HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide ventilation shafts between floors enclosed with construction having a fire resistance rating of at least one hour. Findings:

Building C - NTZI
1) 2nd Floor - south chase is not sealed floor to floor. A large area cut-out of the gypsum board exists in the chase.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least a one half hour fire resistance rating. Findings:

Plaza - Suite 300
1) The south section of the smoke barrier between the Surgery Suite and Recovery was not correctly sealed to the deck above.
2) Penetrations were found above the ceiling in Recovery of the smoke barrier.
3) A duct was found penetrating the smoke barrier between Recovery and Storage.
4) Wall penetrations were not sealed above the double egress corridor doors leading to the restricted corridor in surgery.

Hospital - Tower
1) 8 th Floor - east, wall at conference room, above screen, not sealed at top of wall.
Hospital - B thru 3, Typical findings
2) Gray unidentified caulk at top of several smoke walls, need documentation of UL listing
3) Adjacent to Staff Lounge 2E2213, at corridor wall, urethane foam at top of wall.
4) 1st Floor, east end of smoke barrier between SC:1.2 and S6 is not sealed with fire rated sealant.

Plaza - Bennett Clinic
1) Portions of the 1-hour barrier were not intact and did not provide a 1-hour barrier.

Building A - Anticoagulation Clinic
1) The one hour rated smoke barrier (corridor wall) was found to have an approx. 9"x 15" hole cutout for piping; and unrated penetrations in wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Note: areas renovated after 9/11/03 are subject to 18.3.2.1. Findings:

Hospital
1) The doors to the 2nd Floor Lab Storage Room are not self closing and the doors are not maintained and was disintegrating at the bottom of the door.
2) Concourse Level, Housekeeping Department CDC70: fire rated sealant missing at top of east wall; fireproofing missing on steel beam.
3) Concourse Level, Linen Storage CDC70.03: open penetration under duct, north wall.
3) Expanded foam was found at the juncture of the deck above and the gypsum board wall, and at penetrations thru walls, at the following locations.
a. 10th floor Soiled Utility.
b. Soiled 10C1049.
c. 10 West Clean Utility.
d. 10 East Mechanical Room.
e. 10D1009 Housekeeping.
f. 9 East Housekeeping.
g. 9th Floor Clean Linen.
h. 8 East Soiled 8F894.
i. Clean Linen 8C847.
j. Soiled Utility 8C859.

Plaza - Suite 300
1) Soiled Linen Room adjacent to Nurse Station does not have rated walls or self-closing doors.
2) Door to Sterile Supply/Storage has hardware that is not positive latching that secures the door when closed.
3) The ante room prior the Mechanical Room is used as a storage room, this room is not protected as a hazardous area. The common wall with the soiled holding room is not properly constructed for a rated wall.
Hospital, general,
4) Soiled Linen and other Hazardous Area Rooms have improper expanding foam at the top of the wall that is exposed.

Comprehensive Breast Center 3525 NW 56th, Suite C-100
1) An former office located in the northeast corner of the building is now used as a storage room in excess of 100 square feet, requiring rated walls and door closer.


20935

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Findings:

1) The Storage Room adjacent to the Kitchen has open gaps between the roof deck and the top of the wall on the south and west walls of the Storage Room.

2) The Boiler Room is being used as a general storage room.

Based on observation and interview with staff, the facility failed to protect flammable, combustible, or hazardous materials in the lab that are considered hazardous in accordance with NFPA 99, 10.5.1. Findings:

Seven Plastic Gallon Bottles (Harleco Wright Stain) of combustibles were stored in the Laboratory Storage Room and were not stored in accordance with Policy and Procedure adopted by Integris Health Number MSM-3008. Policy 3.2.1 requires flammable liquids to be stored in flammable rated storage cabinets.

Based on observation and interview with staff, the facility failed to provide corridors serving as a means of egress that are clear and unobstructed. 18.2.3.3/19.2.3.3 Note: Width of corridors may not be reduced. Areas renovated after 9/11/2003 are required to comply with 18.2.3.3 Findings,

Width of egress corridors in the patient acute care units have obstructions and impediments to clear and unobstructed exit access. Obstructions include medication carts both adjacent to the nurse's station and/or against the opposite walls; Work Stations on Wheels (WOWs) are left for extended periods outside of rooms and stored for battery charging at cross-corridor walls, isolation carts that are left in the corridor outside of patient rooms on a 24/7 basis during the patient stay. Scales and lifts are stored in some corridors opposite a patient room door. Carts are not kept to one side when not in use to minimize the obstruction.

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 7.10, 19.2.10.1. Findings:

NZTI - Suite 700
1) Exit light not visible from both directions at intersecting hallway.
2) At intersection of Hall and Reception, light needs to be lowered.
3) West side north and west side south needs to be lowered to be visible.
4) Review to provide exit signs to be displayed in accordance with 7.10.
5) SE office - exit light needs directional arrow.
6) File Room door to Waiting Rooms requires exit sign.
7) Re-orient the exit sign in West Nurse Station.

NTZI - Suite 200
1) SE corner needs exit light.
2) Move NW exit sign to direct means of egress through hallway in lieu of through an occupied room.
3) Remove exit sign leading egress through Research Room.
4) Door at end of west hall needs to read "No Exit."

Based upon observation, interview with staff and review of records of the fire drills that were held at unexpected times under varying conditions, at least quarterly on each shift, the facility failed to include all departments and staff. 19.7.1.2 Findings,

Based upon review of records and substantiated by staff that conducts the fire drills, the Lab only participated once a year in fire drills.

Based upon observation, interview with staff and review of fire alarm testing records, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings:

The vendor providing the maintenance and testing of the fire alarm system failed to provide records and information that are required for verifying the maintenance and testing of the the fire alarm system. The vendor could not provide a directory that reflected the Smoke Evacuation system for the Operating Rooms, Smoke Evacuation system for the Atrium, Magnetic Locks, Control Zams that drop out for Powered Assist Doors located in combination fire and smoke walls, and other equipment connected to the fire alarm system. As-built drawings for new equipment and operation manuals are not available for designated representatives to provide test and maintenance schedules.

Based on interview with Staff on Wednesday 25, 2012 at 2:30 PM, the Egress Control System (magnetic locks) that was installed, had not been tested and documented as required for re-acceptance testing,

Records of the annual testing of the fire alarm system that were provided for review had not been signed by the technician testing the equipment or the owner's representative to provide verification that staff had reviewed the report.

Sliding Doors were not tested in accordance with Policy adopted by the facility. Doors are required to have a speed test and other functions documented on the 2009 test; however, on the 2010, 2011 test of those functions were not documented.

Based on observation and interview with staff, the facility failed to provide a fire sprinkler system in accordance with 19.3.5.2. Findings:

1) Conduit and wiring were found resting on fire sprinkler piping, in violation of NFPA 25, Section 5.2.2.2.

2) Fire sprinkler escutcheons are missing in front of the freezer and in the janitor closet in the kitchen.

Based on observation and interview with staff, the facility failed to provide a fire sprinkler system in accordance with 19.3.5.2. Findings:

Hospital
1) 2nd Floor, outside 2E2188: the support for the chilled water line is in contact with the fire sprinkler piping. NFPA 25, Section 5.2.2.2.
2) 2nd Floor, C-2D28 outside of 2D2198: ceiling grid is wired to fire sprinkler piping. NFPA 25, Section 5.2.2.2.
3) 2nd Floor Radiology: wiring is draped over fire sprinkler piping.


NZTI Building
1) Conduit and wiring were found to be resting on fire sprinkler piping thruout both the 2nd and 7th floors. NFPA 25, Section 5.2.2.2.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2. Findings:

1) Exhaust fans in patient toilet rooms are not operational in one area.

2) There is no exhaust in the Janitor Closet in the Kitchen.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99. Findings:

1) Exam Rooms in Wound Center 3D331 were found to not have a zone valve serving the medical air outlets in the exam rooms, as required by 4-3.1.2.3 (d).

2) Medical Gas Storage Room 2C2126.08 has un-rated penetrations in the one hour rated wall, the duct work needs fire rated sealant, and the electrical switch and receptacle are required to be located greater than 5'-0" above the floor.

3) At the 4 West smoke doors, medical gas lines are in contact with galvanized pipe and wiring ties to electrical conduit.

Based on observation, interview with staff and review of records and policies, the facility failed to provide approval and designation by the governing body of the hospital of all anesthetizing locations in accordance with NFPA 99 12-2.7. The facility failed to provide anesthetizing locations that are protected in accordance with NFPA 99, 5-4.1. The facility failed to provide policies and training that "all areas of hazard are fully recognized by all personnel and is augmented by by attention to detail by all personnel", as required by NFPA 99, 12-4.1.1.3(a). Findings:

Medical Plaza - Suite 300
During a survey of the outpatient surgery suite in the medical plaza, the operating rooms were found to not be protected as required by NFPA 99, 5-4.1, 5-4.2, 5-4.3. The ORs was no documentation the rooms were provided with a smoke evacuation system, or a means to prevent recirculation of smoke originating within the surgical suite. The facility failed to provide documentation of the humidity levels or records that the humidly equipment was maintained and inspected.

Radiology
During a survey tour of the radiology department on 7/24/2012, surveyors observed anesthesia machines present in magnetic resonance imaging (MRI), computed tomography (CT), and interventional radiology room utilized for endoscopic retrograde cholangiopancreatography (ERCP). At the time of the tour, staff told surveyors anesthesia was provided in these locations occasionally, a total of 13 locations outside of the surgery suite were identified. Senior nursing staff was consulted and personally observed a procedure in progress, the senior staff stated they were not aware anesthetizing was provided in these locations. There was no documentation these anesthetizing locations had been reviewed and approved through governance as anesthetizing locations in accordance with NFPA 99, 12-2.7. The facility failed to protect these 13 anesthetizing locations in accordance with NFPA 99 5-4.1 (Rooms are located 2nd. floor IR Supply, IR1, IR3, Angio 1, Angio 2,IR 2, CT 2, GI, Angio 4, Angio 3, CVI 3rd floor, MRI Procedure Room 1st Floor) . They were not provided with smoke evacuation, humidity control, medical gas alarms, medical gas zone valves, waste anesthetic gas requirements, and emergency electrical supply, all as required by NFPA 99, 5-4.1 thru 5-4.6.

During the tour of Radiology, a surveyor asked staff about medical gas shut off valve locations. Staff members were unable to identify locations of medical gas shut off valves. Staff could not verbalize how the valves shut off the medical gas or why the valves would need to be shut off. NFPA 99, 12 5-4.1.1.3(a)

Operating Room Suite
Based on review of the Humidity Logs provided for January 2011-February 2011, the facility logs indicated humidity that was below 35%. Based on interview with operations staff, the facility did not take action to correct the humidity levels. The facility failed to provide documentation that the humidifiers had been inspected, tested or that they were maintained in working condition. The facility failed to provide documentation the smoke evacuation system had been inspected, fire alarm tested or maintained in working condition.

The facility failed to provide documentation that the hospital and professionals established rules and regulations for the control of personnel concerned with anesthetizing locations and prominently posting of the said rules and regulations in the operating room suite, as required by NFPA 99, 12-4.1.1.4.

The medicaments combustibles for Sterile Prep stored in Purchasing and used in all patient care areas is required to have drying times after application; however, the policy was not used in areas other than the OR. NFPA 99, 12-4.1.2.2

The facility failed to provide in-service training in electrical safeguards for personnel working in an anesthetizing location - a scrub tech indicated they were not aware of the function of a line isolation monitor, reference NFPA 99, 12-4.1.2.4(d).

The facility failed to provide documentation that staff have been in-serviced in fire loss prevention procedures in the operating room suite and reviewed annually for all physicians and staff. NFPA 12-4.1.2.10.

Based upon observation, interview with staff and review of records of the testing of the fume hoods, the facility failed to verify that fume hoods installed are balanced to provide negative pressure with respect to the surrounding hospital area. 5-4.2.1 Findings:

Records show the fume hoods in the Micro-Biology area were tested; however, the surrounding area was not documented as being negative pressure relative to the adjacent hospital area. The sliding glass window in the front office was observed left open, the door that opens into the atrium was observed opening outward, due to positive air pressure.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99. 3.4.2.2.2 Findings,

Plaza - Suites 300 & 350, 3433 NW 56 th Street
1) The facility failed to provide a type I EES comprised of two separate Emergency Systems. The two systems are the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3-4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3-4.2.2.3.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Junction boxes without cover plates were found above the ceiling in Adolescent I and in the Kitchen.

2) Electrical wiring, conduit, etc. was found to be improperly supported in violation of NFPA 70.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Electrical junction boxes without cover plates were found above the ceiling in the following as typical locations. Cover plates are required by 314.28 (C).
a. Concourse Level; Linen Room, north area alcove.
b. 1st Floor Room 1B1207.
c. 1st Floor above double door at Gift Shop.
d. 2nd Floor IR Office.
e. 2nd Floor IR office area next to by 4.
g. 2nd Floor Radiology Holding.
g. 2nd Floor SAU smoke doors by Soiled Room, west side.
h. 2nd Floor, NW corner of PACU.
i. 2nd Floor, outside 2E2188.
j. 6 West, east of smoke doors.
h. 10 th floor, above suite entry doors.
i. 10 West, Clean Utility.

Based on observation and interview with staff, the facility failed to provide ventilation shafts between floors enclosed with construction having a fire resistance rating of at least one hour. Findings:

Building C - NTZI
1) 2nd Floor - south chase is not sealed floor to floor. A large area cut-out of the gypsum board exists in the chase.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are at least a one half hour fire resistance rating. Findings:

Plaza - Suite 300
1) The south section of the smoke barrier between the Surgery Suite and Recovery was not correctly sealed to the deck above.
2) Penetrations were found above the ceiling in Recovery of the smoke barrier.
3) A duct was found penetrating the smoke barrier between Recovery and Storage.
4) Wall penetrations were not sealed above the double egress corridor doors leading to the restricted corridor in surgery.

Hospital - Tower
1) 8 th Floor - east, wall at conference room, above screen, not sealed at top of wall.
Hospital - B thru 3, Typical findings
2) Gray unidentified caulk at top of several smoke walls, need documentation of UL listing
3) Adjacent to Staff Lounge 2E2213, at corridor wall, urethane foam at top of wall.
4) 1st Floor, east end of smoke barrier between SC:1.2 and S6 is not sealed with fire rated sealant.

Plaza - Bennett Clinic
1) Portions of the 1-hour barrier were not intact and did not provide a 1-hour barrier.

Building A - Anticoagulation Clinic
1) The one hour rated smoke barrier (corridor wall) was found to have an approx. 9"x 15" hole cutout for piping; and unrated penetrations in wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Note: areas renovated after 9/11/03 are subject to 18.3.2.1. Findings:

Hospital
1) The doors to the 2nd Floor Lab Storage Room are not self closing and the doors are not maintained and was disintegrating at the bottom of the door.
2) Concourse Level, Housekeeping Department CDC70: fire rated sealant missing at top of east wall; fireproofing missing on steel beam.
3) Concourse Level, Linen Storage CDC70.03: open penetration under duct, north wall.
3) Expanded foam was found at the juncture of the deck above and the gypsum board wall, and at penetrations thru walls, at the following locations.
a. 10th floor Soiled Utility.
b. Soiled 10C1049.
c. 10 West Clean Utility.
d. 10 East Mechanical Room.
e. 10D1009 Housekeeping.
f. 9 East Housekeeping.
g. 9th Floor Clean Linen.
h. 8 East Soiled 8F894.
i. Clean Linen 8C847.
j. Soiled Utility 8C859.

Plaza - Suite 300
1) Soiled Linen Room adjacent to Nurse Station does not have rated walls or self-closing doors.
2) Door to Sterile Supply/Storage has hardware that is not positive latching that secures the door when closed.
3) The ante room prior the Mechanical Room is used as a storage room, this room is not protected as a hazardous area. The common wall with the soiled holding room is not properly constructed for a rated wall.
Hospital, general,
4) Soiled Linen and other Hazardous Area Rooms have improper expanding foam at the top of the wall that is exposed.

Comprehensive Breast Center 3525 NW 56th, Suite C-100
1) An former office located in the northeast corner of the building is now used as a storage room in excess of 100 square feet, requiring rated walls and door closer.


20935

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Findings:

1) The Storage Room adjacent to the Kitchen has open gaps between the roof deck and the top of the wall on the south and west walls of the Storage Room.

2) The Boiler Room is being used as a general storage room.

Based on observation and interview with staff, the facility failed to protect flammable, combustible, or hazardous materials in the lab that are considered hazardous in accordance with NFPA 99, 10.5.1. Findings:

Seven Plastic Gallon Bottles (Harleco Wright Stain) of combustibles were stored in the Laboratory Storage Room and were not stored in accordance with Policy and Procedure adopted by Integris Health Number MSM-3008. Policy 3.2.1 requires flammable liquids to be stored in flammable rated storage cabinets.

Based on observation and interview with staff, the facility failed to provide corridors serving as a means of egress that are clear and unobstructed. 18.2.3.3/19.2.3.3 Note: Width of corridors may not be reduced. Areas renovated after 9/11/2003 are required to comply with 18.2.3.3 Findings,

Width of egress corridors in the patient acute care units have obstructions and impediments to clear and unobstructed exit access. Obstructions include medication carts both adjacent to the nurse's station and/or against the opposite walls; Work Stations on Wheels (WOWs) are left for extended periods outside of rooms and stored for battery charging at cross-corridor walls, isolation carts that are left in the corridor outside of patient rooms on a 24/7 basis during the patient stay. Scales and lifts are stored in some corridors opposite a patient room door. Carts are not kept to one side when not in use to minimize the obstruction.

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 7.10, 19.2.10.1. Findings:

NZTI - Suite 700
1) Exit light not visible from both directions at intersecting hallway.
2) At intersection of Hall and Reception, light needs to be lowered.
3) West side north and west side south needs to be lowered to be visible.
4) Review to provide exit signs to be displayed in accordance with 7.10.
5) SE office - exit light needs directional arrow.
6) File Room door to Waiting Rooms requires exit sign.
7) Re-orient the exit sign in West Nurse Station.

NTZI - Suite 200
1) SE corner needs exit light.
2) Move NW exit sign to direct means of egress through hallway in lieu of through an occupied room.
3) Remove exit sign leading egress through Research Room.
4) Door at end of west hall needs to read "No Exit."

Based upon observation, interview with staff and review of records of the fire drills that were held at unexpected times under varying conditions, at least quarterly on each shift, the facility failed to include all departments and staff. 19.7.1.2 Findings,

Based upon review of records and substantiated by staff that conducts the fire drills, the Lab only participated once a year in fire drills.

Based upon observation, interview with staff and review of fire alarm testing records, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings:

The vendor providing the maintenance and testing of the fire alarm system failed to provide records and information that are required for verifying the maintenance and testing of the the fire alarm system. The vendor could not provide a directory that reflected the Smoke Evacuation system for the Operating Rooms, Smoke Evacuation system for the Atrium, Magnetic Locks, Control Zams that drop out for Powered Assist Doors located in combination fire and smoke walls, and other equipment connected to the fire alarm system. As-built drawings for new equipment and operation manuals are not available for designated representatives to provide test and maintenance schedules.

Based on interview with Staff on Wednesday 25, 2012 at 2:30 PM, the Egress Control System (magnetic locks) that was installed, had not been tested and documented as required for re-acceptance testing,

Records of the annual testing of the fire alarm system that were provided for review had not been signed by the technician testing the equipment or the owner's representative to provide verification that staff had reviewed the report.

Sliding Doors were not tested in accordance with Policy adopted by the facility. Doors are required to have a speed test and other functions documented on the 2009 test; however, on the 2010, 2011 test of those functions were not documented.

Based on observation and interview with staff, the facility failed to provide a fire sprinkler system in accordance with 19.3.5.2. Findings:

1) Conduit and wiring were found resting on fire sprinkler piping, in violation of NFPA 25, Section 5.2.2.2.

2) Fire sprinkler escutcheons are missing in front of the freezer and in the janitor closet in the kitchen.

Based on observation and interview with staff, the facility failed to provide a fire sprinkler system in accordance with 19.3.5.2. Findings:

Hospital
1) 2nd Floor, outside 2E2188: the support for the chilled water line is in contact with the fire sprinkler piping. NFPA 25, Section 5.2.2.2.
2) 2nd Floor, C-2D28 outside of 2D2198: ceiling grid is wired to fire sprinkler piping. NFPA 25, Section 5.2.2.2.
3) 2nd Floor Radiology: wiring is draped over fire sprinkler piping.


NZTI Building
1) Conduit and wiring were found to be resting on fire sprinkler piping thruout both the 2nd and 7th floors. NFPA 25, Section 5.2.2.2.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2. Findings:

1) Exhaust fans in patient toilet rooms are not operational in one area.

2) There is no exhaust in the Janitor Closet in the Kitchen.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99. Findings:

1) Exam Rooms in Wound Center 3D331 were found to not have a zone valve serving the medical air outlets in the exam rooms, as required by 4-3.1.2.3 (d).

2) Medical Gas Storage Room 2C2126.08 has un-rated penetrations in the one hour rated wall, the duct work needs fire rated sealant, and the electrical switch and receptacle are required to be located greater than 5'-0" above the floor.

3) At the 4 West smoke doors, medical gas lines are in contact with galvanized pipe and wiring ties to electrical conduit.

Based on observation, interview with staff and review of records and policies, the facility failed to provide approval and designation by the governing body of the hospital of all anesthetizing locations in accordance with NFPA 99 12-2.7. The facility failed to provide anesthetizing locations that are protected in accordance with NFPA 99, 5-4.1. The facility failed to provide policies and training that "all areas of hazard are fully recognized by all personnel and is augmented by by attention to detail by all personnel", as required by NFPA 99, 12-4.1.1.3(a). Findings:

Medical Plaza - Suite 300
During a survey of the outpatient surgery suite in the medical plaza, the operating rooms were found to not be protected as required by NFPA 99, 5-4.1, 5-4.2, 5-4.3. The ORs was no documentation the rooms were provided with a smoke evacuation system, or a means to prevent recirculation of smoke originating within the surgical suite. The facility failed to provide documentation of the humidity levels or records that the humidly equipment was maintained and inspected.

Radiology
During a survey tour of the radiology department on 7/24/2012, surveyors observed anesthesia machines present in magnetic resonance imaging (MRI), computed tomography (CT), and interventional radiology room utilized for endoscopic retrograde cholangiopancreatography (ERCP). At the time of the tour, staff told surveyors anesthesia was provided in these locations occasionally, a total of 13 locations outside of the surgery suite were identified. Senior nursing staff was consulted and personally observed a procedure in progress, the senior staff stated they were not aware anesthetizing was provided in these locations. There was no documentation these anesthetizing locations had been reviewed and approved through governance as anesthetizing locations in accordance with NFPA 99, 12-2.7. The facility failed to protect these 13 anesthetizing locations in accordance with NFPA 99 5-4.1 (Rooms are located 2nd. floor IR Supply, IR1, IR3, Angio 1, Angio 2,IR 2, CT 2, GI, Angio 4, Angio 3, CVI 3rd floor, MRI Procedure Room 1st Floor) . They were not provided with smoke evacuation, humidity control, medical gas alarms, medical gas zone valves, waste anesthetic gas requirements, and emergency electrical supply, all as required by NFPA 99, 5-4.1 thru 5-4.6.

During the tour of Radiology, a surveyor asked staff about medical gas shut off valve locations. Staff members were unable to identify locations of medical gas shut off valves. Staff could not verbalize how the valves shut off the medical gas or why the valves would need to be shut off. NFPA 99, 12 5-4.1.1.3(a)

Operating Room Suite
Based on review of the Humidity Logs provided for January 2011-February 2011, the facility logs indicated humidity that was below 35%. Based on interview with operations staff, the facility did not take action to correct the humidity levels. The facility failed to provide documentation that the humidifiers had been inspected, tested or that they were maintained in working condition. The facility failed to provide documentation the smoke evacuation system had been inspected, fire alarm tested or maintained in working condition.

The facility failed to provide documentation that the hospital and professionals established rules and regulations for the control of personnel concerned with anesthetizing locations and prominently posting of the said rules and regulations in the operating room suite, as required by NFPA 99, 12-4.1.1.4.

The medicaments combustibles for Sterile Prep stored in Purchasing and used in all patient care areas is required to have drying times after application; however, the policy was not used in areas other than the OR. NFPA 99, 12-4.1.2.2

The facility failed to provide in-service training in electrical safeguards for personnel working in an anesthetizing location - a scrub tech indicated they were not aware of the function of a line isolation monitor, reference NFPA 99, 12-4.1.2.4(d).

The facility failed to provide documentation that staff have been in-serviced in fire loss prevention procedures in the operating room suite and reviewed annually for all physicians and staff. NFPA 12-4.1.2.10.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99. 3.4.2.2.2 Findings,

Plaza - Suites 300 & 350, 3433 NW 56 th Street
1) The facility failed to provide a type I EES comprised of two separate Emergency Systems. The two systems are the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3-4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3-4.2.2.3.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Junction boxes without cover plates were found above the ceiling in Adolescent I and in the Kitchen.

2) Electrical wiring, conduit, etc. was found to be improperly supported in violation of NFPA 70.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Electrical junction boxes without cover plates were found above the ceiling in the following as typical locations. Cover plates are required by 314.28 (C).
a. Concourse Level; Linen Room, north area alcove.
b. 1st Floor Room 1B1207.
c. 1st Floor above double door at Gift Shop.
d. 2nd Floor IR Office.
e. 2nd Floor IR office area next to by 4.
g. 2nd Floor Radiology Holding.
g. 2nd Floor SAU smoke doors by Soiled Room, west side.
h. 2nd Floor, NW corner of PACU.
i. 2nd Floor, outside 2E2188.
j. 6 West, east of smoke doors.
h. 10 th floor, above suite entry doors.
i. 10 West, Clean Utility.