located in a designated location.
Chapter 4 Inspection, Maintenance, and Recharging
4-4 Maintenance
4-4.1 Frequency. Fire extinguisher shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During a tour of the facility with Staff I on March 7, 2011 through March 9, 2011, the fire extinguishers were observed.

Outpatient Services at 255 Terracina, Ste. 104 on 3/7/11:
At 3:38 p.m., the fire extinguisher located across the front office had an annual service tag that was dated 8/25/2009.

Main Hospital- Third Floor on 3/8/11:
At 12:05 p.m., the fire extinguisher located in Personnel Services (HR) was unsecured on top of a paper shredder machine. The fire extinguisher did not fit into the wall mount that was located above the extinguisher.

Based on observation, the facility failed to ensure that corridors be kept clear from obstructions. This was evidenced by equipments obstructing the egress path of 1 of 2 emergency exits in a smoke compartment. This had the potential of delaying egress in the event of a fire or other emergency and could result in injury to patients, staff and visitors.

Findings:

During a tour of the facility with the Safety/Risk Analyst, the corridors and emergency exits were observed.

On 03/08/2011, at 2:08 p.m., the corridor by the Engineering Work Area and Receiving was obstructed with items that included IV poles with stands, boxes, tables, and other hospital equipments. The width of the corridor was reduced to less than 4-feet by the hospital equipments placed along the egress path of the corridor. The same items were observed during a tour of the facility on 03/07/2011.

Based on document review and interview, the facility failed to ensure that the humidity level policy for its operating rooms is in accordance with NFPA 99, as evidence by the facility's written policy (H04) Surgery Services/Maternal Child, Policy 3. stating "The relative humidity should be maintained between 20% and 60%." This failure could result in low humidity levels that can potentially lead to an increased risk of fire and affected 8 operating rooms, 3 GI rooms and 2 Labor and Delivery C-Section operating rooms.

NFPA 99, Health Care Facilities
Chapter 5 Environmental Systems
5-4.1 Ventilation-Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system suppling anesthetizing location shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review and interview with Staff I (Facility Director) on March 8, 2011, the facility policy for humidity levels was observed.

At 10:15 a.m., the facility provided a Policy and Procedure (P&P) for review. The P&P indicated that the humidity range should be maintained between 20% and 60%. The range is less than the required 35 percent or greater. During interview, the Facility Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Based on observation, the facility failed to maintain the electrical equipment and wiring, as evidenced by the unauthorized use of electrical equipment such as power strips plugged into power strips and an electrical cover plate missing. This failure could increase the risk of electrical shock or an electrical fire and affected 1 of 5 floors and the basement.
NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with Staff I on March 7, 2011 through March 9, 2011, the electrical equipment was observed.

Main Hospital - Fifth Floor on 3/7/11:
At 10:55 a.m., the electrical cover plate was missing in the right wall of patient room 5162.

Main Hospital - Basement on 3/8/11:
At 9:44 a.m., a power strip was plugged into another power strip in the Pharmacy Library area.

Based on observation, the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispenser are not installed over or adjacent to an ignition source, as evidenced by dispensers installed above an electrical outlet in 1 of 5 floors. This failure could result in the potential increase risk of a fire and affected 1 of 3 smoke compartments, patients, staff and visitors.

NFPA 30 (1996 Edition) 4-8.5 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; cutting or welding; hot sources; frictional heat; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat.

Findings:

During a tour of the facility with Staff I, 2, 3 and 5 on March 7, 2011 through March 9, 2011, the ABHR dispensers throughout the facility were observed.

Main Hospital - Basement on 3/8/11:
At 9:39 a.m., the ABHR dispenser in the Medical Directors offices was installed above an electrical outlet.




29626

During a tour of the facility with the Safety/Risk Analyst, ABHR dispensers were observed.

On 03/07/2011, at 2:20 p.m., a ABHR dispenser was installed within 4 inches adjacent to a light switch by Bed 16 in the Emergency Department.

On 03/07/2011, at 2:53 p.m., a ABHR dispenser was installed above and within 4 inches adjacent to a light switch in the Gift Shop Storage.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations within the facility walls and ceilings in 2 of 5 floors. This failure had the potential to allow the spread of smoke during a fire and could result in harm to patients, staff and visitors.

Findings:

During a tour of the facility with Facility Director on March 7, 2011 through March 9, 2011, the walls and ceilings were observed.

Main Hospital - Fifth Floor on 3/7/11:
At 10:34 a.m., the sprinkler escutcheon ring was missing in the Treatment room restroom revealing a penetration in the ceiling.
At 10:38 a.m., in Patient room 5418 the sprinkler escutcheon ring was missing and revelaed an unsealed penetration in the ceiling of the restroom.
At 10:42 a.m., in Patient room 5410 the sprinkler escutcheon ring was missing revealing an unsealed penetration in the ceiling above bed 3.

Second Floor:
At 2:10 p.m., the Electrical room located next to the Laboratory elevator had two one inch penetrations in the ceiling.





29626

During a tour of the facility with the Safety/Risk Analyst, the facility's walls and ceilings were observed.

On 03/07/2011, at 2:23 p.m., there was an unsealed penetration on the wall inside the Biohazard Room in the Emergency Department. The penetration was located adjacent to the door's handle, measuring approximately 2-inches by 6-inches.

On 03/07/2011, at 3:20 p.m., there was an unsealed penetration on the ceiling to CT Room 1 in the Radiology Department. The penetration surrounded a sprinkler head that was caused by an escutcheon ring not being flushed to the ceiling.

On 03/07/2011, at 3:36 p.m., there was an unsealed penetration on the ceiling to corridor in GI Laboratory 1. The penetration measured approximately 1/2 inch and it surrounded a sprinkler head that was caused by a missing skirt above the escutcheon ring.

On 03/07/2011, at 3:40 p.m., there was an unsealed penetration on the ceiling to corridor by the Medical Gas Storage Room and the GI Laboratory. The penetration measured approximately 1-inch and it surrounded a sprinkler head that was caused by an escutcheon ring not being flushed to the ceiling.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls to provide at least a one-half hour fire resistance rating. This was evidenced by penetrations in 5 smoke barrier walls on the 1st floor of the Main Hospital Building, affecting 5 of 10 smoke compartments. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, resulting in injury to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with the Safety/Risk Analyst, smoke barrier walls were observed.

On 03/07/2011, at 2:10 p.m., the smoke barrier wall, located on the 1st floor and above a single fire door that was between the Cardiopulmonary corridor and the main lobby, had a penetration that measured approximately 1/4-inch by 2-inches. The door was next to the Cardiopulmonary Office and the penetration was located above the door's opening mechanism.

On 03/07/2011, at 2:14 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Cardiopulmonary Department's corridor and the main lobby, had 3 penetrations. The first penetration measured approximately 4-inches and was located in the attic space above the doors. The second penetration measured approximately 1/4-inch and was located above the door's opening mechanism. The third penetration measured approximately 1/2-inch and was located above the door's opening mechanism.

On 03/07/2011, at 2:35 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Emergency Department's corridor and the main lobby, had a penetration that measured approximately 1/4-inch. The penetration was located in the attic space above the doors.

On 03/07/2011, at 2:37 p.m., the smoke barrier wall, located on the 1st floor and above double fire doors that was between the Emergency Department's corridor and the waiting area, had a penetration that measured approximately 1/2-inch. The penetration was located in the attic space above the doors and it surrounded a green electrical conduit.

On 03/07/2011, at 3:56 p.m., the smoke barrier wall, located on the 1st floor corridor that was next to the GI Laboratory and the Open Courtyard, had an opening that measured approximately 8-feet by 1-foot. The open penetration was located in the attic space above the doors. The smoke barrier wall also had multiple penetrations surrounding conduits.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on magnetic device to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by the failure of two smoke barrier doors to latch upon closure on 2 of 5 floors. This could result in the potential spread of fire and smoke from one compartment to another resulting in potential harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with Staff I, 2, 3, 4, 5 and the fire alarm Technician on March 8, 2011 and March 9, 2011, the smoke barrier doors were observed.

Main Hospital - Third Floor on 3/8/11:
At 11:40 a.m., the right leaf to the double doors entering Telemetry failed to latch upon release of its hold open magnetic device during the activation of the fire alarm system.


29626

During a tour of the facility with the Safety/Risk Analyst, smoke barrier doors were observed.

On 03/08/2011, at 9:40 a.m., the smoke barrier doors, located on the 1st floor corridor to Information Systems and next to Volunteer Services, had a 1/2-inch opening between the left and right leaf doors.

On 03/08/2011, at 9:50 a.m., the smoke barrier doors, located on the 1st floor corridor to the Operating Room and next to the Director's Office, had a 1/4-inch opening between the left and right leaf doors.

On 03/08/2011, at 1:59 p.m., 1 of 2 leaf smoke barrier doors on the 1st floor corridor to the Radiology Department and next to the Radiology Reception Area, failed to positively latch upon closure.

Based on observation, the facility failed to ensure that the design of exit components provide at least a one-hour rating and protection against fire and smoke. This was evidenced by a non-rated fire door with no latching mechanism installed on the 2-story stairwell that opens into the 1st floor corridor, affecting the 1st Floor and 2nd Floor of the Main Hospital Building. This had the potential of rapidly spreading smoke and fire from one compartment to the next, resulting in injury to patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with the Safety/Risk Analyst, exit components in stairwells were observed.

On 03/07/2011, at 3:25 p.m., the 39-inch door located on the 1st floor corridor, that opens into a stairwell that leads up to the laboratory on the 2nd floor, was vertically split in half into two leafs doors with no latching mechanism installed. No fire rating listed on door or door frame.

The Vice President (VP) of General Services stated that the door had been in place since 1971. The VP stated that a waiver was requested from the state agency when it was written during a validation survey done in 2007, but no documentation was provided that a waiver was granted from the state agency or CMS.

The Facilities Director provided a signed letter, dated 09/03/2004, from the Joint Commission on Accreditation of Healthcare Organizations that granted the facility equivalency for the stairwell door, but the Fire Safety Evaluation System documentation was not provided.

Based on staff interviews, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff who did not know how to activate the fire alarm system. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to patients and staff.

Findings:

On 03/08/2011, facility staff were interviewed to determine their knowledge of their fire emergency procedures. At 12:09 p.m., Housekeeping Staff 1 was asked to explain fire emergency procedures and to explain how to activate the fire alarm system. The staff member did not know how to activate the fire alarm manual pull station and could not explain a method of alerting the facility of a fire.

Based on observation, the facility failed to maintain its fire extinguishers in accordance with NFPA 10, as evidenced by a fire extinguisher that was not secured and a fire extinguisher with an expired annual inspection tag. This failure could result in the fire extinguisher not functioning as required in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
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. Wheeled typed fire extinguishers shall be located in a designated location.
Chapter 4 Inspection, Maintenance, and Recharging
4-4 Maintenance
4-4.1 Frequency. Fire extinguisher shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During a tour of the facility with Staff I on March 7, 2011 through March 9, 2011, the fire extinguishers were observed.

Outpatient Services at 255 Terracina, Ste. 104 on 3/7/11:
At 3:38 p.m., the fire extinguisher located across the front office had an annual service tag that was dated 8/25/2009.

Main Hospital- Third Floor on 3/8/11:
At 12:05 p.m., the fire extinguisher located in Personnel Services (HR) was unsecured on top of a paper shredder machine. The fire extinguisher did not fit into the wall mount that was located above the extinguisher.

Based on observation, the facility failed to ensure that corridors be kept clear from obstructions. This was evidenced by equipments obstructing the egress path of 1 of 2 emergency exits in a smoke compartment. This had the potential of delaying egress in the event of a fire or other emergency and could result in injury to patients, staff and visitors.

Findings:

During a tour of the facility with the Safety/Risk Analyst, the corridors and emergency exits were observed.

On 03/08/2011, at 2:08 p.m., the corridor by the Engineering Work Area and Receiving was obstructed with items that included IV poles with stands, boxes, tables, and other hospital equipments. The width of the corridor was reduced to less than 4-feet by the hospital equipments placed along the egress path of the corridor. The same items were observed during a tour of the facility on 03/07/2011.

Based on document review and interview, the facility failed to ensure that the humidity level policy for its operating rooms is in accordance with NFPA 99, as evidence by the facility's written policy (H04) Surgery Services/Maternal Child, Policy 3. stating "The relative humidity should be maintained between 20% and 60%." This failure could result in low humidity levels that can potentially lead to an increased risk of fire and affected 8 operating rooms, 3 GI rooms and 2 Labor and Delivery C-Section operating rooms.

NFPA 99, Health Care Facilities
Chapter 5 Environmental Systems
5-4.1 Ventilation-Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system suppling anesthetizing location shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review and interview with Staff I (Facility Director) on March 8, 2011, the facility policy for humidity levels was observed.

At 10:15 a.m., the facility provided a Policy and Procedure (P&P) for review. The P&P indicated that the humidity range should be maintained between 20% and 60%. The range is less than the required 35 percent or greater. During interview, the Facility Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Based on observation, the facility failed to maintain the electrical equipment and wiring, as evidenced by the unauthorized use of electrical equipment such as power strips plugged into power strips and an electrical cover plate missing. This failure could increase the risk of electrical shock or an electrical fire and affected 1 of 5 floors and the basement.
NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with Staff I on March 7, 2011 through March 9, 2011, the electrical equipment was observed.

Main Hospital - Fifth Floor on 3/7/11:
At 10:55 a.m., the electrical cover plate was missing in the right wall of patient room 5162.

Main Hospital - Basement on 3/8/11:
At 9:44 a.m., a power strip was plugged into another power strip in the Pharmacy Library area.