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Based on observation, the facility failed to maintain doors to resist the passage of smoke as evidenced by doors that did not latch and by doors that were blocked by items. This affected two smoke compartments on the first floor and could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with a staff member the facility doors were observed.
1. On 7/18/11, at 3:18 p.m., the door to room 46 could not be readily closed. The patients bed blocked the full and instant closure of the door.

2. On 7/18/11, at 3:18 p.m., the door to room 48 did not positively latch when closed.

3. On 7/18/11, at 3:20 p.m., the door to room 58 was blocked and could not be readily closed. The patients bed blocked the full and instant closure of the door.

4. On 7/19/11, at 7:14 p.m., in the ICU West, the door to room 102 did not positively latch when closed.

5. On 7/19/11, at 1:19 p.m. in the ICE East, the door to room 108 was held open by a small garbage can. When staff moved the small can the door slowly closed.

6. On 7/20/11, at 9:00 a.m., the door to resident rooms 402 was blocked by a Workstation On Wheel (WOWs). The WOW machine was left in the door way and the door could not be readily closed.

7. At 9:05 a.m., the door to resident room 401, was blocked by the Workstation On Wheel (WOWs). The WOW machine was left in the door way and the door could not be readily closed.

8. At 9:10 a.m., the door to resident room 405 was blocked by the Workstation On Wheel (WOWs). The WOW machine was left in the door way and the door could not be readily closed.

9. At 9:15 a.m., the door to resident room 406 was blocked by the Workstation On Wheel (WOWs). The WOW machine was left in the door way and the door could not be readily closed.

Based on interview and observation, the facility failed to maintain emergency exits, as evidenced by chairs, wheelchairs, and bins that were stored along the egress pathways in the Emergency Department and in the Radiology Department. This deficient condition affected two smoke compartments on the first floor and could result in a delayed egress in the event of an emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with staff from 7/18/11 to 7/21/11, the facility's emergency exits were observed.

1. On 7/20/11, at 1:30 p.m., one of three emergency access pathways in the Emergency Department was blocked. The pathway near the ambulance bay had 7 chairs, 6 wheel chairs, 1 geri chair and one Workstation On Wheels stored along the right hand wall. Around the corner, there were two large linen racks that were stored along the pathway. There was approximately a 3.5' clearance between the wall and the items stored in the passage way. There were patient care rooms that would use the exit access way in the event of an emergency exit. Patients in wheelchairs would not be able to access the exit passageway.

During review of the fire drill forms, it was stated that all items in hallways would be moved in the event of a fire. During staff interview, staff stated that the items in the hallway would not necessarily be moved.

2. On 7/20/11, at 2:00 p.m., in the Radiology out patient or XRAY department, there were chairs stored along the right hand side of the exit corridor. At the end of the corridor there was an exit to the exterior of the building. There were two exits to a waiting room along the right wall.

During review of the fire drill forms, it was stated that all items in hallways would be moved in the event of a fire. During staff interview, staff stated that the chairs in the corridor would not be moved as the corridor was a suite leading to an exit corridor.

Based on document review and staff interview, the facility failed to maintain the the Fire Alarm Control Panel (FACP) as evidenced by the panel not recording the correct time that each signal was received and by not reporting the correct alarm address of the device that was activated. These deficient practices affected all five stories of the hospital tower and could result in a delayed fire fighter response.

NFPA 72 National Fire Alarm Code, 1999 Edition
5-2.4 Equipment.
5-2.4.1 The central station and all subsidiary stations shall be equipped so as to receive and record all signals in accordance with 5-5.5. Circuit-adjusting means for emergency operation shall be permitted to be automatic or to be provided through manual operation upon receipt of a trouble signal. Computerized alarm and supervisory signal processing hardware and software shall be listed for the specific application.
5-2.4.4.5 The retransmission signal and the time and date of retransmission shall be recorded at the central station.
5-5 Communications Methods for Supervising Station Fire Alarm Systems.
The requirements of Chapters 1 and 7 shall apply to continuously attended supervising station fire alarm systems, unless they conflict with the requirements of this section.
5-5.1* Scope. Section 5-5 and Figure 5-5.1 shall describe the requirements for the methods of communications between the protected premises and the supervising station. These requirements shall include the following:
(1) The transmitter located at the protected premises
(2) The transmission channel between the protected premises and the supervising station or subsidiary station
(3) If used, any subsidiary station and its communications channel
(4) The signal receiving, processing, display, and recording equipment at the supervising station
Exception: Transmission channels owned by and under the control of the protected premises owner, that are not facilities leased from a supplier of communications service capabilities, such as video cable, telephone, or other communications services that are also offered to other customers.

Findings

During document review of the fire alarm signals received on 7/20/11, the following observations were made.

1. The time stamp for the signals received at the FACP was incorrect by approximately an hour and 15 minutes. Staff stated that the time had not been adjusted on the panel during daylight savings.

2. The address for the water flow device on the second floor in the cafeteria was reported to the panel incorrectly. The water flow device reported in the hallway outside of the cafeteria. Staff stated that the location of the deice was manually entered incorrectly.

Based on observation and document review, the facility failed to maintain their portable fire extinguishers as evidenced by fire extinguishers that were stored without being secured and by a class K-type fire extinguisher that was obstructed in the cafeteria. These deficient practice affected one smoke compartment on the first floor and one smoke compartment on the second floor and could result in damage to the fire extinguishers and a delay in accessing the extinguishers during a fire emergency.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with staff from 7/18/11 to 7/21/11, the fire extinguishers were observed.

1. On 7/18/11, at 2:50 p.m., in the Engineering department, there were 17 spare fire extinguishers and 2 out of service fire extinguishers that were stored without being secured.

2. On 7/20/11, at 10:03 a.m., the class K-type fire extinguisher in the cafeteria was obstructed by boxes.

Staff stated that a shipment had just been received.

Based on observation, the facility failed maintain the relative humidity at equal to or greater than 35% humidity as evidenced by 12 days in the past year that the humidity in the Operating rooms was recorded at less than 30% humidity. This deficient practice affected all 7 procedure rooms in the Operating Suite and could potentially result in an increased risk of an electrostatic fire.

Findings

During document review on 7/19/11, the Operating Room Humidity reports were reviewed. The records provided indicated that the humidity level was below 30%. Each room in the Operating Suite dropped below 30% at least one time in the past year.

a) The Mauve Room dropped below 30% 9 days in the past year.

b)The Cysto Room dropped below 30% 4 days in the past year.

c) Operating Room 1, OR-2, OR-3, OR-4, and OR-5 all dropped below 30% at least one day in the past year.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of power strips, by a broken face plate and by a missing cover plate. These deficient conditions affected 3 of 5 floors and could result in the ignition of an electrical fire.

NFPA 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.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
3-3.2.1.2, All patient care areas. d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.
a. Receptacles for Patient Bed Locations in General Care Areas. Each patient bed location shall be provided with a minimum of four receptacles.
b. Receptacles for Patient Bed Locations in Critical Care Areas. Each patient bed location shall be provided with a minimum of six receptacles.
Exception No. 1: Receptacles shall not be required in bathrooms or toilet rooms.
Exception No. 2: Receptacles shall not be required in areas where medical requirements mandate otherwise; for example, certain psychiatric, pediatric, or hydrotherapy areas.

Findings:

During a tour of the facility with staff, from 7/18/11 to 7/21/11, the electrical wiring in the facility was observed.

1. On 7/18/11, at 3:05 p.m., in the Staff Lounge Room 1120, a toaster, coffee maker and rice cooker were plugged into a power strip instead of directly into the wall outlet.

2. On 7/19/11, at 1:22 p.m., in the ICU East room 114, the patients tube feeding machine was plugged to a power strip instead of directly to the wall outlet.

3. On 7/19/11, at 1:34 p.m., in the radiology communications room, 324B, the cover plate for the junction box was missing.

4. At 9:35 a.m., two outlet receptacle faceplates were missing in the ceiling of Resident Room 11. Upon interview with staff, staff stated some electrical wiring was being upgraded, and faceplates would be installed.

5. At 9:41 a.m., a portable fan was mounted on top of the door frame on the wall and plugged into a white extension cord in the Medical Records Room by the emergency exit near Resident room 11. The extension cord ran across the top of the file cabinets to connect the fan's wiring that was mounted along the door frame. Staff acknowledged the extension cord in this room.

6. At 10.20 a.m., A six outlet surge protector strip was plugged into an extension cord, and the extension cord was plugged into the wall of Resident Room 39. All six outlets were in use during the time of inspection to power electronic equipment. Staff acknowledged the extension cord in the Resident Room.