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Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This could expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed the following doors did not close and latch when tested:
At 4:31pm, I observed that the fire doors by OR #9 did not close and latch when tested.

During the facility tour on February 5, 2014 I observed that doors did not close and latch in the following locations:
At 3:45pm, I observed that the fire doors #63 by Fire Sprinkler valve room by Emergency did not close and latch.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This could expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During the facility tour on February 5, 2014 I observed that doors did not close and latch in the following locations:
At 9:25am, I observed that the fire doors by 3322 door #79 did not close and latch.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to provide sleeping rooms with the required smoke alarms. This has the potential of not waking a sleeping staff member in a fire emergency.

The findings include, but are not limited to:

During survey tour on February 4, 2014 at 3:42pm , I observed that the sleep room in OR did not have a smoke alarm room #353.

During the survey tour on February 5, 2014 at 2:30pm, I observed that the old Mom/Baby Unit is using an office as a sleep room and there is no smoke alarm in this room #449.

During the survey tour on February 6, 2014 at 9:52am, I observed that sleeping rooms #58A and #58C did not have smoke/alarms.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based upon observations, records review, and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

1. During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed escutcheons missing in the following locations:
At 4:35pm, I observed that the escutcheons were missing in Operating Room #14 that is actually a storage room.
At 4:38pm Operating Room Manager ' s office had sprinkler head escutcheon missing.

2. During survey tour of ground level on February 5, 2014 at 10:25am, I observed that the sprinkler riser gages are dated 11-03-1999 in the shipping and receiving room. Sprinkler gages are required to be replaced every 5 years.

3. During survey tour on February 5, 2014 at 2:28pm, I observed that the 1st floor bio med store room does not have appropriate sprinkler coverage. One sprinkler head is obstructed by duct work .

During the facility tour on February 6, 2014 at 10:48am, I observed that Center work room has escutcheon missing on the sprinkler head.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager.

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to ensure that portable heaters are of the approved type in non-sleeping patient room areas of the hospital. This has the potential of a fire starting due to an unapproved heater and exposing patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During facility tour on February 4, 2014 at 2:45pm, I observed that Pallative Care had an unapproved heater.
During the facility tour on February 5, 2014 at 3:38pm, I observed that the switchboard office has an unapproved heater.
During the facility tour on February 6, 2014 at 10:40am, I observed that IT Manager had an unapproved heater.
At 11:21am, I observed that Employee Health Office #G196 had an unapproved heater.

NOTE: All of these unapproved heaters were removed at time of survey.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

The facility has failed to ensure that trash collection receptacles do not exceed 32 gallan capacity within a 64 square foot area. This has the potential of combustibles adding fuel to a fire and thus expose patients, visitors, and staff to the threat of fire or smoke.

The findings include, but are not limited to:

During the survey tour on February 5, 2014 at 11:27am, I observed that 3 refuse containers were out in the reception area that exceeded 32 gallons.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

The facility has failed to provide a mechanical means of controlling humidity levels in an operating room. This could place the patient and staff at risk of fire.

The finding include, but are not limited to:

Record review of the C-Section operating room humidity levels log and interview with OR staff on February 6, 2014 at 8:30am, revealed that humidity levels were consistently below 20%.

This is an operating room in the newly constructed tower of the hospital. It was believed that humidity levels could be controlled by the HVAC system's re-circulation of the air in that room. Interview with maintenance and engineering staff revealed that this was not working as it should and there is no mechanical means of controlling humidity levels in this C-Section Operating Room.

The C-Section operating room staff, Facilities Administrator, and the Engineering Manager confirmed that procedure is that this operating room is close down completely when humidity levels drop below 20%. The main hospital's Operating Room staff is aware and is providing an operating room as standby in these circumstances.

This finding was observed and discussed with the Facilities Administrator and the Engineering Manager.

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to maintain the premises free of electrical hazards. This has the potential of starting an electrical fire that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed the following electrical hazards:
At 4:35pm, I observed that an electrical J box did not have its lid in place and electrical wires were exposed.
At 4:20pm, I observed that a power strip was plugged into another power strip, and a microwave was on a power strip in the OR work room. (fixed at time of survey)
At 4:25pm, I observed that two power strips were plugged into an approved multi-plug adaptor.

During the facility tour on February 5, 2014 between the hours of 9:23am and 3:45pm, I observed the following electrical hazards:

At 9:31am, I observed that a power strip was plugged into a power strip and the power strip was dangling causing stress on cords in the ICU business center.
At 10:28am, I observed that the OB/GYN sleep room as an unapproved adopter and a power strip into a power strip. (Fixed at time of survey)
At 11:18am, I observed Patient Counselor ' s office had a small fridge into a power strip.
At 11:37am, I observed a power strip into a power strip in Pharmacy Room #1432.
At 2:29pm, I observed that Bio/Med Manager ' s office had microwave and refrigerator on power strip. (fixed at time of survey)
At 2:29pm, I observed that restroom #453 has electrical switch without its cover plate.
At 2:45pm, I observed that Resource Unit has an extension cord for coffee maker. (fixed at time of survey_
At 3:05pm, I observed that Lab lounge room #431E has power strip for microwave. (fixed at time of survey.)
At 3:30pm, I observed that Diagnostic/Imaging Director ' s office #4010 has microwave and fridge on power strip and unapproved power strip. (fixed at time of survey)

During the survey tour on February 6, 2014 between the hours of 9:15am and 1:20pm, I observed electrical hazards in the following locations:
At 10:01am, I observed a power strip into a power strip in Utilization Review room #65.
At 10:02am, I observed a microwave on a power strip in Admin #671. (fixed at time of survey)
At 10:13am, I observed that Accounting has refrigerator and microwave into a power strip.
At 10:38am, I observed IT office has microwave into power strip into another power strip.
At 11:04am, I observed that the kitchen room #33B had an unapproved power strip.
At 11:10am, I observed that the Nutrition Services Director room #G216 had a refrigerator into a power strip.
At 11:20am, I observed a refrigerator into a power strip in Employee Health office.
At 1:10pm, I observed that Laundry break room had a microwave on a power strip and was dangling causing stress to the cords. (Fixed at time of survey)

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager.

The facility has failed to maintain the proper distance for hand based alcohol hand gel from an electrical source. This potentially allows the spread of smoke and fire to other areas of the facility, exposing patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility tour on February 5, 2014 at 3:15pm, I observed that X-ray room #1 has ABHS too close to electrical switch.
At 3:37pm, I observed that PBX by room 2000 has ABHS too close to electrical unit.

During the facility tour on February 6, 2014 between the hours of 9:20am and 1:20pm, I observed ABHS too close to electrical units in the following locations:
At 9:20am, I observed that ER nurses station had ABHS too close to electrical switch. (fixed at time of survey)
At 9:24am, I observed that ABHS too close to badge reader by ER triage room.
At 9:59am, I observed that Information Technology hallway has ABHS to close to badge reader.
At 10:50am, I observed that the Morgue had an ABHS to close to electrical switch.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This could expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed the following doors did not close and latch when tested:
At 4:31pm, I observed that the fire doors by OR #9 did not close and latch when tested.

During the facility tour on February 5, 2014 I observed that doors did not close and latch in the following locations:
At 3:45pm, I observed that the fire doors #63 by Fire Sprinkler valve room by Emergency did not close and latch.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This could expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During the facility tour on February 5, 2014 I observed that doors did not close and latch in the following locations:
At 9:25am, I observed that the fire doors by 3322 door #79 did not close and latch.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to provide sleeping rooms with the required smoke alarms. This has the potential of not waking a sleeping staff member in a fire emergency.

The findings include, but are not limited to:

During survey tour on February 4, 2014 at 3:42pm , I observed that the sleep room in OR did not have a smoke alarm room #353.

During the survey tour on February 5, 2014 at 2:30pm, I observed that the old Mom/Baby Unit is using an office as a sleep room and there is no smoke alarm in this room #449.

During the survey tour on February 6, 2014 at 9:52am, I observed that sleeping rooms #58A and #58C did not have smoke/alarms.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

Based upon observations, records review, and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

1. During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed escutcheons missing in the following locations:
At 4:35pm, I observed that the escutcheons were missing in Operating Room #14 that is actually a storage room.
At 4:38pm Operating Room Manager ' s office had sprinkler head escutcheon missing.

2. During survey tour of ground level on February 5, 2014 at 10:25am, I observed that the sprinkler riser gages are dated 11-03-1999 in the shipping and receiving room. Sprinkler gages are required to be replaced every 5 years.

3. During survey tour on February 5, 2014 at 2:28pm, I observed that the 1st floor bio med store room does not have appropriate sprinkler coverage. One sprinkler head is obstructed by duct work .

During the facility tour on February 6, 2014 at 10:48am, I observed that Center work room has escutcheon missing on the sprinkler head.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager.

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to ensure that portable heaters are of the approved type in non-sleeping patient room areas of the hospital. This has the potential of a fire starting due to an unapproved heater and exposing patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During facility tour on February 4, 2014 at 2:45pm, I observed that Pallative Care had an unapproved heater.
During the facility tour on February 5, 2014 at 3:38pm, I observed that the switchboard office has an unapproved heater.
During the facility tour on February 6, 2014 at 10:40am, I observed that IT Manager had an unapproved heater.
At 11:21am, I observed that Employee Health Office #G196 had an unapproved heater.

NOTE: All of these unapproved heaters were removed at time of survey.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

The facility has failed to ensure that trash collection receptacles do not exceed 32 gallan capacity within a 64 square foot area. This has the potential of combustibles adding fuel to a fire and thus expose patients, visitors, and staff to the threat of fire or smoke.

The findings include, but are not limited to:

During the survey tour on February 5, 2014 at 11:27am, I observed that 3 refuse containers were out in the reception area that exceeded 32 gallons.

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager

The facility has failed to provide a mechanical means of controlling humidity levels in an operating room. This could place the patient and staff at risk of fire.

The finding include, but are not limited to:

Record review of the C-Section operating room humidity levels log and interview with OR staff on February 6, 2014 at 8:30am, revealed that humidity levels were consistently below 20%.

This is an operating room in the newly constructed tower of the hospital. It was believed that humidity levels could be controlled by the HVAC system's re-circulation of the air in that room. Interview with maintenance and engineering staff revealed that this was not working as it should and there is no mechanical means of controlling humidity levels in this C-Section Operating Room.

The C-Section operating room staff, Facilities Administrator, and the Engineering Manager confirmed that procedure is that this operating room is close down completely when humidity levels drop below 20%. The main hospital's Operating Room staff is aware and is providing an operating room as standby in these circumstances.

This finding was observed and discussed with the Facilities Administrator and the Engineering Manager.

Based upon observations and staff interviews during a tour of the facility on February 4, 5, and 6, 2014 the facility has failed to maintain the premises free of electrical hazards. This has the potential of starting an electrical fire that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During survey of the Operating Rooms on February 4, 2014 between the hours of 3:30pm and 4:40pm, I observed the following electrical hazards:
At 4:35pm, I observed that an electrical J box did not have its lid in place and electrical wires were exposed.
At 4:20pm, I observed that a power strip was plugged into another power strip, and a microwave was on a power strip in the OR work room. (fixed at time of survey)
At 4:25pm, I observed that two power strips were plugged into an approved multi-plug adaptor.

During the facility tour on February 5, 2014 between the hours of 9:23am and 3:45pm, I observed the following electrical hazards:

At 9:31am, I observed that a power strip was plugged into a power strip and the power strip was dangling causing stress on cords in the ICU business center.
At 10:28am, I observed that the OB/GYN sleep room as an unapproved adopter and a power strip into a power strip. (Fixed at time of survey)
At 11:18am, I observed Patient Counselor ' s office had a small fridge into a power strip.
At 11:37am, I observed a power strip into a power strip in Pharmacy Room #1432.
At 2:29pm, I observed that Bio/Med Manager ' s office had microwave and refrigerator on power strip. (fixed at time of survey)
At 2:29pm, I observed that restroom #453 has electrical switch without its cover plate.
At 2:45pm, I observed that Resource Unit has an extension cord for coffee maker. (fixed at time of survey_
At 3:05pm, I observed that Lab lounge room #431E has power strip for microwave. (fixed at time of survey.)
At 3:30pm, I observed that Diagnostic/Imaging Director ' s office #4010 has microwave and fridge on power strip and unapproved power strip. (fixed at time of survey)

During the survey tour on February 6, 2014 between the hours of 9:15am and 1:20pm, I observed electrical hazards in the following locations:
At 10:01am, I observed a power strip into a power strip in Utilization Review room #65.
At 10:02am, I observed a microwave on a power strip in Admin #671. (fixed at time of survey)
At 10:13am, I observed that Accounting has refrigerator and microwave into a power strip.
At 10:38am, I observed IT office has microwave into power strip into another power strip.
At 11:04am, I observed that the kitchen room #33B had an unapproved power strip.
At 11:10am, I observed that the Nutrition Services Director room #G216 had a refrigerator into a power strip.
At 11:20am, I observed a refrigerator into a power strip in Employee Health office.
At 1:10pm, I observed that Laundry break room had a microwave on a power strip and was dangling causing stress to the cords. (Fixed at time of survey)

These findings were observed and discussed with the Facilities Administrator and the Engineering Manager.