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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This could result in the spread of fire and smoke, causing potential harm to patients and staff, in the event of a fire. This affected 6 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with hospital staff, from 6/11/12 through 6/14/12, the facility walls and ceilings were observed.

EAST BUILDING - 6/12/12
1. At 2:45 p.m., in the autoclave room, Room 2 on the 2nd Floor, there were three approximately 1-inch round penetrations in the wall around water lines, and one approximately 1/2-inch wide penetration around the sprinkler in the ceiling.

2. At 2:49 p.m., there was an approximately 2-inch round penetration in the ceiling, in the Carbon Dioxide Cylinders Storage Room, on the 2nd Floor.

WEST BUILDING - 6/13/12
3. At 9:05 a.m., there was an approximately 2 x 2 inch penetration that went through the wall, into the storage room, in Room 337 on the 3rd Floor.



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EAST BUILDING - 6/11/12
4. At 10:52 a.m., there were two approximately 1/4-inch penetrations on the wall in the 6th Floor Classrooms.

5. At 11:29 a.m., there were four approximately 1/2-inch penetrations on the wall to the Clean Utility Room, by Room 502, in the Acute Care Unit (ACU).
6. At 11:33 a.m., on the 5th Floor by the ACU, there were two penetrations on the door to the Critical Care Director's Office. The penetrations measured approximately 1/2-inch each.

7. At 11:36 a.m., there were 27 penetrations on the wall to the linen closet by Room 516, in the 5th Floor Telemetry Unit. The penetrations measured approximately 1/2-inch.

8. At 11:41 a.m., on the 5th Floor in the Telemetry Unit, there were nine penetrations on the wall to the Staff Lounge. The penetrations ranged from approximately 1/2-inch to 1-inch.

9. On 6/11/12, at 1:57 p.m., on the 4th Floor in the Custody Unit, there was a penetration on the wall in Room 442 that measured approximately 2-inches. The penetration was located next to the medical gas outlets.

10. On 6/11/12, at 2:06 p.m., on the 4th Floor in the Custody Unit, there were seven penetrations on the wall in Room 430. The penetrations measured approximately 1/2-inch each.

11. On 6/11/12, at 2:18 p.m., on the 4th Floor in the Custody Unit, there were 15 penetrations on the wall to the Charge Nurse Office by Room 420. The penetrations ranged from approximately 1/4-inch to 3/4-inch.

12. On 6/11/12, at 3:09 p.m., on the 2nd Floor by the Cath Laboratory, there was a penetration on the wall to the storage room located next to the soiled utility room. The penetration measured approximately 1/2-inch.

13. On 6/12/12, at 9:27 a.m., on the 1st Floor in the Mail Room, there was a penetration on the wall by the copy machine that measured approximately 1-inch.

14. On 6/12/12, at 9:47 a.m., on the 1st Floor in the Gift Shop, the ceiling in the storage room had a penetration that measured approximately 1-inch.

15. On 6/12/12, at 10:43 a.m., on the Basement Floor in the Distribution Storage Area, there was a penetration on the wall that measured approximately 4-inches by 1-inch.

Based on observation, the facility failed to maintain the integrity of the corridor walls. This was evidenced by penetrations in corridor walls located in 3 of 7 floors in the East Building. This could result in the spread of fire and smoke and had the potential to injure patients, visitors, and staff from smoke inhalation and burns.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 and 6/12/12, the corridor walls were observed.

EAST BUILDING - 6/11/12
1. At 1:36 p.m., there was an approximately 1/2-inch penetration on one corridor wall. The penetration was located above a fire extinguisher in the 4th Floor corridor by Room 402.

2. At 2:46 p.m., there was an approximately 1/2-inch penetration on the corridor wall by the fire doors, on the 2nd Floor near the female staff operating room (OR) locker room. The penetration was located above the drop down ceiling.

3. At 4:08 p.m., there was an approximately 2 by 1 inch penetration and an approximately 3 by 5 inch penetration, on the 1st Floor corridor wall, near the laboratory break room. The penetrations were located above the drop down ceiling. The first penetration was located by electrical conduits and the second penetration was located underneath the damper case.

6/12/12
4. At 8:30 a.m., there was an approximately 1 by 3 foot penetration, on the corridor wall to the Nuclear Medicine Exam Room, 1st Floor corridor, by the entrance to the Emergency Department. The penetration was located above the drop down ceiling.

5. At 8:47 a.m., there were three penetrations on the corridor wall to the Radiology Reading Room Offices, 1st Floor corridor, by the Emergency Department. The penetrations were located above the drop down ceiling. The penetrations were approximately 1 foot by 7 inches, 5 by 3 inches, and 4 by 4 inches in size.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that failed to positive latch and by doors with penetrations. This could allow passage of smoke and fire throughout the facility and increased the risk of harm to the patients, staff and visitors, in the event of a fire. This affected 4 of 7 floors in the East Building and 2 of 4 floors in the West Building.

Findings:

During a tour of the facility with the hospital administrative and engineering staff, from 6/11/12 through 6/13/12, the corridor doors were observed.

EAST BUILDING - 6/12/12
1. At 2:49 p.m., the door to the 2nd Floor Carbon Dioxide cylinders storage room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

WEST BUILDING 6/13/12
2. At 9:32 a.m., the door to Room 351, on the 3rd Floor, failed to latch. The latching mechanism was stuck in the door.

3. At 9:48 a.m., the door to Room 244, on the 2nd Floor, failed to latch.



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EAST BUILDING 6/11/12
4. At 1:36 p.m., the corridor door to Room 411, 4th Floor Custody Unit, failed to positive latch.

5. At 2:37 p.m., the corridor door to the 3rd Floor Nursing Station, by Room 339, failed to positive latch.

6. At 2:38 p.m., the corridor door to the 3rd Floor Nursing Station, by Room 324, failed to positive latch.

6/12/12
7. At 8:34 a.m., on the 1st Floor in the Emergency Department, the corridor door to Room 12 (Negative Pressure Room), had a loose door handle and latching mechanism. There was an approximately 1/4-inch penetration in the door.

WEST BUILDING - 2nd Floor 6/13/12
8. At 10 a.m., the corridor door to Room 209 failed to positive latch.

9. At 10:01 a.m., the corridor door to Room 206 failed to positive latch.

Based on observation, the facility failed to ensure that vertical openings were sealed to prevent the migration of fire and smoke. This was evidenced by unsealed vertical openings between floors and walls. This could result in the passage of smoke or fire from one floor to another. This affected 6 of 7 floors in the East Building.

Findings:

During a tour of the facility with the hospital administrative and engineering staff, on 6/11/12 and 6/12/12, the vertical openings in the facility were observed.

EAST BUILDING:
1. On 6/11/12, at 11:42 a.m., on the 5th Floor in the Telemetry Unit, the Telemetry Charge Nurse Office had two vertical openings that measured approximately 2-inches in diameter each.

2. On 6/12/12, at 8:44 a.m., on the 1st Floor in the Radiology Department, the Radiology Reading Room had penetrations surrounding two vertical pipes running up to the 2nd Floor. The penetrations measured approximately 1-inch each.

3. On 6/12/12, at 9:20 a.m., on the 1st Floor in the Kitchen, the Riser Room had a penetration on the wall with white and blue electrical cables running through it. The penetration measured approximately 4-inches by 1-inch. The Riser Room was a vertical shaft that went through each floor and up to the 6th floor.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by a smoke barrier door that failed to release from the magnetic hold open device. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire. This affected 1 of 7 floors in the East Building and 1 of 4 floors in West Building at Alvarado Hospital Medical Center.

Findings:

During alarm testing with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the smoke barrier doors were observed and tested.

EAST BUILDING:
1. On 6/12/12, at 1:48 p.m., the smoke barrier doors on the 5th Floor by the "Telemetry Charge Nurses" failed to release from the magnet on the left side after testing a smoke detector.

WEST BUILDING:
2. On 6/13/12, at 2:05 p.m., the smoke barrier doors by Room 212 on the 2nd Floor could not be tested because the magnetic device had fallen off.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment and increase the risk of harm to the patients and the staff in the event of a fire. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administratvie and engineering staff on 6/11/12 through 6/14/12, the smoke barrier walls were observed.

EAST BUILDING:
On 6/12/12, at 9:04 a.m., on the 1st Floor by the Cafeteria, the smoke barrier wall had a penetration that measured approximately 2-inches in diameter. The penetration was located by electrical conduits above the drop down ceiling.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. This affected 2 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center.

Findings:

During fire alarm testing with the hospital administravie and engineering staff on 6/11/12, 2012 through 6/14/12, the smoke barrier doors were observed.

EAST BUILDING:
1. On 6/12/12, at 2:00 p.m., the smoke barrier doors by Room 441 on the 4th Floor failed to positive latch on the left side after activation of a smoke detector.

2. On 6/12/12, at 3:13 p.m., the smoke barrier doors by Post OP on the 2nd Floor failed to positive latch on the left side after activation of a smoke detector.

WEST BUILDING:
3. On 6/13/12, at 2:20 p.m., the smoke barrier doors by the Oxygen Storage on the 1st Floor floor failed to positive latch on the left side after activation of a smoke detector.



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EAST BUILDING:
4. On 6/12/12, at 9:04 a.m., on the 2nd Floor corridor in the Intensive Care Unit, the smoke barrier doors by the Male Dressing Room failed to latch 1 of 2 leaf doors.

Based on observation, the facility failed to maintain its hazardous areas as evidenced by self-closing mechanisms on doors that failed to function and penetrations on walls to rooms identified as hazardous areas. This had the potential to allow the spread of smoke and fire, resulting in injury to patients, visitors and staff. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, hazardous areas were observed.

EAST BUILDING:
1. On 6/11/12, at 2:49 p.m., on the 2nd Floor corridor by the Operating Rooms' Female Locker Room, the door to the soiled utility room was observed to be open. The door failed to fully close and positive latch when the self-closing mechanism was tested.

2. On 6/11/12, at 2:56 p.m., on the 2nd Floor by Stairwell-2, the wall in the medical gas storage area had two penetrations that measured approximately 1/2-inch in diameter each.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.5.1 Doors shall 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.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Based on observation and interview, the facility failed to maintain their exit access and exits readily accessible at all times. This was evidenced by obstructions in means of egress leading to exit doors, locked door with no key readily available, and doors that did not open readily from the egress side. This had the potential to delay egress and cause harm to patients and staff in the event of an emergency evacuation. This affected 3 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During the tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the exit doors, exit access, and exit discharges were observed.

EAST BUILDING:
1. On 6/12/12, at 3:08 p.m., on the 2nd Floor in the Sterile Processing Room, there were boxes of supplies/disposables stacked in front of the exit doors leading to the corridor. The SPD Manager stated that the Rep will be there tomorrow to unpack all the supplies.



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EAST BUILDING:
2. On 6/11/12, at 1:51 p.m., on the 4th Floor in the Locked Down Unit, the corridor door by Room 443 was locked against egress. This door is one of 2 egress path. The Director of Plant Operations stated that no one in the facility had a key to open the door and the unit had been contracted to the state prisons who maintained possession of the key. The Director of Plant Operations also stated that the area does not have patients in the unit since the facility had no current contract with the state prisons. The 4th Floor was occupied by staff and patients.

3. On 6/12/12, at 9:29 a.m., on the 1st Floor in the Mail Room, the exit door that discharges into the public way did not open readily from the egress side. The door technician stated that there was a faulty latch that prevented the door from opening.

4. On 6/12/12, at 9:51 a.m., on the 1st Floor in the Pharmacy Office, the exit door had a table that blocked the door from opening. An exit sign was displayed above the door.

Based on observation, the facility failed to maintain the lighting units in their means of egress as evidenced by egress lighting units that failed to illuminate. This could result in injury to patients, visitors, and staff during an evacuation. This affected 3 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During the tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the egress lighting units in their means of egress were observed.

EAST BUILDING:
1. On 6/11/12, at 10:46 a.m., on the 6th Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

2. On 6/11/12, at 1:45 p.m., on the 4th Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

3. On 6/11/12, at 2:31 p.m., on the 3rd Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the emergency lighting units were observed and tested.

EAST BUILDING:
1. On 6/12/12, at 2:52 p.m., the emergency lighting in Operating Room 7 on the 2nd Floor had 1 of 2 bulbs that failed to illuminate when tested. The red light on the panel was illuminated indicating there was an issue with one of the bulbs.

2. On 6/12/12, at 2:55 p.m., the emergency lighting in Operating Room 3 on the 2nd Floor failed to illuminate when tested. The panel for the emergency lighting was not functioning and failed to provide a red or green light indicating that the unit was working.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
Table 7-2.2 - 5. Batteries - General Tests - b. Battery Replacement
Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer's recommendations.
Table 7-3.2 - 6. Batteries - Fire Alarm Systems - d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years)

Based on observation, the facility failed to maintain their fire alarm system as evidenced by the batteries not tested and replaced in accordance with NFPA 72. This could cause failure to their fire alarm system and injury to patients and staff in the event of a fire. This affected the West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the fire alarm system was observed.

WEST BUILDING:
1. On 6/13/12, at 1:00 p.m., the fire alarm system in the West Building had a sealed lead-acid battery in the fire alarm control panel dialer that was dated 1/2007, exceeding the manufacturer's recommended lifespan.

2. On 6/13/12, at 1:38 p.m., the fire alarm system's Inspector's Test Valve (ITV) was activated and the strobe with chime located in the Service Yard failed to function.

3. On 6/13/12, at 1:43 p.m., the fire alarm system's ITV was activated and the bell located in the North exterior area of the building failed to function.

4. On 6/13/12, at 2:12 p.m., on the 1st Floor by the elevators, the fire alarm manual pull station was not visible and obstructed by a large plant.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 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.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by tamper switches that failed to send a signal to the central monitoring company and a sprinkler head with debris. This deficient practice affected all patients, staff, and visitors in the East Building and could result in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with the Director of Plant Operations, the sprinkler system was tested and observed, and records were reviewed.

EAST BUILDING:
1. On 6/11/12, at 3:47 p.m., on the 6th Floor in the Linen Chute located on the South section of the building, the sprinkler head was covered with heavy accumulation of dirt and debris.

2. On 6/12/12, at 3:47 p.m., the tamper alarm to the fire alarm system's Post Indicator Valve (PIV) in the East Building was activated and a trouble signal was sent and received at the Fire Alarm Control Panel. The facility's monitoring company's activity report dated 6/12/12 was reviewed and it did not show that a signal was received. The PIV was tested a second time on 6/13/12 at 2:42 p.m. with the monitoring company on the phone line. The representative from the monitoring company stated that no signal had been received during this time.

NFPA 10, Standard for Portable Fire Extinguishers, 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.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by a portable fire extinguisher that was obstructed from immediate access and by extinguishers mounted more than 5-feet from the floor. This could result in delaying access to fire extinguishers and cause harm from the spread of a fire. This affected 4 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the portable fire extinguishers were observed.

EAST BUILDING:
1. On 6/12/12, at 2:48 p.m., on the 2nd Floor in the Operating Room corridor, the fire extinguisher by the "Open Heart Utility Room" was impeded from immediate access by a medical cart.



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EAST BUILDING:
2. On 6/11/12, at 11:12 a.m., on the 6th Floor in the Telemetry Unit, the fire extinguisher by Room 62 was mounted 68-inches from the floor, exceeding the 60-inches maximum height allowed.

3. On 6/11/12, at 4:01 p.m., on the 1st Floor in the Laboratory, the fire extinguisher by the entrance into the Specimen Refrigeration Room was mounted 66-inches from the floor, exceeding the 60-inches maximum height allowed.

4. On 6/12/12, at 10:44 a.m., on the Basement Floor in the Distribution Storage Area, the fire extinguisher was mounted at a height greater than 60-inches from the floor.

Based on observation, the facility failed to ensure that sprinkler coverage was provided on roof extensions that were not limited combustible material. This was evidenced by a canvas cover installed over a patio on the second floor by the walkway located between the East and West Buildings. This could result in the rapid spread of fire and cause smoke inhalation and burns to residents and staff in the event of a fire.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the roof extension on the walkway between East and West buildings was observed.

On 6/13/12, at 10:13 a.m., on the 2nd Floor by the walkway between the East and West Buildings, the mobility area patio had a canvas cover with no tag that identified the flame spread rating of the material. The facility had no records from the manufacturer to identify if the material is limited combustible material. The size is approximately 20 feet by 15 feet extending from the fully sprinklered walkway.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation, the facility failed to ensure that medical gas cylinders were secured to prevent tipping over. This was evidenced by a medical gas cylinder that was not sufficiently secured. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on June 11, 2012 through June 14, 2012, the medical gas cylinders were observed.

EAST BUILDING:
On 6/11/12, at 3:32 p.m., on the 2nd Floor Procedure Room, a Lung Diffusion cylinder container that measured approximately 250 cubic feet was standing up right with a chain wrapped around the cylinder. The link to the chain was hooked to a short hook on the wall that could easily get knocked off and unfastened.

Based on record review, the facility failed to ensure that their piped-in medical gas was maintained. This was evidenced by vendor report stating that not all rooms shutoff valve's had been repaired. This deficient practice affected all patients, staff, and visitors in the East Building at Alvarado Hospital Medical Center and could result in the increase risk of fire and hazard to life.

Findings:

During document review with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the medical gas service report was reviewed and staff was interviewed.

EAST BUILDING:
On 6/13/12, at 10:00 a.m., the vendor's report dated 6/14/12 was reviewed and documented that not all shutoff valves had been corrected. The Director of Plant Operations stated that the facility would need to shut down the system in order to fix those leaks in the valves and they had not scheduled the vendor to come out and do that yet.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on document review and interview, the facility failed to maintained the relative humidity levels at equal to or greater than 35% for various Surgery Rooms during the 2/27/12 through 6/12/12 time period, the facility failed to provide documentation of corrective actions that were taken to correct the humidity levels when they were out of range, and the facility failed to document humidity readings for various Surgery Rooms during the 2/27/12 through 6/12/12 time period. This failure could increase fire hazard, resulting in potential harm to patients and staff during surgery from fire. This affected patients and staff in the operating rooms in the East Building at Alvarado Hospital Medical Center.

Findings:

During record review and interview with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the humidity logs were reviewed.

EAST BUILDING:
The facility provided the Engineering Policy and Procedure for Humidity Control Systems which states "Humidity shall be maintained between 35% and 60% at all times. Notification to the surgery department and corrective action shall be documented in the humidity log book."

There was no documentation of corrective action was provided in the humidity log book per the Engineering Polity and Procedure for Humidity Control Systems.

The computerized control system was observed to be set at 33.33%. The Director of Plant Operations confirmed that the computerized control system was set at 33.33%.

The time documented on the humidity logs provided by the Engineering Department to the OR Staff had a deferential of 1.5 hours. The Engineering Staff ran a report on 6/13/12 at 10:55 a.m. and the time on the print out stated 12:30 p.m. Engineering Staff confirmed that the actual time did not match the time printed on log sheets.

Humidity Levels for Surgery Rooms 1 - 8:
1. Humidity levels documented on 2/28/12 for Surgery 2 was 33.31% and Surgery 3 was 32.00%.
2. Humidity levels documented on 2/29/12 for Surgery 2 was 33.33% (according to graph, percentage not listed), Surgery 3 was 29.40%, Surgery 4 was 31.03%, Surgery 5 was 30.00%, Surgery 6 was 30.25%, and Surgery 8 was 32.62%.
3. Humidity levels documented on 3/2/12 for Surgery 2 was 34.50% and Surgery 3 was 33.93%.
4. Humidity levels documented on 3/3/12 for Surgery 5 was 12.81%, Surgery 6 was 11.78%. No documentation was provided for Surgery 7 and 8.
5. No documentation of humidity levels on 3/4/12 were provided for Surgery 1, 2, 3, 4, 7 and 8.
6. Humidity levels documented on 3/5/12 for Surgery 1 were 28%, Surgery 2 was 16.87%, Surgery 3 was 19.97%, Surgery 4 was 21.00%, Surgery 5 was 18.81% and Surgery 6 was 18.78%.
7. Humidity levels documented on 3/7/12 for Surgery 2 was 33.00%, Surgery 3 was 30.00%.
8. Humidity levels documented on 3/8/12 for Surgery 1 was 26.00%, Surgery 2 was 14.94%, Surgery 3 was 21.00% and Surgery 4 was 18.06%, Surgery 5 was 16.22%, Surgery 6 was 16.00% and Surgery 8 was 20.56%.
9. Humidity levels documented on 3/9/12 for Surgery 1 were 23.00%, Surgery 2 was 11.94%, Surgery 3 was 18.00%, Surgery 4 was 15.06%, Surgery 5 was 14.25%, Surgery 6 was 14.00% and Surgery 8 was 17.56%.
10. No documentation of humidity levels on 3/11/12 for Surgery 7 and 8 were provided.
11. No documentation of humidity levels on 3/17/12 for Surgery 7 and 8 were provided.
12. Humidity levels documented on 3/18/12 for Surgery 2 was 33.81%, Surgery 3 was 33.50%. No documentation of humidity levels were provided for Surgery 5, 6, 7, and 8.
13. Humidity levels documented on 3/20/12 for Surgery 2 was 34.04% and Surgery 3 was 33.03%.
14. Humidity levels documented on 3/21/12 for Surgery 2 was 32.62% and Surgery 3 was 32.40%.
15. No documentation of humidity levels on 3/25/12 for Surgery 5, 6, 7 and 8 were provided.
16. Humidity levels documented on 3/26/12 for Surgery 3 were 32.00%.
17. No documentation of humidity levels on 3/31/12 for Surgery 1, 2, 3 and 4 were provided.
18. Humidity levels documented on 4/3/12 for Surgery 2 were 23.87%, Surgery 3 was 27.00%, Surgery 4 was 28.00%, Surgery 5 was 26.03%, Surgery 6 was 26.03% and Surgery 8 was 29.65%.
19. Humidity levels documented on 4/4/12 for Surgery 2 were 30.53%, Surgery 3 was 31.18%, Surgery 4 was 34.03%, Surgery 5 was 34.04% and Surgery 6 was 34.00%.
20. Humidity levels documented on 4/7/12 for Surgery 5 was 26.03% and Surgery 6 was 26.09%.
21. Humidity levels documented on 4/8/12 for Surgery 1 were 32.90%, Surgery 2 was 21.03%, Surgery 3 was 25.12%, Surgery 4 was 25.34%, Surgery 5 was 23.00% and Surgery 6 was 23.00%.
22. Humidity levels documented on 4/9/12 for Surgery 2 were 30.00%, Surgery 3 was 30.00%, Surgery 4 was 33.00%, Surgery 5 was 32.00% and Surgery 6 was 32.00%.
23. No documentation of humidity levels on 4/14/12 for Surgery 1, 2, 3, 4, 5 and 6 were provided.
24. Humidity levels documented on 4/19/12 for Surgery 4 was 33.33% (according to graph, percentage not listed).
25. No documentation of humidity levels on 4/28/12 for Surgery 1, 2, 3, 4, 5 and 6 were provided.
26. No documentation of humidity levels on 5/4/12 for Surgery 1 - 8 were provided.
27. No documentation of humidity levels on 5/5/12 for Surgery 5, 6, 7 and 8 were provided.
28. Humidity levels documented on 5/17/12 for Surgery 7 was 34.04%.
29. No documentation of humidity levels on 5/21/12 for Surgery 1 - 8 were provided.
30. Humidity levels documented on 5/22/12 for Surgery 7 was 34.04%.
31. No documentation of humidity levels on 5/24/12 for Surgery 1 - 8 were provided.
32. No documentation of humidity levels on 5/26/12 for Surgery 1 - 6 were provided.
33. No documentation of humidity levels on 5/27/12 for Surgery 1 - 8 were provided.
34. No documentation of humidity levels on 6/2/12 for Surgery 1 - 6 were provided.
35. No documentation of humidity levels on 6/3/12 for Surgery 1 - 6 were provided.
36. No documentation of humidity levels on 6/4/12 for Surgery 1 - 6 were provided.
37. No documentation of humidity levels on 6/9/12 for Surgery 1 - 6 were provided.
38. Humidity levels documented on 6/10/12 for Surgery 4 was 33.00% (according to graph, percentage not listed).
39. No documentation of humidity levels on 6/11/12 for Surgery 1 - 8 were provided.
40. Humidity levels documented on 6/12/12 for Surgery 1 - 6 were not provided.

NFPA 99, Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units.
One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

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 (see definition of 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).

Based on observation, document review, and interview, the facility failed to install Battery-Powered Emergency Lighting Units in accordance with NFPA 99. This was evidenced by no battery-powered emergency lighting in the Catheterization Laboratories (Cath Lab). This could result in injury to patients and staff during the loss of power. This affected 2 of 10 Anesthetizing Locations in the East Building at Alvarado Hospital Medical Center.

Findings:

During record review, observation, and interview with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the anesthetizing locations were observed.

EAST BUILDING:
The Director of Cath Lab provided Policy No. 101 Titled "Procedural Sedation." The policy stated that the Cath Lab may provide procedural sedation and its defined as follows: "2. Procedural sedation/analgesia ('conscious sedation') - A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained."

1. On 6/11/12, at 3:13 p.m., on the 2nd Floor in Cath Lab-2, no battery-powered emergency lighting unit was observed. The Director of Plant Operations confirmed that the Cath Lab did not have a battery-powered lighting unit.

2. On 6/11/12, at 3:16 p.m., on the 2nd Floor in Cath Lab-1, no battery-powered emergency lighting unit was observed. The Director of Plant Operations confirmed that the Cath Lab did not have a battery-powered lighting unit.

NFPA 30, Flammable and Combustible Liquids Code, 2000 Edition
4.4.3.6 Limited quantities of combustible commodities, as defined in the scope of NFPA 230, Standard for the Fire Protection of Storage, shall be permitted to be stored in liquid storage areas if the ordinary combustibles, other than those used for packaging the liquids, are separated from the liquids in storage by a minimum of 8 ft (2.4 m) horizontally, either by aisles or by open racks, and if protection is provided in accordance with Section 4.8.

Based on observation, the facility failed to ensure that flammable liquids were properly stored. This was evidenced by two 5-Gallon containers of flammable liquids stored outside of an approved storage cabinet and combustible materials located within 8-feet of the containers. This could result in the rapid spread of fire and potentially cause injury to patients and staff in the event of a fire. This affected the Penthouse located above the 6th Floor in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, flammable liquids were observed.

EAST BUILDING:
On 6/11/12, at 10:36 a.m., in the Penthouse located above the 6th Floor, the Exhaust Fan Room EF-3 had two 5-gallon containers of motor oil stored outside of a storage cabinet. The room was not sprinklered and contained combustible materials within 1-foot of the 5-gallon containers.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6 Remote Controls and Alarms.
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. (see figure Figure A-6-3.1(a) in NFPA 110 for suggested maintenance schedule)

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation, record review, and interview, the facility failed to maintain their Emergency Power Supply (EPS) System in accordance with NFPA 110. This was evidenced by failing to perform a load bank test or running monthly load test at greater than 30% of the EPSS nameplate rating, no remote alarm annunciator located in a constantly attended area, by no battery-powered emergency lighting unit found by the generator and by an unreliable generator for the east building. This had the potential for generator failure during the loss of power, had the inability to monitor the condition of the generator, and had the inability of troubleshooting a failure of the generator during darkness. This affected the East Building and West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on June 11, 2012 through June 14, 2012, the generator was observed and documents were reviewed.

EAST BUILDING:
1. On 6/12/12, at 10:25 a.m., there was no remote alarm annunciator located in an area that is constantly manned by staff. The Plant Operations Supervisor confirmed that they did not have a remote alarm annunciator. The emergency electrical panel was observed to contain the following systems connected to the generator for their secondary power source: telephone and intercom system, emergency lights, exits signs, emergency receptacle wall outlets, and the fire alarm system.

WEST BUILDING:
2. On 6/13/12, at 9:21 a.m., the area where the generator was located did not have battery-powered emergency lighting units. The Plant Operations Supervisor confirmed that there was no battery-powered lighting units.

3. On 6/13/12, at 3:53 p.m., the Corporate Plant Operations Director stated that the facility did not have documents showing that an annual load bank test had been done for the generator, as required when the EPSS monthly full load test were not tested at greater than 30% of the EPSS' nameplate rating. The records for the monthly load test did not show that the generators ran at or greater than 30% of their 600 KW rating during the following months: 8/2011, 12/2011, and 5/2012.

EAST BUILDING:
4. On 6/14/12, at 2:10 p.m., the Corporate Plant Operations Director informed the survey team during the exit conference that the generator for the East Building was unreliable and that a temporary generator was in route to the facility as a backup replacement until repairs have been made. Field notes, dated 6/14/12, from Bay City Technician stated the following: "Trouble call, found coolant in oil pan, needs engine diagnosis." The Plant Operations Director stated that repairs for the generator are scheduled to start on 6/15/12 at 7 a.m.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.3.2.5 Test Equipment. Electrical safety test instruments shall be tested periodically, but not less than annually, for acceptable performance.

3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 15g (4oz).

3-3.4.3 Recordkeeping.
3-3.4.3.1 General. A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or area tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Based on observation and document review, the facility failed to maintain the electrical equipment and wiring. This was evidenced by no annual receptacle testing, electrical appliances plugged into extension cords, and not providing effective protection to prevent accidental contact to energized parts. This affected 4 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center and could cause harm to patients and staff in the event of a fire due to an electrical short.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the facility's electrical wiring and equipments were observed.

EAST BUILDING:
1. On 6/12/12, at 2:40 p.m., the Employee Lounge had a water cooler plugged into an extension cord.

2. On 6/13/12 at 10:30 a.m., the facility failed to provide written documentation for annual receptacle testing for general location and semi-annual for critical care/wet locations.

WEST BUILDING:
3. On 6/13/12, at 9:15 a.m., in Room 328 on the 3rd floor, there was a refrigerator plugged into a surge protector.

4. On 6/13/12, at 10:30 a.m., the facility failed to provide written documentation for annual receptacle testing for general location and semi-annual for critical care/wet locations.



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EAST BUILDING:
5. On 6/11/12, at 2:15 p.m., on the 4th Floor in the Custody Unit, there was a broken cover plate to a two plug receptacle wall outlet located by the sink in the Staff Lounge next to Room 423.

6. On 6/11/12, at 2:16 p.m., on the 4th Floor in the Custody Unit, there were exposed electrical wires with no cover protection located by the television monitor in the Staff Lounge next to Room 423.

7. On 6/11/12, at 2:19 p.m., on the 4th Floor in the Custody Unit, there were exposed electrical wires with no cover protection in the Charge Nurse Office by Room 420.

8. On 6/11/12, at 3:12 p.m., on the 2nd Floor in Cath Lab-2, there was a broken red colored cover plate to a four plug receptacle wall outlet located in the surveillance control area.

9. On 6/12/12, at 9:52 a.m., on the 1st Floor in the Pharmacy Department, there was a computer unit plugged into an orange extension cord that ran through a doorway and was plugged into an outlet in the adjacent room.

10. On 6/12/12, at 10:42 a.m., on the Basement Floor in the Distribution Storage Area, there was no cover plate to a two plug receptacle wall outlet.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This could result in the spread of fire and smoke, causing potential harm to patients and staff, in the event of a fire. This affected 6 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with hospital staff, from 6/11/12 through 6/14/12, the facility walls and ceilings were observed.

EAST BUILDING - 6/12/12
1. At 2:45 p.m., in the autoclave room, Room 2 on the 2nd Floor, there were three approximately 1-inch round penetrations in the wall around water lines, and one approximately 1/2-inch wide penetration around the sprinkler in the ceiling.

2. At 2:49 p.m., there was an approximately 2-inch round penetration in the ceiling, in the Carbon Dioxide Cylinders Storage Room, on the 2nd Floor.

WEST BUILDING - 6/13/12
3. At 9:05 a.m., there was an approximately 2 x 2 inch penetration that went through the wall, into the storage room, in Room 337 on the 3rd Floor.



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EAST BUILDING - 6/11/12
4. At 10:52 a.m., there were two approximately 1/4-inch penetrations on the wall in the 6th Floor Classrooms.

5. At 11:29 a.m., there were four approximately 1/2-inch penetrations on the wall to the Clean Utility Room, by Room 502, in the Acute Care Unit (ACU).
6. At 11:33 a.m., on the 5th Floor by the ACU, there were two penetrations on the door to the Critical Care Director's Office. The penetrations measured approximately 1/2-inch each.

7. At 11:36 a.m., there were 27 penetrations on the wall to the linen closet by Room 516, in the 5th Floor Telemetry Unit. The penetrations measured approximately 1/2-inch.

8. At 11:41 a.m., on the 5th Floor in the Telemetry Unit, there were nine penetrations on the wall to the Staff Lounge. The penetrations ranged from approximately 1/2-inch to 1-inch.

9. On 6/11/12, at 1:57 p.m., on the 4th Floor in the Custody Unit, there was a penetration on the wall in Room 442 that measured approximately 2-inches. The penetration was located next to the medical gas outlets.

10. On 6/11/12, at 2:06 p.m., on the 4th Floor in the Custody Unit, there were seven penetrations on the wall in Room 430. The penetrations measured approximately 1/2-inch each.

11. On 6/11/12, at 2:18 p.m., on the 4th Floor in the Custody Unit, there were 15 penetrations on the wall to the Charge Nurse Office by Room 420. The penetrations ranged from approximately 1/4-inch to 3/4-inch.

12. On 6/11/12, at 3:09 p.m., on the 2nd Floor by the Cath Laboratory, there was a penetration on the wall to the storage room located next to the soiled utility room. The penetration measured approximately 1/2-inch.

13. On 6/12/12, at 9:27 a.m., on the 1st Floor in the Mail Room, there was a penetration on the wall by the copy machine that measured approximately 1-inch.

14. On 6/12/12, at 9:47 a.m., on the 1st Floor in the Gift Shop, the ceiling in the storage room had a penetration that measured approximately 1-inch.

15. On 6/12/12, at 10:43 a.m., on the Basement Floor in the Distribution Storage Area, there was a penetration on the wall that measured approximately 4-inches by 1-inch.

Based on observation, the facility failed to maintain the integrity of the corridor walls. This was evidenced by penetrations in corridor walls located in 3 of 7 floors in the East Building. This could result in the spread of fire and smoke and had the potential to injure patients, visitors, and staff from smoke inhalation and burns.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 and 6/12/12, the corridor walls were observed.

EAST BUILDING - 6/11/12
1. At 1:36 p.m., there was an approximately 1/2-inch penetration on one corridor wall. The penetration was located above a fire extinguisher in the 4th Floor corridor by Room 402.

2. At 2:46 p.m., there was an approximately 1/2-inch penetration on the corridor wall by the fire doors, on the 2nd Floor near the female staff operating room (OR) locker room. The penetration was located above the drop down ceiling.

3. At 4:08 p.m., there was an approximately 2 by 1 inch penetration and an approximately 3 by 5 inch penetration, on the 1st Floor corridor wall, near the laboratory break room. The penetrations were located above the drop down ceiling. The first penetration was located by electrical conduits and the second penetration was located underneath the damper case.

6/12/12
4. At 8:30 a.m., there was an approximately 1 by 3 foot penetration, on the corridor wall to the Nuclear Medicine Exam Room, 1st Floor corridor, by the entrance to the Emergency Department. The penetration was located above the drop down ceiling.

5. At 8:47 a.m., there were three penetrations on the corridor wall to the Radiology Reading Room Offices, 1st Floor corridor, by the Emergency Department. The penetrations were located above the drop down ceiling. The penetrations were approximately 1 foot by 7 inches, 5 by 3 inches, and 4 by 4 inches in size.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that failed to positive latch and by doors with penetrations. This could allow passage of smoke and fire throughout the facility and increased the risk of harm to the patients, staff and visitors, in the event of a fire. This affected 4 of 7 floors in the East Building and 2 of 4 floors in the West Building.

Findings:

During a tour of the facility with the hospital administrative and engineering staff, from 6/11/12 through 6/13/12, the corridor doors were observed.

EAST BUILDING - 6/12/12
1. At 2:49 p.m., the door to the 2nd Floor Carbon Dioxide cylinders storage room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

WEST BUILDING 6/13/12
2. At 9:32 a.m., the door to Room 351, on the 3rd Floor, failed to latch. The latching mechanism was stuck in the door.

3. At 9:48 a.m., the door to Room 244, on the 2nd Floor, failed to latch.



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EAST BUILDING 6/11/12
4. At 1:36 p.m., the corridor door to Room 411, 4th Floor Custody Unit, failed to positive latch.

5. At 2:37 p.m., the corridor door to the 3rd Floor Nursing Station, by Room 339, failed to positive latch.

6. At 2:38 p.m., the corridor door to the 3rd Floor Nursing Station, by Room 324, failed to positive latch.

6/12/12
7. At 8:34 a.m., on the 1st Floor in the Emergency Department, the corridor door to Room 12 (Negative Pressure Room), had a loose door handle and latching mechanism. There was an approximately 1/4-inch penetration in the door.

WEST BUILDING - 2nd Floor 6/13/12
8. At 10 a.m., the corridor door to Room 209 failed to positive latch.

9. At 10:01 a.m., the corridor door to Room 206 failed to positive latch.

Based on observation, the facility failed to ensure that vertical openings were sealed to prevent the migration of fire and smoke. This was evidenced by unsealed vertical openings between floors and walls. This could result in the passage of smoke or fire from one floor to another. This affected 6 of 7 floors in the East Building.

Findings:

During a tour of the facility with the hospital administrative and engineering staff, on 6/11/12 and 6/12/12, the vertical openings in the facility were observed.

EAST BUILDING:
1. On 6/11/12, at 11:42 a.m., on the 5th Floor in the Telemetry Unit, the Telemetry Charge Nurse Office had two vertical openings that measured approximately 2-inches in diameter each.

2. On 6/12/12, at 8:44 a.m., on the 1st Floor in the Radiology Department, the Radiology Reading Room had penetrations surrounding two vertical pipes running up to the 2nd Floor. The penetrations measured approximately 1-inch each.

3. On 6/12/12, at 9:20 a.m., on the 1st Floor in the Kitchen, the Riser Room had a penetration on the wall with white and blue electrical cables running through it. The penetration measured approximately 4-inches by 1-inch. The Riser Room was a vertical shaft that went through each floor and up to the 6th floor.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by a smoke barrier door that failed to release from the magnetic hold open device. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire. This affected 1 of 7 floors in the East Building and 1 of 4 floors in West Building at Alvarado Hospital Medical Center.

Findings:

During alarm testing with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the smoke barrier doors were observed and tested.

EAST BUILDING:
1. On 6/12/12, at 1:48 p.m., the smoke barrier doors on the 5th Floor by the "Telemetry Charge Nurses" failed to release from the magnet on the left side after testing a smoke detector.

WEST BUILDING:
2. On 6/13/12, at 2:05 p.m., the smoke barrier doors by Room 212 on the 2nd Floor could not be tested because the magnetic device had fallen off.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment and increase the risk of harm to the patients and the staff in the event of a fire. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administratvie and engineering staff on 6/11/12 through 6/14/12, the smoke barrier walls were observed.

EAST BUILDING:
On 6/12/12, at 9:04 a.m., on the 1st Floor by the Cafeteria, the smoke barrier wall had a penetration that measured approximately 2-inches in diameter. The penetration was located by electrical conduits above the drop down ceiling.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. This affected 2 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center.

Findings:

During fire alarm testing with the hospital administravie and engineering staff on 6/11/12, 2012 through 6/14/12, the smoke barrier doors were observed.

EAST BUILDING:
1. On 6/12/12, at 2:00 p.m., the smoke barrier doors by Room 441 on the 4th Floor failed to positive latch on the left side after activation of a smoke detector.

2. On 6/12/12, at 3:13 p.m., the smoke barrier doors by Post OP on the 2nd Floor failed to positive latch on the left side after activation of a smoke detector.

WEST BUILDING:
3. On 6/13/12, at 2:20 p.m., the smoke barrier doors by the Oxygen Storage on the 1st Floor floor failed to positive latch on the left side after activation of a smoke detector.



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EAST BUILDING:
4. On 6/12/12, at 9:04 a.m., on the 2nd Floor corridor in the Intensive Care Unit, the smoke barrier doors by the Male Dressing Room failed to latch 1 of 2 leaf doors.

Based on observation, the facility failed to maintain its hazardous areas as evidenced by self-closing mechanisms on doors that failed to function and penetrations on walls to rooms identified as hazardous areas. This had the potential to allow the spread of smoke and fire, resulting in injury to patients, visitors and staff. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, hazardous areas were observed.

EAST BUILDING:
1. On 6/11/12, at 2:49 p.m., on the 2nd Floor corridor by the Operating Rooms' Female Locker Room, the door to the soiled utility room was observed to be open. The door failed to fully close and positive latch when the self-closing mechanism was tested.

2. On 6/11/12, at 2:56 p.m., on the 2nd Floor by Stairwell-2, the wall in the medical gas storage area had two penetrations that measured approximately 1/2-inch in diameter each.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.5.1 Doors shall 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.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Based on observation and interview, the facility failed to maintain their exit access and exits readily accessible at all times. This was evidenced by obstructions in means of egress leading to exit doors, locked door with no key readily available, and doors that did not open readily from the egress side. This had the potential to delay egress and cause harm to patients and staff in the event of an emergency evacuation. This affected 3 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During the tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the exit doors, exit access, and exit discharges were observed.

EAST BUILDING:
1. On 6/12/12, at 3:08 p.m., on the 2nd Floor in the Sterile Processing Room, there were boxes of supplies/disposables stacked in front of the exit doors leading to the corridor. The SPD Manager stated that the Rep will be there tomorrow to unpack all the supplies.



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EAST BUILDING:
2. On 6/11/12, at 1:51 p.m., on the 4th Floor in the Locked Down Unit, the corridor door by Room 443 was locked against egress. This door is one of 2 egress path. The Director of Plant Operations stated that no one in the facility had a key to open the door and the unit had been contracted to the state prisons who maintained possession of the key. The Director of Plant Operations also stated that the area does not have patients in the unit since the facility had no current contract with the state prisons. The 4th Floor was occupied by staff and patients.

3. On 6/12/12, at 9:29 a.m., on the 1st Floor in the Mail Room, the exit door that discharges into the public way did not open readily from the egress side. The door technician stated that there was a faulty latch that prevented the door from opening.

4. On 6/12/12, at 9:51 a.m., on the 1st Floor in the Pharmacy Office, the exit door had a table that blocked the door from opening. An exit sign was displayed above the door.

Based on observation, the facility failed to maintain the lighting units in their means of egress as evidenced by egress lighting units that failed to illuminate. This could result in injury to patients, visitors, and staff during an evacuation. This affected 3 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During the tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the egress lighting units in their means of egress were observed.

EAST BUILDING:
1. On 6/11/12, at 10:46 a.m., on the 6th Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

2. On 6/11/12, at 1:45 p.m., on the 4th Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

3. On 6/11/12, at 2:31 p.m., on the 3rd Floor in Stairwell-2, the light fixtures did not illuminate and left the means of egress in darkness.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the emergency lighting units were observed and tested.

EAST BUILDING:
1. On 6/12/12, at 2:52 p.m., the emergency lighting in Operating Room 7 on the 2nd Floor had 1 of 2 bulbs that failed to illuminate when tested. The red light on the panel was illuminated indicating there was an issue with one of the bulbs.

2. On 6/12/12, at 2:55 p.m., the emergency lighting in Operating Room 3 on the 2nd Floor failed to illuminate when tested. The panel for the emergency lighting was not functioning and failed to provide a red or green light indicating that the unit was working.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
Table 7-2.2 - 5. Batteries - General Tests - b. Battery Replacement
Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer's recommendations.
Table 7-3.2 - 6. Batteries - Fire Alarm Systems - d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years)

Based on observation, the facility failed to maintain their fire alarm system as evidenced by the batteries not tested and replaced in accordance with NFPA 72. This could cause failure to their fire alarm system and injury to patients and staff in the event of a fire. This affected the West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12 through 6/14/12, the fire alarm system was observed.

WEST BUILDING:
1. On 6/13/12, at 1:00 p.m., the fire alarm system in the West Building had a sealed lead-acid battery in the fire alarm control panel dialer that was dated 1/2007, exceeding the manufacturer's recommended lifespan.

2. On 6/13/12, at 1:38 p.m., the fire alarm system's Inspector's Test Valve (ITV) was activated and the strobe with chime located in the Service Yard failed to function.

3. On 6/13/12, at 1:43 p.m., the fire alarm system's ITV was activated and the bell located in the North exterior area of the building failed to function.

4. On 6/13/12, at 2:12 p.m., on the 1st Floor by the elevators, the fire alarm manual pull station was not visible and obstructed by a large plant.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 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.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by tamper switches that failed to send a signal to the central monitoring company and a sprinkler head with debris. This deficient practice affected all patients, staff, and visitors in the East Building and could result in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with the Director of Plant Operations, the sprinkler system was tested and observed, and records were reviewed.

EAST BUILDING:
1. On 6/11/12, at 3:47 p.m., on the 6th Floor in the Linen Chute located on the South section of the building, the sprinkler head was covered with heavy accumulation of dirt and debris.

2. On 6/12/12, at 3:47 p.m., the tamper alarm to the fire alarm system's Post Indicator Valve (PIV) in the East Building was activated and a trouble signal was sent and received at the Fire Alarm Control Panel. The facility's monitoring company's activity report dated 6/12/12 was reviewed and it did not show that a signal was received. The PIV was tested a second time on 6/13/12 at 2:42 p.m. with the monitoring company on the phone line. The representative from the monitoring company stated that no signal had been received during this time.

NFPA 10, Standard for Portable Fire Extinguishers, 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.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by a portable fire extinguisher that was obstructed from immediate access and by extinguishers mounted more than 5-feet from the floor. This could result in delaying access to fire extinguishers and cause harm from the spread of a fire. This affected 4 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the portable fire extinguishers were observed.

EAST BUILDING:
1. On 6/12/12, at 2:48 p.m., on the 2nd Floor in the Operating Room corridor, the fire extinguisher by the "Open Heart Utility Room" was impeded from immediate access by a medical cart.



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EAST BUILDING:
2. On 6/11/12, at 11:12 a.m., on the 6th Floor in the Telemetry Unit, the fire extinguisher by Room 62 was mounted 68-inches from the floor, exceeding the 60-inches maximum height allowed.

3. On 6/11/12, at 4:01 p.m., on the 1st Floor in the Laboratory, the fire extinguisher by the entrance into the Specimen Refrigeration Room was mounted 66-inches from the floor, exceeding the 60-inches maximum height allowed.

4. On 6/12/12, at 10:44 a.m., on the Basement Floor in the Distribution Storage Area, the fire extinguisher was mounted at a height greater than 60-inches from the floor.

Based on observation, the facility failed to ensure that sprinkler coverage was provided on roof extensions that were not limited combustible material. This was evidenced by a canvas cover installed over a patio on the second floor by the walkway located between the East and West Buildings. This could result in the rapid spread of fire and cause smoke inhalation and burns to residents and staff in the event of a fire.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the roof extension on the walkway between East and West buildings was observed.

On 6/13/12, at 10:13 a.m., on the 2nd Floor by the walkway between the East and West Buildings, the mobility area patio had a canvas cover with no tag that identified the flame spread rating of the material. The facility had no records from the manufacturer to identify if the material is limited combustible material. The size is approximately 20 feet by 15 feet extending from the fully sprinklered walkway.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation, the facility failed to ensure that medical gas cylinders were secured to prevent tipping over. This was evidenced by a medical gas cylinder that was not sufficiently secured. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 7 floors in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on June 11, 2012 through June 14, 2012, the medical gas cylinders were observed.

EAST BUILDING:
On 6/11/12, at 3:32 p.m., on the 2nd Floor Procedure Room, a Lung Diffusion cylinder container that measured approximately 250 cubic feet was standing up right with a chain wrapped around the cylinder. The link to the chain was hooked to a short hook on the wall that could easily get knocked off and unfastened.

Based on record review, the facility failed to ensure that their piped-in medical gas was maintained. This was evidenced by vendor report stating that not all rooms shutoff valve's had been repaired. This deficient practice affected all patients, staff, and visitors in the East Building at Alvarado Hospital Medical Center and could result in the increase risk of fire and hazard to life.

Findings:

During document review with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the medical gas service report was reviewed and staff was interviewed.

EAST BUILDING:
On 6/13/12, at 10:00 a.m., the vendor's report dated 6/14/12 was reviewed and documented that not all shutoff valves had been corrected. The Director of Plant Operations stated that the facility would need to shut down the system in order to fix those leaks in the valves and they had not scheduled the vendor to come out and do that yet.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on document review and interview, the facility failed to maintained the relative humidity levels at equal to or greater than 35% for various Surgery Rooms during the 2/27/12 through 6/12/12 time period, the facility failed to provide documentation of corrective actions that were taken to correct the humidity levels when they were out of range, and the facility failed to document humidity readings for various Surgery Rooms during the 2/27/12 through 6/12/12 time period. This failure could increase fire hazard, resulting in potential harm to patients and staff during surgery from fire. This affected patients and staff in the operating rooms in the East Building at Alvarado Hospital Medical Center.

Findings:

During record review and interview with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the humidity logs were reviewed.

EAST BUILDING:
The facility provided the Engineering Policy and Procedure for Humidity Control Systems which states "Humidity shall be maintained between 35% and 60% at all times. Notification to the surgery department and corrective action shall be documented in the humidity log book."

There was no documentation of corrective action was provided in the humidity log book per the Engineering Polity and Procedure for Humidity Control Systems.

The computerized control system was observed to be set at 33.33%. The Director of Plant Operations confirmed that the computerized control system was set at 33.33%.

The time documented on the humidity logs provided by the Engineering Department to the OR Staff had a deferential of 1.5 hours. The Engineering Staff ran a report on 6/13/12 at 10:55 a.m. and the time on the print out stated 12:30 p.m. Engineering Staff confirmed that the actual time did not match the time printed on log sheets.

Humidity Levels for Surgery Rooms 1 - 8:
1. Humidity levels documented on 2/28/12 for Surgery 2 was 33.31% and Surgery 3 was 32.00%.
2. Humidity levels documented on 2/29/12 for Surgery 2 was 33.33% (according to graph, percentage not listed), Surgery 3 was 29.40%, Surgery 4 was 31.03%, Surgery 5 was 30.00%, Surgery 6 was 30.25%, and Surgery 8 was 32.62%.
3. Humidity levels documented on 3/2/12 for Surgery 2 was 34.50% and Surgery 3 was 33.93%.
4. Humidity levels documented on 3/3/12 for Surgery 5 was 12.81%, Surgery 6 was 11.78%. No documentation was provided for Surgery 7 and 8.
5. No documentation of humidity levels on 3/4/12 were provided for Surgery 1, 2, 3, 4, 7 and 8.
6. Humidity levels documented on 3/5/12 for Surgery 1 were 28%, Surgery 2 was 16.87%, Surgery 3 was 19.97%, Surgery 4 was 21.00%, Surgery 5 was 18.81% and Surgery 6 was 18.78%.
7. Humidity levels documented on 3/7/12 for Surgery 2 was 33.00%, Surgery 3 was 30.00%.
8. Humidity levels documented on 3/8/12 for Surgery 1 was 26.00%, Surgery 2 was 14.94%, Surgery 3 was 21.00% and Surgery 4 was 18.06%, Surgery 5 was 16.22%, Surgery 6 was 16.00% and Surgery 8 was 20.56%.
9. Humidity levels documented on 3/9/12 for Surgery 1 were 23.00%, Surgery 2 was 11.94%, Surgery 3 was 18.00%, Surgery 4 was 15.06%, Surgery 5 was 14.25%, Surgery 6 was 14.00% and Surgery 8 was 17.56%.
10. No documentation of humidity levels on 3/11/12 for Surgery 7 and 8 were provided.
11. No documentation of humidity levels on 3/17/12 for Surgery 7 and 8 were provided.
12. Humidity levels documented on 3/18/12 for Surgery 2 was 33.81%, Surgery 3 was 33.50%. No documentation of humidity levels were provided for Surgery 5, 6, 7, and 8.
13. Humidity levels documented on 3/20/12 for Surgery 2 was 34.04% and Surgery 3 was 33.03%.
14. Humidity levels documented on 3/21/12 for Surgery 2 was 32.62% and Surgery 3 was 32.40%.
15. No documentation of humidity levels on 3/25/12 for Surgery 5, 6, 7 and 8 were provided.
16. Humidity levels documented on 3/26/12 for Surgery 3 were 32.00%.
17. No documentation of humidity levels on 3/31/12 for Surgery 1, 2, 3 and 4 were provided.
18. Humidity levels documented on 4/3/12 for Surgery 2 were 23.87%, Surgery 3 was 27.00%, Surgery 4 was 28.00%, Surgery 5 was 26.03%, Surgery 6 was 26.03% and Surgery 8 was 29.65%.
19. Humidity levels documented on 4/4/12 for Surgery 2 were 30.53%, Surgery 3 was 31.18%, Surgery 4 was 34.03%, Surgery 5 was 34.04% and Surgery 6 was 34.00%.
20. Humidity levels documented on 4/7/12 for Surgery 5 was 26.03% and Surgery 6 was 26.09%.
21. Humidity levels documented on 4/8/12 for Surgery 1 were 32.90%, Surgery 2 was 21.03%, Surgery 3 was 25.12%, Surgery 4 was 25.34%, Surgery 5 was 23.00% and Surgery 6 was 23.00%.
22. Humidity levels documented on 4/9/12 for Surgery 2 were 30.00%, Surgery 3 was 30.00%, Surgery 4 was 33.00%, Surgery 5 was 32.00% and Surgery 6 was 32.00%.
23. No documentation of humidity levels on 4/14/12 for Surgery 1, 2, 3, 4, 5 and 6 were provided.
24. Humidity levels documented on 4/19/12 for Surgery 4 was 33.33% (according to graph, percentage not listed).
25. No documentation of humidity levels on 4/28/12 for Surgery 1, 2, 3, 4, 5 and 6 were provided.
26. No documentation of humidity levels on 5/4/12 for Surgery 1 - 8 were provided.
27. No documentation of humidity levels on 5/5/12 for Surgery 5, 6, 7 and 8 were provided.
28. Humidity levels documented on 5/17/12 for Surgery 7 was 34.04%.
29. No documentation of humidity levels on 5/21/12 for Surgery 1 - 8 were provided.
30. Humidity levels documented on 5/22/12 for Surgery 7 was 34.04%.
31. No documentation of humidity levels on 5/24/12 for Surgery 1 - 8 were provided.
32. No documentation of humidity levels on 5/26/12 for Surgery 1 - 6 were provided.
33. No documentation of humidity levels on 5/27/12 for Surgery 1 - 8 were provided.
34. No documentation of humidity levels on 6/2/12 for Surgery 1 - 6 were provided.
35. No documentation of humidity levels on 6/3/12 for Surgery 1 - 6 were provided.
36. No documentation of humidity levels on 6/4/12 for Surgery 1 - 6 were provided.
37. No documentation of humidity levels on 6/9/12 for Surgery 1 - 6 were provided.
38. Humidity levels documented on 6/10/12 for Surgery 4 was 33.00% (according to graph, percentage not listed).
39. No documentation of humidity levels on 6/11/12 for Surgery 1 - 8 were provided.
40. Humidity levels documented on 6/12/12 for Surgery 1 - 6 were not provided.

NFPA 99, Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations. e. Battery-Powered Emergency Lighting Units.
One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

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 (see definition of 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).

Based on observation, document review, and interview, the facility failed to install Battery-Powered Emergency Lighting Units in accordance with NFPA 99. This was evidenced by no battery-powered emergency lighting in the Catheterization Laboratories (Cath Lab). This could result in injury to patients and staff during the loss of power. This affected 2 of 10 Anesthetizing Locations in the East Building at Alvarado Hospital Medical Center.

Findings:

During record review, observation, and interview with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the anesthetizing locations were observed.

EAST BUILDING:
The Director of Cath Lab provided Policy No. 101 Titled "Procedural Sedation." The policy stated that the Cath Lab may provide procedural sedation and its defined as follows: "2. Procedural sedation/analgesia ('conscious sedation') - A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained."

1. On 6/11/12, at 3:13 p.m., on the 2nd Floor in Cath Lab-2, no battery-powered emergency lighting unit was observed. The Director of Plant Operations confirmed that the Cath Lab did not have a battery-powered lighting unit.

2. On 6/11/12, at 3:16 p.m., on the 2nd Floor in Cath Lab-1, no battery-powered emergency lighting unit was observed. The Director of Plant Operations confirmed that the Cath Lab did not have a battery-powered lighting unit.

NFPA 30, Flammable and Combustible Liquids Code, 2000 Edition
4.4.3.6 Limited quantities of combustible commodities, as defined in the scope of NFPA 230, Standard for the Fire Protection of Storage, shall be permitted to be stored in liquid storage areas if the ordinary combustibles, other than those used for packaging the liquids, are separated from the liquids in storage by a minimum of 8 ft (2.4 m) horizontally, either by aisles or by open racks, and if protection is provided in accordance with Section 4.8.

Based on observation, the facility failed to ensure that flammable liquids were properly stored. This was evidenced by two 5-Gallon containers of flammable liquids stored outside of an approved storage cabinet and combustible materials located within 8-feet of the containers. This could result in the rapid spread of fire and potentially cause injury to patients and staff in the event of a fire. This affected the Penthouse located above the 6th Floor in the East Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, flammable liquids were observed.

EAST BUILDING:
On 6/11/12, at 10:36 a.m., in the Penthouse located above the 6th Floor, the Exhaust Fan Room EF-3 had two 5-gallon containers of motor oil stored outside of a storage cabinet. The room was not sprinklered and contained combustible materials within 1-foot of the 5-gallon containers.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6 Remote Controls and Alarms.
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. (see figure Figure A-6-3.1(a) in NFPA 110 for suggested maintenance schedule)

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation, record review, and interview, the facility failed to maintain their Emergency Power Supply (EPS) System in accordance with NFPA 110. This was evidenced by failing to perform a load bank test or running monthly load test at greater than 30% of the EPSS nameplate rating, no remote alarm annunciator located in a constantly attended area, by no battery-powered emergency lighting unit found by the generator and by an unreliable generator for the east building. This had the potential for generator failure during the loss of power, had the inability to monitor the condition of the generator, and had the inability of troubleshooting a failure of the generator during darkness. This affected the East Building and West Building at Alvarado Hospital Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on June 11, 2012 through June 14, 2012, the generator was observed and documents were reviewed.

EAST BUILDING:
1. On 6/12/12, at 10:25 a.m., there was no remote alarm annunciator located in an area that is constantly manned by staff. The Plant Operations Supervisor confirmed that they did not have a remote alarm annunciator. The emergency electrical panel was observed to contain the following systems connected to the generator for their secondary power source: telephone and intercom system, emergency lights, exits signs, emergency receptacle wall outlets, and the fire alarm system.

WEST BUILDING:
2. On 6/13/12, at 9:21 a.m., the area where the generator was located did not have battery-powered emergency lighting units. The Plant Operations Supervisor confirmed that there was no battery-powered lighting units.

3. On 6/13/12, at 3:53 p.m., the Corporate Plant Operations Director stated that the facility did not have documents showing that an annual load bank test had been done for the generator, as required when the EPSS monthly full load test were not tested at greater than 30% of the EPSS' nameplate rating. The records for the monthly load test did not show that the generators ran at or greater than 30% of their 600 KW rating during the following months: 8/2011, 12/2011, and 5/2012.

EAST BUILDING:
4. On 6/14/12, at 2:10 p.m., the Corporate Plant Operations Director informed the survey team during the exit conference that the generator for the East Building was unreliable and that a temporary generator was in route to the facility as a backup replacement until repairs have been made. Field notes, dated 6/14/12, from Bay City Technician stated the following: "Trouble call, found coolant in oil pan, needs engine diagnosis." The Plant Operations Director stated that repairs for the generator are scheduled to start on 6/15/12 at 7 a.m.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.3.2.5 Test Equipment. Electrical safety test instruments shall be tested periodically, but not less than annually, for acceptable performance.

3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 15g (4oz).

3-3.4.3 Recordkeeping.
3-3.4.3.1 General. A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, this record shall contain the date, the rooms or area tested, and an indication of which items have met or have failed to meet the performance requirements of this chapter.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Based on observation and document review, the facility failed to maintain the electrical equipment and wiring. This was evidenced by no annual receptacle testing, electrical appliances plugged into extension cords, and not providing effective protection to prevent accidental contact to energized parts. This affected 4 of 7 floors in the East Building and 1 of 4 floors in the West Building at Alvarado Hospital Medical Center and could cause harm to patients and staff in the event of a fire due to an electrical short.

Findings:

During a tour of the facility with the hospital administrative and engineering staff on 6/11/12, 2012 through 6/14/12, the facility's electrical wiring and equipments were observed.

EAST BUILDING:
1. On 6/12/12, at 2:40 p.m., the Employee Lounge had a water cooler plugged into an extension cord.

2. On 6/13/12 at 10:30 a.m., the facility failed to provide written documentation for annual receptacle testing for general location and semi-annual for critical care/wet locations.

WEST BUILDING:
3. On 6/13/12, at 9:15 a.m., in Room 328 on the 3rd floor, there was a refrigerator plugged into a surge protector.

4. On 6/13/12, at 10:30 a.m., the facility failed to provide written documentation for annual receptacle testing for general location and semi-annual for critical care/wet locations.



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EAST BUILDING:
5. On 6/11/12, at 2:15 p.m., on the 4th Floor in the Custody Unit, there was a broken cover plate to a two plug receptacle wall outlet located by the sink in the Staff Lounge next to Room 423.

6. On 6/11/12, at 2:16 p.m., on the 4th Floor in the Custody Unit, there were exposed electrical wires with no cover protection located by the television monitor in the Staff Lounge next to Room 423.

7. On 6/11/12, at 2:19 p.m., on the 4th Floor in the Custody Unit, there were exposed electrical wires with no cover protection in the Charge Nurse Office by Room 420.

8. On 6/11/12, at 3:12 p.m., on the 2nd Floor in Cath Lab-2, there was a broken red colored cover plate to a four plug receptacle wall outlet located in the surveillance control area.

9. On 6/12/12, at 9:52 a.m., on the 1st Floor in the Pharmacy Department, there was a computer unit plugged into an orange extension cord that ran through a doorway and was plugged into an outlet in the adjacent room.

10. On 6/12/12, at 10:42 a.m., on the Basement Floor in the Distribution Storage Area, there was no cover plate to a two plug receptacle wall outlet.