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Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 25 of the patients in the med/surg wing. The facility census was 37.

Findings included:

1. Observation on 01/10/12 at 11:15 AM showed the entrance door of room 155 failed to latch when closed into the jamb. The door was pulled closed several times with varying amounts of force and the latch bolt failed to catch because the opening in the jamb was below where the latch bolt was striking.

During an interview on 01/11/12 at 9:3 AM, Staff H, Maintenance Supervisor, stated that the last time the door was checked was probably over a year ago, and it would only have been if there had been a problem that required repairs. He stated that with only two staff to cover the whole campus, maintenance does not currently have the time or manpower scheduled to do preventive maintenance rounds that include checking patient room doors to see if they latch. He stated the maladjustment appeared to be caused by a protective plastic covering applied to door frames to prevent damage from beds and equipment being moved in and out of the rooms.

Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers dividing the facility in accordance with 8.3 and 19.3.7.5 to ensure a minimum one half-hour fire resistance rating, and prevent the potential spread of smoke and fire from one section of the building to other areas. This deficient practice potentially affects all visitors, staff and patient census of 37.

Findings included:

1. Observations on 01/10/12 from 1:30 PM through 3:00 PM showed unsealed penetrations of cable and pipe through smoke and fire barriers above the ceilings as follows:
-Numerous (19) holes and annular (ring shaped) spaces of various sizes around wiring and electrical conduit that penetrated the walls of an electrical room in the dialysis unit.
-Two inch annular space around a flexible conduit, a two inch annular space around fiber optic cable, and a one inch space around multiple communication wire and wire tray that penetrated the wall above the corridor fire doors outside of the recovery room.
-Unsealed gaps and annular spaces around bundles of electrical conduit, flex conduit, copper and PVC pipe in a opening that measured 30 inches wide by four inches high, in addition to several other wire and conduit penetrations of a fire barrier above the corridor doors separating Surgery from the Obstetrical unit.
-Three and one half inch annular space around a half-inch hot water pipe, three and one half inch annular space around a metal flex conduit, and a two inch annular space around metal conduit that penetrated the barrier outside of the Outpatient 2 clinic.
-Eight inch wide by two inch high open area around pipe and electrical conduit that penetrated the smoke wall in the corridor outside of Pharmacy.
-Six inch square hole for pipe and wire penetrated the wall of a smoke barrier above the entrance to med/surg patient rooms and ICU.
-Two inch high by one inch wide penetration through a cinder block fire wall for a metal conduit and fire alarm wire above an area referred to as the "Monarch hallway."

During an interview on 01/10/12 at 2:40 PM, Staff H, Maintenance Supervisor acknowledged the penetrations and stated they do not have a policy or procedure to cover above ceiling work by contractors, but will be developing one now. He stated that he will be calling in the contractor who has done much of their wiring for renovations and expansions.

Based on observations and interviews, the facility failed to maintain the sprinkler system in accordance with the NFPA 13, 8.5.6.1, by ensuring a minimum clearance of 18 inches between sprinkler deflectors and the top shelf of the food storage pantry of storage above the walk-in freezer in the kitchen. The facility census was 37.

Findings included:

1. Observation on 01/10/12 at 9:20 AM showed a clear space of less than six inches between a pendant type sprinkler head and several large cardboard boxes and containers of food related products and cooking equipment stacked on the top shelf of a food storage pantry. The shelves extended from the floor to the ceiling on three sides of the small room which was served by two pendant type sprinkler heads.

2. Observation on 01/10/12 at 9:30 AM showed a three foot high open area between the ceiling and the top of a walk-in freezer located across from the food pantry closet in the back of the kitchen. Numerous pieces of cook ware, racks and equipment were stacked around the perimeter of the freezer, all within six inches of the ceiling, totally obscuring the pendant type sprinkler head from visibility and potentially obstructing the spray pattern. The freezer interior is protected by a dry or antifreeze loop sprinkler. Only two sprinkler heads serve the external food storage and external storage area above and around the walk-in freezer.

During an interview on 01/11/12 at 11:00 AM, Staff M (Dietary Manager) stated they did not have a formal policy that addressed high storage in the kitchen. She stated that she was aware of items stacked on top shelves of the food pantry and walk-in freezer.

Based on observation, and policy review, and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, (5.1.3.3.2.(7 ),with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 37.

Findings included:

1. Observation on 01/09/12 at 3:38 PM showed 13 "H" size cylinders of compressed gasses and 10 "E" size oxygen cylinders chained in two groups against opposite corners of the room, not individually secured or chained to prevent them from being turned over during change outs.

Policy review on 01/11/10 at 11:30 AM revealed the facility has two separate policies on compressed gas and oxygen use; one for Surgical Services dated 05/02/06 warns that "Cylinders must be secured at all times so they cannot fall." The second policy for Cardiopulmonary Services dated 02/22/08 states that "Gas cylinders are not, at any time to be left free standing."

During an interview on 01/11/12 at 9:45 AM, Staff H, Maintenance Supervisor stated that he thought they were ok even if they were chained as a group. He stated he spoke with vendor about reducing the overall number of cylinders and planned to rearrange the storage so the cylinders could be individually restrained.

Based on observation and interview, the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were not installed over, or adjacent to an ignition (electrical) source. The facility census was 37.

Observation on 01/09/12 at 3:08 PM showed ABHR dispensers installed above and within five inches of unprotected light switches in five of five obstetrical (OB) patient room numbers 181, 182, 183, 184, and 185.

During an interview on 01/09/12 at 3:10 PM, Staff H, Maintenance Supervisor stated he was concerned about lack of other places to mount the dispensers. He stated that ICU staff didn't want the dispensers on the wooden cabinets next to the door or outside each room in the corridor, so the 20 inch wide wall just inside each door was just about the only place that remained where the dispensers could be mounted. He stated that he would discuss options with the infection control committee.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as 25 of the patients in the med/surg wing. The facility census was 37.

Findings included:

1. Observation on 01/10/12 at 11:15 AM showed the entrance door of room 155 failed to latch when closed into the jamb. The door was pulled closed several times with varying amounts of force and the latch bolt failed to catch because the opening in the jamb was below where the latch bolt was striking.

During an interview on 01/11/12 at 9:3 AM, Staff H, Maintenance Supervisor, stated that the last time the door was checked was probably over a year ago, and it would only have been if there had been a problem that required repairs. He stated that with only two staff to cover the whole campus, maintenance does not currently have the time or manpower scheduled to do preventive maintenance rounds that include checking patient room doors to see if they latch. He stated the maladjustment appeared to be caused by a protective plastic covering applied to door frames to prevent damage from beds and equipment being moved in and out of the rooms.

Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers dividing the facility in accordance with 8.3 and 19.3.7.5 to ensure a minimum one half-hour fire resistance rating, and prevent the potential spread of smoke and fire from one section of the building to other areas. This deficient practice potentially affects all visitors, staff and patient census of 37.

Findings included:

1. Observations on 01/10/12 from 1:30 PM through 3:00 PM showed unsealed penetrations of cable and pipe through smoke and fire barriers above the ceilings as follows:
-Numerous (19) holes and annular (ring shaped) spaces of various sizes around wiring and electrical conduit that penetrated the walls of an electrical room in the dialysis unit.
-Two inch annular space around a flexible conduit, a two inch annular space around fiber optic cable, and a one inch space around multiple communication wire and wire tray that penetrated the wall above the corridor fire doors outside of the recovery room.
-Unsealed gaps and annular spaces around bundles of electrical conduit, flex conduit, copper and PVC pipe in a opening that measured 30 inches wide by four inches high, in addition to several other wire and conduit penetrations of a fire barrier above the corridor doors separating Surgery from the Obstetrical unit.
-Three and one half inch annular space around a half-inch hot water pipe, three and one half inch annular space around a metal flex conduit, and a two inch annular space around metal conduit that penetrated the barrier outside of the Outpatient 2 clinic.
-Eight inch wide by two inch high open area around pipe and electrical conduit that penetrated the smoke wall in the corridor outside of Pharmacy.
-Six inch square hole for pipe and wire penetrated the wall of a smoke barrier above the entrance to med/surg patient rooms and ICU.
-Two inch high by one inch wide penetration through a cinder block fire wall for a metal conduit and fire alarm wire above an area referred to as the "Monarch hallway."

During an interview on 01/10/12 at 2:40 PM, Staff H, Maintenance Supervisor acknowledged the penetrations and stated they do not have a policy or procedure to cover above ceiling work by contractors, but will be developing one now. He stated that he will be calling in the contractor who has done much of their wiring for renovations and expansions.

Based on observations and interviews, the facility failed to maintain the sprinkler system in accordance with the NFPA 13, 8.5.6.1, by ensuring a minimum clearance of 18 inches between sprinkler deflectors and the top shelf of the food storage pantry of storage above the walk-in freezer in the kitchen. The facility census was 37.

Findings included:

1. Observation on 01/10/12 at 9:20 AM showed a clear space of less than six inches between a pendant type sprinkler head and several large cardboard boxes and containers of food related products and cooking equipment stacked on the top shelf of a food storage pantry. The shelves extended from the floor to the ceiling on three sides of the small room which was served by two pendant type sprinkler heads.

2. Observation on 01/10/12 at 9:30 AM showed a three foot high open area between the ceiling and the top of a walk-in freezer located across from the food pantry closet in the back of the kitchen. Numerous pieces of cook ware, racks and equipment were stacked around the perimeter of the freezer, all within six inches of the ceiling, totally obscuring the pendant type sprinkler head from visibility and potentially obstructing the spray pattern. The freezer interior is protected by a dry or antifreeze loop sprinkler. Only two sprinkler heads serve the external food storage and external storage area above and around the walk-in freezer.

During an interview on 01/11/12 at 11:00 AM, Staff M (Dietary Manager) stated they did not have a formal policy that addressed high storage in the kitchen. She stated that she was aware of items stacked on top shelves of the food pantry and walk-in freezer.

Based on observation, and policy review, and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, (5.1.3.3.2.(7 ),with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 37.

Findings included:

1. Observation on 01/09/12 at 3:38 PM showed 13 "H" size cylinders of compressed gasses and 10 "E" size oxygen cylinders chained in two groups against opposite corners of the room, not individually secured or chained to prevent them from being turned over during change outs.

Policy review on 01/11/10 at 11:30 AM revealed the facility has two separate policies on compressed gas and oxygen use; one for Surgical Services dated 05/02/06 warns that "Cylinders must be secured at all times so they cannot fall." The second policy for Cardiopulmonary Services dated 02/22/08 states that "Gas cylinders are not, at any time to be left free standing."

During an interview on 01/11/12 at 9:45 AM, Staff H, Maintenance Supervisor stated that he thought they were ok even if they were chained as a group. He stated he spoke with vendor about reducing the overall number of cylinders and planned to rearrange the storage so the cylinders could be individually restrained.