HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their walls. This was evidenced by penetrations in walls throughout the facility. This affected 3 of 3 floors and could result in the spread of smoke or fire to from one area to another.

Findings:

During a facility tour with staff, the walls in the facility were observed.

1. On 3/16/10 at 9:14 a.m., there was an approximately 1.5 inch by 2 inch penetration in the wall behind the door to Room 308.

2. On 3/16/10 at 9:41 a.m., there were three approximately 1/4 inch wide penetrations in a wall of the supply room A384.

3. On 3/16/10 at 9:44 a.m., there were seven approximately 1/2 inch wide penetrations in the wall near the television in Room A380.

4. On 3/16/10 at 9:50 a.m., there were 20 approximately 1/4 inch wide penetrations in the walls of Room A359.

5. On 3/16/10 at 9:58 a.m., there were two approximately 1/2 inch wide penetrations in a wall of Room A370.

6. On 3/16/10 at 9:59 a.m., there were 15 approximately 1/4 inch wide penetrations in a wall of the clean utility room A367.

7. On 3/16/10 at 10:00 a.m., there were seven approximately 1/2 inch wide penetrations in a wall of the housekeeping closet, A366.

8. On 3/16/10 at 10:35 a.m., there was an approximately 2.5 inch by 2 inch damaged area in the wall behind the door in Room 231.

9. On 3/16/10 at 11:11 a.m., there was an approximately 1/2 inch wide penetration in a wall of the storage room, A246.

10. On 3/16/10 at 11:14 a.m., there were seven approximately 1/4 inch wide penetrations in a wall of the housekeeping closet, A262.

11. On 3/16/10 at 11:40 a.m., there were six approximately 1/4 inch wide penetrations in the wall near a paper towel dispenser in the hospitality suite Room A272.

12. On 3/16/10 at 3:18 p.m., there were six approximately 1/2 inch wide penetrations in the wall below the desk, in the office B1456.

13. On 3/17/10 at 8:49 a.m., there was an approximately 1 inch wide penetration in the wall of the radiology work room, near the blanket warmer.

14. On 3/17/10 at 9:03 a.m., there was an approximately 3 inch by 3 inch penetration in the wall of mammography processor room, B1566. Two tubes were running through the penetration.

15. On 3/17/10 at 9:56 a.m., there were two approximately 1/4 inch wide penetrations in the wall near doors to the critical care unit A1268.

16. On 3/17/10 at 10:13 a.m., there was an approximately 3 inch by 2 inch penetration in the wall near the television, in respiratory therapy room, A1343. A television cable was running through the penetration.

Based on observation, the facility failed to maintain their doors. This was evidenced by three doors equipped with self closing devices that failed to close and latch and by three doors that were obstructed from closing. This affected 3 of 3 floors and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

1. On 3/16/10 at 9:35 a.m., the door to the exam room across from Room 347 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the depressed position.

2. On 3/16/10 at 10:30 a.m., the door to exam room A296 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the depressed position.

3. On 3/16/10 at 4:05 p.m., the door to the laboratory supply room A1329 was equipped with a self closing device. The door was held in the open position by a box, placed directly in the swing path of the door. A sign on the door said, "Please keep this door closed."

4. On 3/17/10 at 9:28 a.m., the door to the exam room A109 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from closing by dragging on the floor and by the door frame.

5. On 3/17/10 at 9:43 a.m., the door to the electrical/transfer switch room A1254 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from closing by dragging on the floor.

6. On 3/17/10 at 9:53 a.m., the door to the director of emergency services and critical care room A1280 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by two smoke barrier walls that had unsealed penetrations. This affected 2 of 3 floors and could result in the spread of smoke to other smoke compartments.

Findings:

During a facility tour with staff on 3/15/10, the smoke barrier walls were observed.

1. At 2:16 p.m., there was an approximately 4.5 inch wide pipe, running through the smoke barrier wall, on the 3rd floor near room 331. Wires were running though the opening in the pipe. The opening was not sealed to prevent the passage of smoke.

2. At 2:47 p.m., there was an approximately 1 inch wide penetration in the smoke barrier wall on the 1st floor near the medical staff offices.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by a smoke barrier door that was not equipped with a self closing device and by two smoke barrier doors that failed to latch when released from their holding devices. This affected 1 of 3 floors and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff, the smoke barrier doors were observed.

1. On 3/16/10 at 3:04 p.m., the smoke barrier door on the 1st floor, near medical records, was not equipped with a self closing device.

2. On 3/16/10 at 3:14 p.m., the smoke barrier door, on the 1st floor near the accounting/budget/payroll office, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

3. On 3/17/10 at 9:37 a.m., the smoke barrier door on the 1st floor by the emergency room was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by penetrations in the walls of two hazardous areas. This affected 1 of 3 floors and could result in the spread of smoke or fire from one area to another. Combustible storage areas, greater than 50 square feet, are required to be protected as hazardous areas.

Findings:

During a facility tour with staff, the hazardous areas were observed.

1. On 3/16/10 at 2:22 p.m., there were two penetrations approximately 1.5 by 1.5 inches and 1.5 by 3.5 inches, in the wall of the main linen supply room. The penetrations were in the back wall opposite the entrance to the room. The room contained clean linen and was greater than 50 square feet in size.

2. On 3/17/10 at 9:39 a.m., there were three penetrations approximately 5 by 1 inch, 8 by 1 inch, and 13 by 1 inch in size, in the wall of the central distribution room A1321. The penetrations were in the lower wall on the right-hand side of the room when entering from the critical care unit. The room contained combustible items and was greater than 50 square feet in size.

Based on observation, the facility failed to maintain one egress path. This was evidenced by the storage of items near an emergency exit door. This affected 1 of 3 floors and could result in a delayed evacuation in the event of a fire or other emergency.

Findings:

During a facility tour with staff, on 3/17/10 at 10:24 a.m., the exit door near the surgery waiting room was observed. There were two wheel chairs positioned in the aisle in that area. The clear width measured from the wall to the wheel chairs was approximately 47 inches.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by missing escutcheon rings on two sprinklers. This affected 2 of 3 floors and could result in the spread of smoke or fire due to openings in the ceiling around the sprinklers.
Escutcheon rings cover penetrations in the ceiling or walls around the sprinkler pipes.

NFPA 25, 1998 edition:
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff on 3/16/10, the sprinklers in the facility were observed.

1. At 11:14 a.m., the sprinkler in the housekeeping closet A262, was missing an escutcheon ring. There was an approximately 1/2 inch wide penetration in the ceiling surrounding the sprinkler pipe.

2. At 2:12 p.m., the sprinkler in the electrical room B1634 was missing and escutcheon ring. There was an approximately 1/2 inch wide penetration in the ceiling surrounding the sprinkler pipe.

Based on observation, the facility failed to monitor their use of portable space heating devices. This was evidenced five portable space heaters, located in staff areas, that were not verified that temperatures did not exceed 212 degrees Fahrenheit. This affected 1 of 3 floors and could result in a fire ignited by a portable space heater.

Findings:

During a facility tour with staff, portable space heaters were observed in staff locations.

1. On 3/16/10 at 2:05 p.m., there were portable space heaters in two 1st floor rehabilitation department offices. The space heaters were the heated coil type. There was no documentation verifying that the space heaters did not exceed 212 degrees Fahrenheit.

2. On 3/16/10 at 2:47 p.m., there was a portable space heater in the dietary office B1613. The space heater was the heated coil type. There was no documentation verifying that the space heater did not exceed 212 degrees Fahrenheit. The space heater was located below a desk in that office. A warning tag on the heater indicated that the heater should have 3 feet of clearance.

3. On 3/17/10 at 9:17 a.m., there was a portable space heater in the case management office A1299. The space heater was the heated coil type. There was no documentation verifying that the space heater did not exceed 212 degrees Fahrenheit. The space heater was plugged into a surge protected multi-outlet extension cord. A warning tag on the heater said to avoid the use of an extension cord.

Based on observation, the facility failed to maintain their storage of medical gas. This was evidenced by medical gas cylinders and tanks that were free standing or unsecured. This affected 1 of 3 floors and could result in damage to a cylinder or tank if it were dislocated.

NFPA 99, 1999 edition:
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the medical gas storage areas were observed.

1. On 3/16/10 at 1:39 p.m., the outside medical gas storage area, near the loading dock, was observed. In the area designated for empty cylinders, there were 4 oxygen E cylinders and 6 other compressed medical gas cylinders that were free standing and unsecured. In the area designated for full cylinders, 25 of 38 H tank sized compressed medical gas cylinders were not secured. The tanks were in racks designed to hold 6 large tanks and secured by a chain that was draped over a hook. There was no latching mechanism or device preventing the chain from falling off the hook. Some racks contained as few as 2 tanks. There was nothing preventing one of those tanks from falling over.

2. On 3/16/10 at 3:29 p.m., 1 of 3 oxygen E cylinders in the wound care center was tipped over and lying on the floor. The cylinder was unsecured.

3. On 3/16/10 at 4:17 p.m., there were two compressed gas cylinders in the pulmonary function lab room B1541 that were lying on the floor and unsecured. There was an oxygen E cylinder lying on a gurney in the same room. There was a recessed slot on the gurney designed to hold the cylinder. The cylinder was not in that slot and was unsecured.

4. On 3/17/10 at 9:19 a.m., 1 of 15 oxygen E cylinders in exam room 1, in the emergency room, was free standing and unsecured.

Based on document review, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the failure to ensure the relative humidity levels were maintained equal to or greater than 35%. This could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During document review, on 3/17/10 at 10:45 a.m., the relative humidity logs for the anesthetizing locations were reviewed. Staff indicated that the relative humidity for their anesthetizing locations are measured and recorded once per day in the morning.

From 11/1/09 to 2/28/10 the relative humidity in operating room 1 dropped below 35% 12 times with a low of 30%. From 11/1/09 to 2/28/10 the relative humidity in operating room 2 dropped below 35% 8 times with a low of 26%. From 11/1/09 to 2/28/10 the relative humidity in operating room 3 dropped below 35% 10 times with a low of 30%. From 11/1/09 to 2/28/10 the relative humidity in operating room 4 dropped below 35% 6 times with a low of 30%. The humidity monitoring policy and procedure for operating rooms was reviewed. The policy and procedure said, "The relative humidity will (be) maintained within the range of 30-60%."

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by one electrical receptacle that had a cracked faceplate, by computer equipment plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord, and by 4 of 4 operating rooms that did not have battery-powered emergency lighting units. This affected 3 of 3 floors and could increase the risk of an electrical fire or a loss of visibility in an operating room in the event of a power failure and emergency generator failure.

NFPA 70, 1999 edition:
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

410-56(e) 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, 1999 edition:
3-3.2.1.2 All Patient Care Areas.
(a) 5 Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electric Code, Section 700-12(e).

Findings:

During a facility tour with staff, the electrical equipment and wiring were observed.

1. On 3/16/10 at 9:57 a.m., an electrical receptacle in the corridor by room A372 had a cracked faceplate.

2. On 3/16/10 at 10:25 a.m., computer equipment in room A281 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

3. On 3/17/10 at 10:55 a.m., the operating rooms were observed. Four of four operating rooms did not have battery-powered emergency lighting units. The lights in the operating rooms were tied to the emergency generator. There were no other lighting units in the operating rooms that would provide illumination in the event that there was a power failure and an emergency generator failure.

Based on observation, the facility failed to ensure their installation of alcohol based hand rub dispensers meets current regulations. This was evidenced by one alcohol based hand rub dispenser that was mounted over an ignition source. This affected 1 of 3 floors and could result in a fire ignited by the alcohol based hand rub and an electrical spark.

Findings:

During a facility tour with staff, on 3/16/10 at 9:23 a.m., an alcohol based hand rub dispenser was located in the corridor near the 3rd floor waiting area. The dispenser was mounted approximately 14 inches above a light switch. The hand rub was 62% ethyl alcohol by volume.

Based on observation, the facility failed to maintain the integrity of their walls. This was evidenced by penetrations in walls throughout the facility. This affected 3 of 3 floors and could result in the spread of smoke or fire to from one area to another.

Findings:

During a facility tour with staff, the walls in the facility were observed.

1. On 3/16/10 at 9:14 a.m., there was an approximately 1.5 inch by 2 inch penetration in the wall behind the door to Room 308.

2. On 3/16/10 at 9:41 a.m., there were three approximately 1/4 inch wide penetrations in a wall of the supply room A384.

3. On 3/16/10 at 9:44 a.m., there were seven approximately 1/2 inch wide penetrations in the wall near the television in Room A380.

4. On 3/16/10 at 9:50 a.m., there were 20 approximately 1/4 inch wide penetrations in the walls of Room A359.

5. On 3/16/10 at 9:58 a.m., there were two approximately 1/2 inch wide penetrations in a wall of Room A370.

6. On 3/16/10 at 9:59 a.m., there were 15 approximately 1/4 inch wide penetrations in a wall of the clean utility room A367.

7. On 3/16/10 at 10:00 a.m., there were seven approximately 1/2 inch wide penetrations in a wall of the housekeeping closet, A366.

8. On 3/16/10 at 10:35 a.m., there was an approximately 2.5 inch by 2 inch damaged area in the wall behind the door in Room 231.

9. On 3/16/10 at 11:11 a.m., there was an approximately 1/2 inch wide penetration in a wall of the storage room, A246.

10. On 3/16/10 at 11:14 a.m., there were seven approximately 1/4 inch wide penetrations in a wall of the housekeeping closet, A262.

11. On 3/16/10 at 11:40 a.m., there were six approximately 1/4 inch wide penetrations in the wall near a paper towel dispenser in the hospitality suite Room A272.

12. On 3/16/10 at 3:18 p.m., there were six approximately 1/2 inch wide penetrations in the wall below the desk, in the office B1456.

13. On 3/17/10 at 8:49 a.m., there was an approximately 1 inch wide penetration in the wall of the radiology work room, near the blanket warmer.

14. On 3/17/10 at 9:03 a.m., there was an approximately 3 inch by 3 inch penetration in the wall of mammography processor room, B1566. Two tubes were running through the penetration.

15. On 3/17/10 at 9:56 a.m., there were two approximately 1/4 inch wide penetrations in the wall near doors to the critical care unit A1268.

16. On 3/17/10 at 10:13 a.m., there was an approximately 3 inch by 2 inch penetration in the wall near the television, in respiratory therapy room, A1343. A television cable was running through the penetration.

Based on observation, the facility failed to maintain their doors. This was evidenced by three doors equipped with self closing devices that failed to close and latch and by three doors that were obstructed from closing. This affected 3 of 3 floors and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

1. On 3/16/10 at 9:35 a.m., the door to the exam room across from Room 347 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the depressed position.

2. On 3/16/10 at 10:30 a.m., the door to exam room A296 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the depressed position.

3. On 3/16/10 at 4:05 p.m., the door to the laboratory supply room A1329 was equipped with a self closing device. The door was held in the open position by a box, placed directly in the swing path of the door. A sign on the door said, "Please keep this door closed."

4. On 3/17/10 at 9:28 a.m., the door to the exam room A109 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from closing by dragging on the floor and by the door frame.

5. On 3/17/10 at 9:43 a.m., the door to the electrical/transfer switch room A1254 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from closing by dragging on the floor.

6. On 3/17/10 at 9:53 a.m., the door to the director of emergency services and critical care room A1280 was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by two smoke barrier walls that had unsealed penetrations. This affected 2 of 3 floors and could result in the spread of smoke to other smoke compartments.

Findings:

During a facility tour with staff on 3/15/10, the smoke barrier walls were observed.

1. At 2:16 p.m., there was an approximately 4.5 inch wide pipe, running through the smoke barrier wall, on the 3rd floor near room 331. Wires were running though the opening in the pipe. The opening was not sealed to prevent the passage of smoke.

2. At 2:47 p.m., there was an approximately 1 inch wide penetration in the smoke barrier wall on the 1st floor near the medical staff offices.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by a smoke barrier door that was not equipped with a self closing device and by two smoke barrier doors that failed to latch when released from their holding devices. This affected 1 of 3 floors and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff, the smoke barrier doors were observed.

1. On 3/16/10 at 3:04 p.m., the smoke barrier door on the 1st floor, near medical records, was not equipped with a self closing device.

2. On 3/16/10 at 3:14 p.m., the smoke barrier door, on the 1st floor near the accounting/budget/payroll office, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

3. On 3/17/10 at 9:37 a.m., the smoke barrier door on the 1st floor by the emergency room was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by penetrations in the walls of two hazardous areas. This affected 1 of 3 floors and could result in the spread of smoke or fire from one area to another. Combustible storage areas, greater than 50 square feet, are required to be protected as hazardous areas.

Findings:

During a facility tour with staff, the hazardous areas were observed.

1. On 3/16/10 at 2:22 p.m., there were two penetrations approximately 1.5 by 1.5 inches and 1.5 by 3.5 inches, in the wall of the main linen supply room. The penetrations were in the back wall opposite the entrance to the room. The room contained clean linen and was greater than 50 square feet in size.

2. On 3/17/10 at 9:39 a.m., there were three penetrations approximately 5 by 1 inch, 8 by 1 inch, and 13 by 1 inch in size, in the wall of the central distribution room A1321. The penetrations were in the lower wall on the right-hand side of the room when entering from the critical care unit. The room contained combustible items and was greater than 50 square feet in size.

Based on observation, the facility failed to maintain one egress path. This was evidenced by the storage of items near an emergency exit door. This affected 1 of 3 floors and could result in a delayed evacuation in the event of a fire or other emergency.

Findings:

During a facility tour with staff, on 3/17/10 at 10:24 a.m., the exit door near the surgery waiting room was observed. There were two wheel chairs positioned in the aisle in that area. The clear width measured from the wall to the wheel chairs was approximately 47 inches.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by missing escutcheon rings on two sprinklers. This affected 2 of 3 floors and could result in the spread of smoke or fire due to openings in the ceiling around the sprinklers.
Escutcheon rings cover penetrations in the ceiling or walls around the sprinkler pipes.

NFPA 25, 1998 edition:
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff on 3/16/10, the sprinklers in the facility were observed.

1. At 11:14 a.m., the sprinkler in the housekeeping closet A262, was missing an escutcheon ring. There was an approximately 1/2 inch wide penetration in the ceiling surrounding the sprinkler pipe.

2. At 2:12 p.m., the sprinkler in the electrical room B1634 was missing and escutcheon ring. There was an approximately 1/2 inch wide penetration in the ceiling surrounding the sprinkler pipe.

Based on observation, the facility failed to monitor their use of portable space heating devices. This was evidenced five portable space heaters, located in staff areas, that were not verified that temperatures did not exceed 212 degrees Fahrenheit. This affected 1 of 3 floors and could result in a fire ignited by a portable space heater.

Findings:

During a facility tour with staff, portable space heaters were observed in staff locations.

1. On 3/16/10 at 2:05 p.m., there were portable space heaters in two 1st floor rehabilitation department offices. The space heaters were the heated coil type. There was no documentation verifying that the space heaters did not exceed 212 degrees Fahrenheit.

2. On 3/16/10 at 2:47 p.m., there was a portable space heater in the dietary office B1613. The space heater was the heated coil type. There was no documentation verifying that the space heater did not exceed 212 degrees Fahrenheit. The space heater was located below a desk in that office. A warning tag on the heater indicated that the heater should have 3 feet of clearance.

3. On 3/17/10 at 9:17 a.m., there was a portable space heater in the case management office A1299. The space heater was the heated coil type. There was no documentation verifying that the space heater did not exceed 212 degrees Fahrenheit. The space heater was plugged into a surge protected multi-outlet extension cord. A warning tag on the heater said to avoid the use of an extension cord.

Based on observation, the facility failed to maintain their storage of medical gas. This was evidenced by medical gas cylinders and tanks that were free standing or unsecured. This affected 1 of 3 floors and could result in damage to a cylinder or tank if it were dislocated.

NFPA 99, 1999 edition:
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the medical gas storage areas were observed.

1. On 3/16/10 at 1:39 p.m., the outside medical gas storage area, near the loading dock, was observed. In the area designated for empty cylinders, there were 4 oxygen E cylinders and 6 other compressed medical gas cylinders that were free standing and unsecured. In the area designated for full cylinders, 25 of 38 H tank sized compressed medical gas cylinders were not secured. The tanks were in racks designed to hold 6 large tanks and secured by a chain that was draped over a hook. There was no latching mechanism or device preventing the chain from falling off the hook. Some racks contained as few as 2 tanks. There was nothing preventing one of those tanks from falling over.

2. On 3/16/10 at 3:29 p.m., 1 of 3 oxygen E cylinders in the wound care center was tipped over and lying on the floor. The cylinder was unsecured.

3. On 3/16/10 at 4:17 p.m., there were two compressed gas cylinders in the pulmonary function lab room B1541 that were lying on the floor and unsecured. There was an oxygen E cylinder lying on a gurney in the same room. There was a recessed slot on the gurney designed to hold the cylinder. The cylinder was not in that slot and was unsecured.

4. On 3/17/10 at 9:19 a.m., 1 of 15 oxygen E cylinders in exam room 1, in the emergency room, was free standing and unsecured.

Based on document review, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the failure to ensure the relative humidity levels were maintained equal to or greater than 35%. This could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During document review, on 3/17/10 at 10:45 a.m., the relative humidity logs for the anesthetizing locations were reviewed. Staff indicated that the relative humidity for their anesthetizing locations are measured and recorded once per day in the morning.

From 11/1/09 to 2/28/10 the relative humidity in operating room 1 dropped below 35% 12 times with a low of 30%. From 11/1/09 to 2/28/10 the relative humidity in operating room 2 dropped below 35% 8 times with a low of 26%. From 11/1/09 to 2/28/10 the relative humidity in operating room 3 dropped below 35% 10 times with a low of 30%. From 11/1/09 to 2/28/10 the relative humidity in operating room 4 dropped below 35% 6 times with a low of 30%. The humidity monitoring policy and procedure for operating rooms was reviewed. The policy and procedure said, "The relative humidity will (be) maintained within the range of 30-60%."

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by one electrical receptacle that had a cracked faceplate, by computer equipment plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord, and by 4 of 4 operating rooms that did not have battery-powered emergency lighting units. This affected 3 of 3 floors and could increase the risk of an electrical fire or a loss of visibility in an operating room in the event of a power failure and emergency generator failure.

NFPA 70, 1999 edition:
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

410-56(e) 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, 1999 edition:
3-3.2.1.2 All Patient Care Areas.
(a) 5 Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electric Code, Section 700-12(e).

Findings:

During a facility tour with staff, the electrical equipment and wiring were observed.

1. On 3/16/10 at 9:57 a.m., an electrical receptacle in the corridor by room A372 had a cracked faceplate.

2. On 3/16/10 at 10:25 a.m., computer equipment in room A281 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

3. On 3/17/10 at 10:55 a.m., the operating rooms were observed. Four of four operating rooms did not have battery-powered emergency lighting units. The lights in the operating rooms were tied to the emergency generator. There were no other lighting units in the operating rooms that would provide illumination in the event that there was a power failure and an emergency generator failure.