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Based on observations and confirmed by staff, the hospital failed to assure that corridor doors are constructed and maintained as required. Section 19.3.6.3.2 states doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf is applied at the latch edge of the door.

THE FINDINGS INCLUDE:

- During the tour of the hospital on both 2/3/10 and 2/4/10, numerous corridor doors were noted as not being maintained as required. These doors include but are not limited to the following locations:

1) All of the patient doors on the Geriatric-Psyche unit are free swinging doors which can open in either direction. Because these doors swing through the frames, the frames are not equipped with normal side and head stops. In lieu of the stops, the edges of the doors are equipped with a felt like gasketing material to fill the void surrounding the doors. The space between the gasketing material and the jamb exceeds 1/8" in numerous locations on most of the doors. The door jamb is equipped with a "thumb style stop" which can be flipped inside of the jamb, this stop is not spring loaded and stays within the jamb. When each of these patient doors were tested for operation, each door would swing either all the way into the patient room, or into the egress corridor. There is no device to cause the door to stop and latch into the frame when the thumb stop is retracted, the door is "free swinging".

2) Geriatric-Psyche unit patient room #307 has a door with a 1/2" gap along the entire top portion of the door. Note: The patient room doors on this unit are free swinging doors which can open in either direction. Because these doors swing through the frames, the frames are not equipped with normal side and head stops.

3) St. Mary's unit patient room #334 has a door with a broken latch which is stuck in the retracted position. As a result, the door can not latch when closed.

4) North 1 patient room #1113 has a door which does not latch. The latch is currently out of adjustment and hits the frame when in the closed position.

These were acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.

Based on observations, the facility failed to assure that smoke detectors for door release are installed in accordance with NFPA #72. Where the depth of the wall section above the door is less than 24 inches Section 2.10.6.2.5.1.1 and Figure 2.10.6.2.5.1.1 require one smoke detector to be placed within 5 feet of the door and not less than 12 inches from the door. NOTE: If the depth of the wall section above the door is more than 24 inches an additional smoke detector may be required.

THE FINDINGS INCLUDE:

1. Observations on the afternoon of February 4, 2010 revealed that a the door to the dishwashing room is equipped with magnetic hold open device and that a smoke detector is not provided in the corridor within five (5) feet of the door.

2. Observations on the afternoon of February 4, 2010 revealed that the pair of doors to the main electric room located in the basement mechanical room are wedged open.

This was confirmed by the Director of Facilities.

Based on observations, the facility failed to assure that smoke barriers doors are self-closing.

THE FINDINGS INCLUDE:

- Observations on the afternoon of February 4, 2010 revealed that a door to an office on the Pediatric unit that is in the smoke barrier partition is not equipped with a closing device.

This was confirmed by the Director of Facilities.

Based on observations, the facility failed to assure that hazardous areas are enclosed as required.

THE FINDINGS INCLUDE:

1. During a tour of the hospital on February 4, 2010, it was reveled that the door to the UPS Power Conditioning Electrical Room is not self-closing.

2. During the tour of the hospital on February 3 and 4, 2010, it was reveled that numerous electrical closets are not sprinklered and have unrated doors. These electrical closets include but are not limited to the following locations:

a. The first floor telephone Data closet by Elevator "C".

b. The first floor electrical closet (3 pairs of doors) off of the ramp in the Service Building.

c. The second floor electrical closet (3 pairs of doors) by the dishroom in the Service Building.

d. The second floor electrical closet in the utility room on the Telemetry Unit.

e. The second floor electrical closets on the Pediatric Unit.



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f. The Emergency Room ground floor electrical closet located directly across from the "A" elevator has two non-rated doors which are also lacking self closing devices.

g. The St. Mary's unit electrical closet next to the East stairs has a total of four (4) non-rated doors.

h. The St. Mary's unit electrical closet next to elevator #8 has two non-rated doors which are also lacking self closing devices.

i. The 1st floor electrical closet next to the East stairs has a total of four (4) non-rated doors.

j. The 1st floor electrical closet located directly across from the "A" elevator has four (4) non-rated doors which are also lacking self closing devices.

k. The 2nd floor electrical closet next to the "C" elevator has a total of four (4) non-rated doors.

l. The North 1 unit electrical closet has a total of four (4) non-rated doors.

These were acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.

Based on observations, the facility failed to assure that doors in the means of egress are in accordance with Section 7.2.1. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Section 7.2.1.5.4 requires a latch or other fastening device on a door to be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. Doors shall be operable with not more than one releasing operation.
Section 7.2.1.14 allows horizontal sliding doors in means of egress, provided that the following criteria are met: (1) The door is readily operable from either side without special knowledge or effort. (2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf. (3) The force required to operate the door in the direction of door travel is not more than 30 lbf to set the door in motion and is not more than 15 lbf to close the door or open it to the minimum required width. (4) The door is operable with a force not more than 50 lbf when a force of 250 lbf is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of fewer than 50.
Section 7.2.1.9.1 regarding powered doors states: " Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf. The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4) " .
Section 7.2.1.4.5 states: " The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width " .


THE FINDINGS INCLUDE:

1. Observations on the afternoon of February 4, 2010 revealed that the exit door by the Medical Records office is equipped with a dead bolt lock which when locked requires two operations to open.

2. Observations on the afternoon of February 4, 2010 revealed that the automatic sliding door at the main entrance is equipped with a dead bolt lock which when locked requires two operations to open. This lock also prevents the door from being opened in an emergency.

3. Observations on the afternoon of February 4, 2010 revealed that the emergency breakout mode of the automatic sliding door at the main entrance does not function. When the power to the door was turned off and the emergency breakout mode tested the door only opened about eight (8) to ten (10) inches, this is because the inactive leaf (which must open in order for the active leaf to open) would not open blocking the active leaf from opening.

4. Observations on the afternoon of February 4, 2010 revealed that the biparting sliding doors at the main entrance to the Emergency Department are equipped with a dead bolt lock that when locked prevents the emergency breakout mode from functioning.

These were confirmed by the Director of Facilities.

Based on observations, the facility failed to assure that exit stairways are enclosed as required. Section 8.2.3.2.3.1 requires openings in stairways enclosed with 2-hour fire rated construction to be protected by doors having at least a 1.5-hour fire rating. Section 8.2.3.2.1(a) requires door assemblies to be of an approved type installed in accordance with NFPA #80.

THE FINDINGS INCLUDE:

1. Observations on the afternoon of February 4, 2010 revealed that the door to an electric room in the stairway by the Radiology Department is not fire rated.

This was confirmed by the Director of Facilities.



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During the afternoon tour of the hospital on 2/3/10, it was noted that all stairwell doors are not maintained as required. The doors include but are not limited to the following locations:

2. Door #5 on the Geriatric-Psyche unit has a sweep installed on door. The sweep currently drags on the platform preventing the door from closing.

3. The internal stairway (by "C" elevator) on the ground floor has a door which leads into a mechanical crawl space. The self closing device has been disconnected from this door causing the door to remain in the open position when tested.

These were acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.

Based on observations, the facility failed to assure that corridors are at least 8 feet wide. Section 4.6.7 prohibits existing life safety features that exceed the requirements for existing buildings, to be diminished. Section 4.6.7 requiems facilities constructed with corridors up to 8 feet in width maintain the width. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no objects be so placed so as to obstruct exits, access thereto, egress therefrom, or visibility thereof. Large mobile receptacle(s) may be moved along the corridors as collections occur but must be attended by staff. If staff must leave the immediate area the container(s) must be stored in a room designed and maintained as a hazardous area in accordance with 19.3.2.1. CMS S&C-04-41 states that original corridor widths cannot be diminished by any chairs, tables, filling cabinets or any not in use carts or janitorial equipment or devices affixed to the wall that exceed 3.5 inches in thickness.

THE FINDINGS INCLUDE:

- Observations on the afternoon of February 3, 2010 revealed that three (3) workstations on wheels (WOWS) are stored in the third floor corridor, plugged into receptacles on the st Mary's unit.
This was confirmed by the Director of Security and Safety.

Based on record review and confirmed by staff interview, the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff. Section 19.7.2.3 requires all health care occupancy personnel to be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.
Section 19.7.1.3 requires employees of health care occupancies to be instructed in life safety procedures and devices.

THE FINDING INCLUDE:

- While reviewing records on February 5, 2010, it was revealed that the fire plan does not contain a code phrase for staff to call out before going to the aid of an endangered person. Interview with the Director of Security and Safety revealed that staff are not trained to call out a code phrase before going to the aid of an endangered person.

Based on record review and confirmed by staff, it was revealed that the hospital failed to assure that the fire alarm system is properly maintained & tested. NFPA #72 section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis.

THE FINDINGS INCLUDE:

- While conducting the record review process during the morning hours on 2/3/10, the following fire alarm deficiency was noted:

1) The fire alarm system was not tested/inspected during the 1st quarter (January, February, March) of 2009. The hospital supplied inspection forms dated 10/16/08; 4/7/09; 7/8/09; 10/7/09 and 1/12/10.
It was stated by the Director of Facilities that the hospital changed fire alarm vendors after the 10/08 inspection, as a result the 1st quarter inspection was inadvertently missed and the quarterly off-premise test was not conducted.

This item was acknowledged by the Director of Facilities as well as Director of Security during the record review process.

Based on record review and confirmed by staff, the hospital failed to assure that sprinkler systems are maintained as required. NFPA 25 section 9.2.7 states all waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions. Section 1.8 states records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
Section 1.4.4 states the owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.
Section 2.2.1.1 states sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
NFPA #13 section 5.5.6 states the clearance between the deflector and the top of storage shall be 18 in. or greater. Section 5.1.1 requires sprinklers to be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. Where installed in areas of unobstructed construction, ceilings are required to be smooth. Smooth ceilings are ones which do not impede heat flow or water distribution in a manner that affects the ability of the sprinklers to control or suppress a fire. Section 5.6.5.2.3 requires cubicle curtains located 30 or more inches from sprinkler heads to be provided with top panels of mesh fabric having holes 1/2 " or greater in size measured on the diagonal for a horizontal distance of 18' below sprinkler deflectors.

THE FINDINGS INCLUDE:

1. While touring the facility on February 3 & 4, 2010 it was revealed that the top 18" of fabric on four (4) ceiling hung cubicle curtains {two (2) each in room #333 and in the Pain Management Clinic} have holes less than 1/2" in size.

2. While touring the facility on February 3, 2010 it was revealed that the nine 2' x 2' ceiling tiles in the second floor ICU are of an egg crate type design that allows heat to flow through.



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- While conducting the record review process during the morning hours on 2/3/10, the following sprinkler system deficiencies were noted:

3) The sprinkler system was not tested/inspected during the 1st quarter (January, February, March) of 2009. The hospital supplied inspection forms dated 10/16/08; 4/7/09; 7/8/09; 10/7/09 and 1/12/10.
It was stated by the Director of Facilities that the hospital changed sprinkler vendors after the 10/08 inspection, as a result the 1st quarter inspection was inadvertently missed.

4) The last five inspections which were performed all indicated that numerous tamper switches were non-functional during the testing process. A total of twenty one (21) switches were noted on the 10/16/08 inspection as non-functional. As of the 1/12/10 inspection, there are still four (4) switches noted as non-functional. The hospital has not maintained these switches as required and made repairs in a timely manner.

5) During the tour of the hospital on both 2/3/10 and 2/4/10, numerous recessed sprinkler heads were noted as being painted. These sprinkler heads include but are not limited to the following locations:
a) St. Mary's Unit- inside the storage room bathroom located across from room #347.
b) The 2nd floor Administration corridor closet for the dietary use of ensure products.
c) Two (2) shower rooms by room #333.
d) The Case Management office on the St. Mary's Unit.
e) Toilet room off of room #204.
f) X-Ray room #1.
g) Toilet room in the ground floor Medical Records room.

6) During the afternoon hours of 2/4/10 while touring the hospital, the top shelves located in the rear room of the gift shop were noted as obstructing two sprinkler heads. The shelving units were located directly below the sprinkler heads with storage items in direct contact with the sprinkler heads.

Each of these items were acknowledged by the Director of Facilities as well as Director of Security.

Based on record review and confirmed by staff, the hospital failed to assure that fire dampers are maintained as required. NFPA #90A section 3-4.7 states at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

THE FINDINGS INCLUDE:

- While conducting the record review process during the morning hours on 2/3/10, it was noted that the hospital does not have an actual list of all fire dampers substantiating that they have been inspected as required. The hospital produced a "floor plan" of the building with circles drawn on the plans indicating the locations of fire dampers. The hospital also produced a "statement" from a vendor stating that the dampers were inspected during the week of 2/15/07. The statement says that "most" dampers were in proper operating condition. The statement does not say what was done to correct any dampers which may have not been in proper operating condition. Also, the "statement" does not list the devices out individually by floor, zone, compartment, etc. It can not be substantiated that each damper was individually inspected and the proper maintenance performed.

This was acknowledged by the Director of Facilities during the record review process.

Based on observations and documentation provided, the hospital failed to assure that kitchen hood exhaust systems are properly maintained. NFPA 96 Section 8.3.1 states hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8.3.1. The system is required to be inspected/cleaned semi-annually per table 8.3.1.
Section 8.3.1.1 states that upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8.3.
Section 8.3.1.2 states when a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.
NFPA #17A, Section 5.2.1 requires inspections to be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
Section 5.2.4 requires that at least monthly, the date the inspection is performed and the initials of the person performing the inspection to be recorded.

THE FINDINGS INCLUDE:

1. While conducting the record review process during the morning hours on 2/3/10, it was noted that the kitchen hood exhaust system is not maintained as required. The hospital currently uses two different vendors for cleaning/inspecting the hood & duct work associated with the hood. One of these vendors is noted as cleaning/inspecting the "hood only" and not any of the duct work. The other vendor is noted as cleaning/inspecting the hood and the duct work as well. The last service date by this vendor which completes the cleaning/inspection of the "ducts" is documented as 5/6/09. As a result, the ducts are nearly 3-months over due for cleaning/inspection.
Note: The hospital uses fryolators and does have a substantial amount of grease-laden vapors produced. This was noticed on the hood system while touring the kitchen during the morning hours of 2/4/10.
2. While touring the facility on February 4, 2010 it was revealed that monthly inspections of the kitchen range extinguishing system are not performed.

This was acknowledged by the Director of Facilities during the record review process.

Based on observations, the facility did not assure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

- While touring the facility on February 3, 2010 at 4:45 p.m. a portable electric heater was found behind a desk in the administrative office on top of a plastic wastebasket. Although it was plugged in it was not turned on at the time.
This was confirmed by the Director of Security and Safety.

Based on observations and confirmed by staff, the hospital failed to assure that egress corridors are kept clear of all obstructions.

THE FINDINGS INCLUDE:

- During the morning tour of the North 1 unit on 2/4/10, three (3) portable blood pressure machines were noted as being stored in the corridor. It was also noticed that each of these machines were plugged into a wall outlet recharging the electrical batteries.

This was acknowledged by The Director of Security while conducting the tour.

Based on observations and confirmed by staff, the hospital failed to assure that oxygen cylinders are properly secured. NFPA 99 section 8-3.1.11.2 (h) requires cylinder storage to meet the requirements of 4-3.5.2.1(b) 27 which states free-standing cylinders must be properly chained or supported in a stand or cart.

THE FINDINGS INCLUDE:

- On 2/3/10 during the afternoon tour of the the Geriatric-Psyche unit, a free standing e-tank of oxygen was observed in room #302. At the time of observation, the tank was being used as it was connected to the patient sleeping in the bed.

This was acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.

Based on observations, record review and confirmed by staff, the facility failed to inspect and maintain the medical gas systems as required. NFPA 99, Section 4.3.1.1.2(a)(10)(b) and NFPA #50, Section 4.2.1 require each bulk oxygen system installed on consumer premises to be inspected annually and maintained by a qualified representative of the equipment owner. NFPA 101, Section 4.5.7 requires 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 maintained unless the Code exempts such maintenance.
NFPA section 4.3.1.2.14 refers to the identification of piping and shutoffs and states the following:
(b) Shutoff Valves. Shutoff valves shall be identified as to the following:
1. The particular medical gas or vacuum system
2. A caution to not close or open the valve except in an emergency
3. The rooms or areas served
Section 4-3.1.1.2 states the following: Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

THE FINDINGS INCLUDE:

1. While reviewing records on February 5, 2010, it was revealed that the bulk oxygen tank is not inspected annually. According to facility records the last annual inspection was performed on April 16, 2008.

2. While reviewing records on February 5, 2010, it was revealed that the bulk oxygen tank is not properly maintained. The inspection report dated April 16, 2008 note the following two problems: (1) The high/low pressure alarms are not present/not functioning and (2) An emergency oxygen connection is not available. The facility has no documentation substantiating that these two issues have been resolved.

3. While reviewing records on February 5, 2010, it was revealed that the medical gas and vacuum systems were not properly maintained. The inspection report dated October 20, 2009 noted 27 problems including but not limited to "Pressure Gauges are Inaccurate", "Marginal Flow", Low Flow", Sight Leak", Moderate Leak", Major Leak" and "Operating Pressure for Medical Air is below 50 PSI for the entire Hospital". The facility has no documentation substantiating that the issues in the 10/20/09 have been resolved or that any arrangements have been made to resolve them.



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4. On 2/3/10 during the afternoon tour of the the Geriatric-Psyche unit, it was noted that the oxygen & vacuum shutoffs are not labeled as required. It was further noted that the labels on the shutoff boxes were in fact left blank and never filled out with the appropriate room numbers which are served.

5) The Nitrous Oxide closet has a total of two (2) non-rated doors.

6) The Nitrogen closet has a total of two (2) non-rated doors.

These items were acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.

Based on record review and staff interview, the facility failed to maintain anesthetizing locations in accordance with NFPA 99. NFPA 99, Section 3.3.3.4.2(b) requires Line Isolation Monitors (LIM) to be tested at intervals of not more than 1 month by actuating the LIM test switch. Section 3.3.3.4.2(c) requires LIM's to be tested after any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3.3.2.2.3(b)] shall be activated. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

THE FINDINGS INCLUDE:

- While reviewing records on February 5, 2010, documentation regarding the testing of the facilities LIM's was requested. According to the Director of Facilities no testing is performed on the LIM's.

Based on record review and confirmed by staff, the hospital failed to assure that generator systems are maintained as required. NFPA 110 section 6-4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

THE FINDINGS INCLUDE:

- While conducting the record review process during the morning hours on 2/3/10, it was noted that the generators (2) are not maintained as required. After reviewing the last year of records provided, the hospital inspects the generators on average of less than two times per month. A total of 28 monthly inspections are documented for each generator during the period of January 1, 2009 through December 31, 2009.

This was acknowledged by the Director of Facilities during the record review process.

Based on observations and confirmed by staff, the hospital failed to assure that wall mounted alcohol hand sanitizers are installed as required.

THE FINDINGS INCLUDE:

- During the tour of the hospital on both 2/3/10 and 2/4/10, numerous hand sanitizers were noted as not properly installed. Two dispensers located by rooms #333 and 335 are two (2) feet apart. Several dispensers are installed directly above an electrical outlet or directly adjacent to an electrical switch. These hand sanitizers include but are not limited to the following locations:

1) The MRI ramp and trailer contains three (3) sanitizers improperly installed.
2) The express care "C" & "G" cubicles have two (2) sanitizers improperly installed.
3) The Telemetry 1 unit next to elevator #6 has one (1) sanitizer improperly installed.
4) The Geriatric-Psyche unit across from the O.T. room has one (1) sanitizer improperly installed.
5) The O.R. suite outside of room #5 has one (1) sanitizer improperly installed.

Each of these items were acknowledged by the Director of Facilities as well as Director of Security while conducting the tour.