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Based on observation, record review, and interview with staff, the facility failed to provide fire drills that are in accordance with NFPA 101, Section 18.7.1.2. Findings:

1) Code Red-Fire Drill critique forms were not filled out completely (numerous yes and no answers were not answered on forms).

2) The facility could not verify that 100 % of staff were inserviced and trained for drills held.

3) Corrective action was not taken for deficiencies identified by the drill conducted on 7/21/2011.

Based on observation, record review, and interview with staff, the facility failed to provide anesthetizing locations with relative humidity maintained equal to or greater than 35%.

Findings:

1) Operating Room 2 was found to be at 18% humidity. A review of the HVAC Energy Management System provided information that humidity on multiple days was under the range of 35%. The facility failed to take corrective action and postpone or relocate the procedures until levels were at acceptable levels.

(1) NFPA 99, 1999 Edition, Section 12-4.1.2.10 which states that 1) "an evaluation shall be made of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associates with the operation of surgical equipment, and hazards associated with the nature of the environment", and 2) "Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel."
Finding:
Based on observation, record review, and interview with the Director of Plant Operations, the facility failed to provide a Hazard Assessment in accordance with NFPA 99, 1999 Edition, Section 12-4.1.2.10

(2) NFPA 99, 1999 Edition, Section 5-4.2.1 which states "locations provided with mechanical ventilation throughout or employing fume hoods as a fixed part of the exhaust system shall have the air supply and exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies." 5-6.2 states that "warning signs describing the nature of any hazardous effluent content shall be posted at fume hoods' discharge points, assess points, and filter locations."

Finding:
Based on observation, record review, and interview, the hospital failed to provide hoods that are in compliance with NFPA 99
(a) The hood located in the chemotherapy treatment area is not in compliance with NFPA 99, 1999 Edition, Section 5-4.2.1. and 5-6.2. There is no documentation that the area had exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies and that the roof exhaust had signs describing the nature of the hazards.
(b) The fume hood in the laboratory is not in an area that has an air supply and exhaust balanced to provide a negative pressure with respect to the surrounding area.

(3) NFPA 99, 1999 Edition, Section 7-5.1.3.1 states "the physical integrity of the power cord and attachment plug and cord-strain relief shall be confirmed by visual inspection or other appropriate tests, and Section 7-5.1.3.2 states "resistance between the appliance and chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be measured."
Finding:
Based on review of the medical equipment and interview with the Director of Maintenance, the facility failed to test medical equipment in accordance with NFPA 99, 1999 Edition. The Vital Sign Welch Allyn Monitor located in the Wound Care Center had an expired inspection tag.