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Based on observation, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, and by corridor doors that were obstructed from closing. This affected two of six floors, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with facility management staff, from 6/28/11 to 6/29/11, the facility corridor doors were observed.

On 6/28/11, the fourth floor of the hospital was observed.

1. At 2:30 p.m., the door to the dirty utility room, across from Room 470, was equipped with a self-closing device. The door closed, but failed to latch.

2. At 2:34 p.m., the door to the clean linen closet, across from Room 471, was equipped with a self-closing device. The door closed, but failed to latch.

On 6/29/11, the first floor of the hospital was observed.

3. At 9:59 a.m., the door to the east wing manager's office was equipped with a self-closing device. The door was held open by a metallic wedge.

Based on observation and interview, the facility failed to maintain their vertical openings. This was evidenced by one fire rated shaft wall that had an unsealed penetration, two corridor doors to chute rooms that were obstructed from latching, and two chute doors that were obstructed from closing. This affected six of six floors in the Main Hospital, and could result in the spread of smoke or fire from one floor to another.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the vertical openings in the facility were observed.

1. On 6/28/11 at 11:42 a.m., there was an approximately two foot by two foot unsealed penetration in a two hour fire rated shaft wall near the Labor and Delivery Waiting Room. The penetration was located in the space above the suspended ceiling. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that facility staff had been working in that area earlier in the morning, and were then reassigned to another task. There was no interim life safety measures taken to maintain that two hour fire rated shaft wall when it was not being worked on.

2. On 6/28/11 at 3:00 p.m., the Linen Chute Room in the Lower Level West Tower was observed. The corridor door to the room 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 due to the door frame.

3. On 6/29/11 at 8:26 a.m., the Linen Chute Room near the Engineering Workshop was observed. The corridor door to the room 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 due to the door frame.

4. On 6/29/11 at 10:18 a.m., the Chute Room near the Interventional Radiology Department was observed. The Soiled Linen Chute door was held in the open position, and was obstructed from closing by a bag of soiled linen in the swing path of the door. The Trash Chute door was stuck in the open position, and was obstructed from closing due to portions of the door that were bent.

Based on observation, the facility failed to maintain doors that are held open by devices designed to release upon activation of the fire alarm system. This was evidenced by three doors that failed to release and close during fire alarm testing. This affected three of six floors, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 6/28/11, doors held open with magnetic and electronic hold-open devices were observed.

1. At 11:23 a.m., the smoke barrier door in Four West CCU was held open by an electronic hold open device. The door did not release and close upon activation of the fire alarm system.

2. At 11:40 a.m., the smoke barrier double doors in Third East Post Partum were held open by an electronic hold open device. The right door did not release and close upon activation of the fire alarm system.

3. At 12:11 a.m., the double doors near the First West service elevator lobby were held open by an electronic hold open device. The door did not release and close upon activation of the fire alarm system.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by one hour fire rated construction, and self-closing doors. This was evidenced by one hazardous area with no self-closing device on the door. This affected one of six floors, and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 6/28/11 to 6/29/11, the hazardous areas were observed in the main hospital.

On 6/28/11, the fourth floor of the hospital was observed.

At 2:50 p.m., the storage room at the end of the CCU hallway was observed. The storage room was approximately 250 square feet in size, and contained more than 15 shelves of medical supplies in cardboard boxes and plastic coverings. The door to the storage room did not have a self-closing device.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests on three of three battery powered emergency lighting units. This affected all patients at the Mercy Woundcare Clinic, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:34 a.m., the facility's battery powered emergency lighting unit test records were observed. Three of three battery powered emergency lighting units at the Mercy Woundcare Clinic were tested for a ninety minute duration in June, 2011. There were no records that indicated the battery powered emergency lighting units were tested monthly for thirty seconds prior to June, 2011. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the battery powered emergency lighting units located at the Mercy Woundcare Clinic had just been added to the testing schedule in June, 2011.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests on two of two battery powered emergency lighting units. This affected all patients at the Mercy Maternity Clinic, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:34 a.m., the facility's battery powered emergency lighting unit test records were reviewed. Two of two battery powered emergency lighting units at the Mercy Maternity Clinic were tested for a ninety minute duration in June of 2011. There were no records that indicated the battery powered emergency lighting units were tested monthly for thirty seconds prior to June of 2011. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the battery powered emergency lighting units located at the Mercy Maternity Clinic had just been added to the testing schedule in June, 2011.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests, and an annual ninety minute test, on two of nine battery powered emergency lighting units located in the Operating Rooms. This affected two of nine Operating Rooms, and could result in the loss of visibility in the event of a power failure in conjunction with a generator malfunction.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:32 a.m., the facility's battery powered emergency lighting unit test records were observed. There were no records that indicated the battery powered emergency lighting units located in Operating Room 8 and Operating Room 9 were being tested monthly for thirty seconds, or annually for ninety minutes. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the battery powered emergency lighting units at those locations were not on the lighting unit test schedule. Engineering Staff 2 did not know when the two battery powered emergency lighting units had last been tested.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source and one exit sign that failed to remain illuminated when tested. This affected two of six floors in the Main Hospital, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the exit signs in the facility were observed.

1. On 6/28/11 at 3:59 p.m., the Endoscopy Department was observed to have eight exit signs equipped with an internal emergency power supply source along their means of egress. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the signs are not tested monthly for thirty seconds. Engineering Staff 2 indicated that the signs are not tested annually for ninety minutes. Engineering Staff 2 indicated that they were unaware that the Endoscopy Department had exit signs equipped with an internal emergency power supply.

2. On 6/29/11 at 10:14 a.m., the exit sign by Interventional Radiology Room 7 was tested by pressing the test button on the unit. The exit sign failed to remain illuminated when the test button for the device was pressed.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Mercy Family Health Center, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review, on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Mercy Family Health Center were requested. There were no records that indicated the Mercy Family Health Center had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Mercy Family Health Center had not been tested for smoke sensitivity. Engineering Staff 2 indicated that they did not know the building needed to comply with that requirement.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Mercy Woundcare Clinic, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Mercy Woundcare Clinic were requested. There were no records that indicated the Mercy Woundcare Clinic had had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Mercy Woundcare Clinic had not been tested for smoke sensitivity. Engineering Staff 2 indicated that they did not know the building needed to comply with that requirement.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Pre-operative Clinic, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review, on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Pre-operative Clinic were requested. There were no records that indicated the Pre-operative Clinic had had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Pre-operative Clinic had not been tested for smoke sensitivity. Engineering Staff 2 indicated that he did not know the building needed to comply with that requirement.

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by one portable fire extinguisher had not been serviced in the past twelve months, two portable fire extinguishers that were obstructed, and one Class K portable fire extinguisher that was missing an instructional placard. This affected two of six floors in the Main Hospital, and could result in a delay to extinguish a fire in the event of an emergency.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the facility's portable fire extinguishers were observed.

1. On 6/28/11 at 2:19 p.m., the dry chemical portable fire extinguisher located near the Helipad had a service tag dated 6/4/09. There were no records that indicated the fire extinguisher had been serviced within the past twelve months.

2. On 6/28/11 at 2:20 p.m., the dry chemical portable fire extinguisher located near the Helipad was located inside a storage enclosure. There was no sign on the door, or in the vicinity, that indicated a portable fire extinguisher was located inside that enclosure. The fire portable fire extinguisher was visually obstructed.

3. On 6/28/11 at 4:31 p.m., the Class K portable fire extinguisher in the Kitchen was observed. There was no placard in the vicinity that indicated the fire protection system should be used prior to using the fire extinguisher.


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Findings:

On 6/29/11, the second floor of the hospital was surveyed.

4. At 9:59 a.m., the portable fire extinguisher near Room 232 was blocked by a bed.

Based on observation and interview, the facility failed to maintain the use of portable space heaters. This was evidenced by portable space heaters that were not tested to ensure they did not exceed two hundred and twelve degrees Fahrenheit, portable space heaters that were plugged into extension cords, portable space heaters that were within three feet of furnishings or combustibles, and a portable space heater that were not unplugged when not in use. This affected two of six floors in the Main Hospital, and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the portable space heaters in the facility were observed.

1. On 6/28/11 at 3:23 p.m., a portable space heater was located in the Medical Director of Emergency Services Office. The portable space heater was located under a desk, and was plugged into a surge protected multi-outlet extension cord. The portable space heater did not have a tag that indicated it had been tested and approved by the facility. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heater at that location had not been approved.

2. On 6/28/11 at 3:47 p.m., there were approximately ten portable space heaters located in the Medical Records Department. The portable space heaters were plugged into surge protected multi-outlet extension cords, located within three feet of furnishings and combustibles, or plugged in when not being used.

3. On 6/29/11 at 8:30 a.m., a portable space heater was located in the Medical Library. The portable space heater was located within three feet of a desk, and was plugged into a surge protected multi-outlet extension cord. The portable space heater did not have a tag that indicated it had been tested and approved by the facility. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heater at that location had not been approved.

4. On 6/29/11 at 9:06 a.m., two portable space heaters located in the Admitting Office area did not have tags indicating they had been tested and approved. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heaters at that location had not been approved.

Based on observation, the facility failed to maintain their means of egress free from obstructions. This was evidenced by four locations that had obstructions in the means of egress. This affected two of six floors in the Main Hospital, and could result in a delayed evacuation in the event of an emergency.

NFPA 101, 2000 edition
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the means of egress in the facility were observed.

1. On 6/28/11 at 3:31 p.m., the exit passageway near the Outpatient Chemotherapy Waiting Room was observed. The exit passageway was approximately six feet wide. The exit passageway was reduced to approximately thirty inches in clear width due to eight chairs and a cabinet unit located on both sides of the passageway.

2. On 6/29/11 at 8:47 p.m., the exit door leading from the Boiler Room to the corridor near Cardiac Rehabilitation was observed. A wheelchair was located directly in front of the exit door, and obstructed the door from opening.

3. On 6/29/11 at 8:51 a.m., the exit door leading from Cardiac Rehabilitation to the corridor near Central Sterile was observed. The clear width at that location was reduced to approximately twenty-nine inches, due to an emergency crash cart located in front of the door.

4. On 6/29/11 at 9:53 a.m., the exit doors leading from the Ambulance Entrance Vestibule towards the corridor was observed. The clear width at that location was reduced to approximately twenty-four inches, due to two linen carts located directly in front of the doors.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or greater, and by three anesthetizing locations that were not being monitored for humidity levels. This affected twelve of twelve Operating Rooms, and three of three Procedure Rooms in the Main Hospital, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

NFPA 99, 1999 edition
Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.
Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Findings:

During record review and a facility tour with staff on 6/28/11, the facility's anesthetizing locations were observed.

1. At 10:15 a.m., the relative humidity logs for the facility's anesthetizing locations were reviewed. Twelve of twelve Operating Rooms had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.

Operating Room 1 had recorded a relative humidity level below thirty-five percent on approximately fifty-five days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on approximately sixty-nine days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on approximately forty-five days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on approximately eighty-five days during the past twelve months.

Operating Room 5 had recorded a relative humidity level below thirty-five percent on approximately forty-six days during the past twelve months.

Operating Room 6 had recorded a relative humidity level below thirty-five percent on approximately eighty days during the past twelve months.

Operating Room 7 had recorded a relative humidity level below thirty-five percent on approximately fifty-seven days during the past twelve months.

Operating Room 8 had recorded a relative humidity level below thirty-five percent on approximately sixty-eight days during the past twelve months.

Operating Room 9 had recorded a relative humidity level below thirty-five percent on approximately thirty-seven days during the past twelve months.

Obstetrics Operating Room 1 had recorded a relative humidity level below thirty-five percent on approximately seventy days during the past twelve months.

Obstetrics Operating Room 2 had recorded a relative humidity level below thirty-five percent on approximately eighty-five days during the past twelve months.

Cardiac Surgery Operating Room had recorded a relative humidity level below thirty-five percent on approximately ten days during the past twelve months.

The humidity logs indicated that the facility would maintain their relative humidity between twenty and sixty percent for Operating Rooms 1-9. The humidity logs indicated that the facility would maintain their relative humidity between thirty and sixty percent for the Obstetrics Operating Rooms and Cardiac Surgery Operating Room.

2. At 4:04 p.m., the Endoscopy Department was observed. The Endoscopy Department had three Procedure Rooms. Endoscopy Staff 1 was interviewed at that time. Endoscopy Staff 1 indicated that conscious sedation is utilized in the Endoscopy Procedure Rooms. Endoscopy Staff 1 indicated that the relative humidity levels in three of three Procedure Rooms are not monitored.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by extension cords plugged into other extension cords, the use of non-surge protected extension cords as a substitute for permanent wiring, high powered appliances that were plugged into extension cords, and electrical receptacles that were missing faceplates. This affected three of six floors in the Main Hospital, and could result in an electrical fire to occur.

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.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
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.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the facility's electrical equipment and wiring were observed.

1. On 6/28/11 at 3:12 p.m., computer equipment in the Information Technology (IT) cubicle work area was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord.

2. On 6/28/11 at 4:36 p.m., holiday string lighting at the coffee stand in the Cafeteria was observed. The string lighting was plugged into a non-surge protected multi-outlet extension cord. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that they did not know if the lights have been up on the coffee stand for longer than ninety days.

3. On 6/29/11 at 9:06 a.m., two non-surge protected multi-outlet extension cords were in use in the Admitting Office area.

4. On 6/29/11 at 9:43 a.m., a coffee maker and a toaster oven in the Pharmacy Break Room were plugged into a white non-surge protected multi-outlet extension cord.


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Findings:

On 6/28/11, the fourth floor of the hospital was observed.

5. At 2:43 p.m., there was a microwave, a refrigerator, and a toaster plugged into a six-plug surge protector in the Electrocardiogram (EKG) breakroom.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of one alcohol based hand rub dispenser over an ignition source. This affected one of six floors in the Main Hospital, and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff on 6/29/11 at 9:47 a.m., an alcohol based hand rub dispenser in the Emergency Department Annex Waiting Room was mounted on the wall approximately three feet above an electrical receptacle. The hand rub was sixty-three percent isopropyl alcohol by volume.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, and by corridor doors that were obstructed from closing. This affected two of six floors, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with facility management staff, from 6/28/11 to 6/29/11, the facility corridor doors were observed.

On 6/28/11, the fourth floor of the hospital was observed.

1. At 2:30 p.m., the door to the dirty utility room, across from Room 470, was equipped with a self-closing device. The door closed, but failed to latch.

2. At 2:34 p.m., the door to the clean linen closet, across from Room 471, was equipped with a self-closing device. The door closed, but failed to latch.

On 6/29/11, the first floor of the hospital was observed.

3. At 9:59 a.m., the door to the east wing manager's office was equipped with a self-closing device. The door was held open by a metallic wedge.

Based on observation and interview, the facility failed to maintain their vertical openings. This was evidenced by one fire rated shaft wall that had an unsealed penetration, two corridor doors to chute rooms that were obstructed from latching, and two chute doors that were obstructed from closing. This affected six of six floors in the Main Hospital, and could result in the spread of smoke or fire from one floor to another.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the vertical openings in the facility were observed.

1. On 6/28/11 at 11:42 a.m., there was an approximately two foot by two foot unsealed penetration in a two hour fire rated shaft wall near the Labor and Delivery Waiting Room. The penetration was located in the space above the suspended ceiling. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that facility staff had been working in that area earlier in the morning, and were then reassigned to another task. There was no interim life safety measures taken to maintain that two hour fire rated shaft wall when it was not being worked on.

2. On 6/28/11 at 3:00 p.m., the Linen Chute Room in the Lower Level West Tower was observed. The corridor door to the room 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 due to the door frame.

3. On 6/29/11 at 8:26 a.m., the Linen Chute Room near the Engineering Workshop was observed. The corridor door to the room 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 due to the door frame.

4. On 6/29/11 at 10:18 a.m., the Chute Room near the Interventional Radiology Department was observed. The Soiled Linen Chute door was held in the open position, and was obstructed from closing by a bag of soiled linen in the swing path of the door. The Trash Chute door was stuck in the open position, and was obstructed from closing due to portions of the door that were bent.

Based on observation, the facility failed to maintain doors that are held open by devices designed to release upon activation of the fire alarm system. This was evidenced by three doors that failed to release and close during fire alarm testing. This affected three of six floors, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 6/28/11, doors held open with magnetic and electronic hold-open devices were observed.

1. At 11:23 a.m., the smoke barrier door in Four West CCU was held open by an electronic hold open device. The door did not release and close upon activation of the fire alarm system.

2. At 11:40 a.m., the smoke barrier double doors in Third East Post Partum were held open by an electronic hold open device. The right door did not release and close upon activation of the fire alarm system.

3. At 12:11 a.m., the double doors near the First West service elevator lobby were held open by an electronic hold open device. The door did not release and close upon activation of the fire alarm system.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by one hour fire rated construction, and self-closing doors. This was evidenced by one hazardous area with no self-closing device on the door. This affected one of six floors, and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 6/28/11 to 6/29/11, the hazardous areas were observed in the main hospital.

On 6/28/11, the fourth floor of the hospital was observed.

At 2:50 p.m., the storage room at the end of the CCU hallway was observed. The storage room was approximately 250 square feet in size, and contained more than 15 shelves of medical supplies in cardboard boxes and plastic coverings. The door to the storage room did not have a self-closing device.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests on three of three battery powered emergency lighting units. This affected all patients at the Mercy Woundcare Clinic, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:34 a.m., the facility's battery powered emergency lighting unit test records were observed. Three of three battery powered emergency lighting units at the Mercy Woundcare Clinic were tested for a ninety minute duration in June, 2011. There were no records that indicated the battery powered emergency lighting units were tested monthly for thirty seconds prior to June, 2011. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the battery powered emergency lighting units located at the Mercy Woundcare Clinic had just been added to the testing schedule in June, 2011.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests on two of two battery powered emergency lighting units. This affected all patients at the Mercy Maternity Clinic, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:34 a.m., the facility's battery powered emergency lighting unit test records were reviewed. Two of two battery powered emergency lighting units at the Mercy Maternity Clinic were tested for a ninety minute duration in June of 2011. There were no records that indicated the battery powered emergency lighting units were tested monthly for thirty seconds prior to June of 2011. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the battery powered emergency lighting units located at the Mercy Maternity Clinic had just been added to the testing schedule in June, 2011.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to perform monthly thirty second tests, and an annual ninety minute test, on two of nine battery powered emergency lighting units located in the Operating Rooms. This affected two of nine Operating Rooms, and could result in the loss of visibility in the event of a power failure in conjunction with a generator malfunction.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:32 a.m., the facility's battery powered emergency lighting unit test records were observed. There were no records that indicated the battery powered emergency lighting units located in Operating Room 8 and Operating Room 9 were being tested monthly for thirty seconds, or annually for ninety minutes. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the battery powered emergency lighting units at those locations were not on the lighting unit test schedule. Engineering Staff 2 did not know when the two battery powered emergency lighting units had last been tested.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source and one exit sign that failed to remain illuminated when tested. This affected two of six floors in the Main Hospital, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the exit signs in the facility were observed.

1. On 6/28/11 at 3:59 p.m., the Endoscopy Department was observed to have eight exit signs equipped with an internal emergency power supply source along their means of egress. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the signs are not tested monthly for thirty seconds. Engineering Staff 2 indicated that the signs are not tested annually for ninety minutes. Engineering Staff 2 indicated that they were unaware that the Endoscopy Department had exit signs equipped with an internal emergency power supply.

2. On 6/29/11 at 10:14 a.m., the exit sign by Interventional Radiology Room 7 was tested by pressing the test button on the unit. The exit sign failed to remain illuminated when the test button for the device was pressed.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Mercy Family Health Center, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review, on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Mercy Family Health Center were requested. There were no records that indicated the Mercy Family Health Center had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Mercy Family Health Center had not been tested for smoke sensitivity. Engineering Staff 2 indicated that they did not know the building needed to comply with that requirement.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Mercy Woundcare Clinic, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Mercy Woundcare Clinic were requested. There were no records that indicated the Mercy Woundcare Clinic had had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Mercy Woundcare Clinic had not been tested for smoke sensitivity. Engineering Staff 2 indicated that they did not know the building needed to comply with that requirement.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for sensitivity. This affected all patients at the Pre-operative Clinic, and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101, 2000 edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During record review, on 6/28/11 at 9:00 a.m., the smoke detector sensitivity test records for the Pre-operative Clinic were requested. There were no records that indicated the Pre-operative Clinic had had their smoke detectors tested for sensitivity. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 confirmed that the smoke detectors at the Pre-operative Clinic had not been tested for smoke sensitivity. Engineering Staff 2 indicated that he did not know the building needed to comply with that requirement.

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by one portable fire extinguisher had not been serviced in the past twelve months, two portable fire extinguishers that were obstructed, and one Class K portable fire extinguisher that was missing an instructional placard. This affected two of six floors in the Main Hospital, and could result in a delay to extinguish a fire in the event of an emergency.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the facility's portable fire extinguishers were observed.

1. On 6/28/11 at 2:19 p.m., the dry chemical portable fire extinguisher located near the Helipad had a service tag dated 6/4/09. There were no records that indicated the fire extinguisher had been serviced within the past twelve months.

2. On 6/28/11 at 2:20 p.m., the dry chemical portable fire extinguisher located near the Helipad was located inside a storage enclosure. There was no sign on the door, or in the vicinity, that indicated a portable fire extinguisher was located inside that enclosure. The fire portable fire extinguisher was visually obstructed.

3. On 6/28/11 at 4:31 p.m., the Class K portable fire extinguisher in the Kitchen was observed. There was no placard in the vicinity that indicated the fire protection system should be used prior to using the fire extinguisher.


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Findings:

On 6/29/11, the second floor of the hospital was surveyed.

4. At 9:59 a.m., the portable fire extinguisher near Room 232 was blocked by a bed.

Based on observation and interview, the facility failed to maintain the use of portable space heaters. This was evidenced by portable space heaters that were not tested to ensure they did not exceed two hundred and twelve degrees Fahrenheit, portable space heaters that were plugged into extension cords, portable space heaters that were within three feet of furnishings or combustibles, and a portable space heater that were not unplugged when not in use. This affected two of six floors in the Main Hospital, and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the portable space heaters in the facility were observed.

1. On 6/28/11 at 3:23 p.m., a portable space heater was located in the Medical Director of Emergency Services Office. The portable space heater was located under a desk, and was plugged into a surge protected multi-outlet extension cord. The portable space heater did not have a tag that indicated it had been tested and approved by the facility. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heater at that location had not been approved.

2. On 6/28/11 at 3:47 p.m., there were approximately ten portable space heaters located in the Medical Records Department. The portable space heaters were plugged into surge protected multi-outlet extension cords, located within three feet of furnishings and combustibles, or plugged in when not being used.

3. On 6/29/11 at 8:30 a.m., a portable space heater was located in the Medical Library. The portable space heater was located within three feet of a desk, and was plugged into a surge protected multi-outlet extension cord. The portable space heater did not have a tag that indicated it had been tested and approved by the facility. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heater at that location had not been approved.

4. On 6/29/11 at 9:06 a.m., two portable space heaters located in the Admitting Office area did not have tags indicating they had been tested and approved. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the facility has approved two types of portable space heaters for usage based on their heat output. Engineering Staff 2 indicated that the approved portable space heaters are equipped with a facility tag. Engineering Staff 2 indicated that the portable space heaters at that location had not been approved.

Based on observation, the facility failed to maintain their means of egress free from obstructions. This was evidenced by four locations that had obstructions in the means of egress. This affected two of six floors in the Main Hospital, and could result in a delayed evacuation in the event of an emergency.

NFPA 101, 2000 edition
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the means of egress in the facility were observed.

1. On 6/28/11 at 3:31 p.m., the exit passageway near the Outpatient Chemotherapy Waiting Room was observed. The exit passageway was approximately six feet wide. The exit passageway was reduced to approximately thirty inches in clear width due to eight chairs and a cabinet unit located on both sides of the passageway.

2. On 6/29/11 at 8:47 p.m., the exit door leading from the Boiler Room to the corridor near Cardiac Rehabilitation was observed. A wheelchair was located directly in front of the exit door, and obstructed the door from opening.

3. On 6/29/11 at 8:51 a.m., the exit door leading from Cardiac Rehabilitation to the corridor near Central Sterile was observed. The clear width at that location was reduced to approximately twenty-nine inches, due to an emergency crash cart located in front of the door.

4. On 6/29/11 at 9:53 a.m., the exit doors leading from the Ambulance Entrance Vestibule towards the corridor was observed. The clear width at that location was reduced to approximately twenty-four inches, due to two linen carts located directly in front of the doors.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or greater, and by three anesthetizing locations that were not being monitored for humidity levels. This affected twelve of twelve Operating Rooms, and three of three Procedure Rooms in the Main Hospital, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

NFPA 99, 1999 edition
Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.
Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Findings:

During record review and a facility tour with staff on 6/28/11, the facility's anesthetizing locations were observed.

1. At 10:15 a.m., the relative humidity logs for the facility's anesthetizing locations were reviewed. Twelve of twelve Operating Rooms had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.

Operating Room 1 had recorded a relative humidity level below thirty-five percent on approximately fifty-five days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on approximately sixty-nine days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on approximately forty-five days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on approximately eighty-five days during the past twelve months.

Operating Room 5 had recorded a relative humidity level below thirty-five percent on approximately forty-six days during the past twelve months.

Operating Room 6 had recorded a relative humidity level below thirty-five percent on approximately eighty days during the past twelve months.

Operating Room 7 had recorded a relative humidity level below thirty-five percent on approximately fifty-seven days during the past twelve months.

Operating Room 8 had recorded a relative humidity level below thirty-five percent on approximately sixty-eight days during the past twelve months.

Operating Room 9 had recorded a relative humidity level below thirty-five percent on approximately thirty-seven days during the past twelve months.

Obstetrics Operating Room 1 had recorded a relative humidity level below thirty-five percent on approximately seventy days during the past twelve months.

Obstetrics Operating Room 2 had recorded a relative humidity level below thirty-five percent on approximately eighty-five days during the past twelve months.

Cardiac Surgery Operating Room had recorded a relative humidity level below thirty-five percent on approximately ten days during the past twelve months.

The humidity logs indicated that the facility would maintain their relative humidity between twenty and sixty percent for Operating Rooms 1-9. The humidity logs indicated that the facility would maintain their relative humidity between thirty and sixty percent for the Obstetrics Operating Rooms and Cardiac Surgery Operating Room.

2. At 4:04 p.m., the Endoscopy Department was observed. The Endoscopy Department had three Procedure Rooms. Endoscopy Staff 1 was interviewed at that time. Endoscopy Staff 1 indicated that conscious sedation is utilized in the Endoscopy Procedure Rooms. Endoscopy Staff 1 indicated that the relative humidity levels in three of three Procedure Rooms are not monitored.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by extension cords plugged into other extension cords, the use of non-surge protected extension cords as a substitute for permanent wiring, high powered appliances that were plugged into extension cords, and electrical receptacles that were missing faceplates. This affected three of six floors in the Main Hospital, and could result in an electrical fire to occur.

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.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
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.

Findings:

During a facility tour with staff from 6/28/11 to 6/29/11, the facility's electrical equipment and wiring were observed.

1. On 6/28/11 at 3:12 p.m., computer equipment in the Information Technology (IT) cubicle work area was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord.

2. On 6/28/11 at 4:36 p.m., holiday string lighting at the coffee stand in the Cafeteria was observed. The string lighting was plugged into a non-surge protected multi-outlet extension cord. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that they did not know if the lights have been up on the coffee stand for longer than ninety days.

3. On 6/29/11 at 9:06 a.m., two non-surge protected multi-outlet extension cords were in use in the Admitting Office area.

4. On 6/29/11 at 9:43 a.m., a coffee maker and a toaster oven in the Pharmacy Break Room were plugged into a white non-surge protected multi-outlet extension cord.


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Findings:

On 6/28/11, the fourth floor of the hospital was observed.

5. At 2:43 p.m., there was a microwave, a refrigerator, and a toaster plugged into a six-plug surge protector in the Electrocardiogram (EKG) breakroom.