HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetrations in the facility walls. This failure could allow the migration of smoke and fire and potential harm to the occupants. This affected one of three floors.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/2013 through 2/27/13, the building construction was observed.

On 2/25/2013

At 2:15 p.m., there was an approximately two inch round unsealed penetration in the east wall and behind the Ice Machine in the Nourishment Room near Room 223 on the second floor.

On 2/25/2013:
1. At 10:33 a.m., the door frame to Room 317 on the third floor was missing a strike plate, and failed to positive latch when tested.

2. At 11:05 a.m., the corridor door to Room 302 on the third floor was impeded from closing with medical equipment that was attached to the bed footboard. The equipment impeded the door from closing.

3. At 11:45 a.m., the corridor door to ICU 8 on the third floor was impeded from closing with a trash can that was between the door frame and door.

4. At 1:56 p.m., the south self-closing corridor door to the Clean Linen Closet 2 east on the second floor was not latching when tested. The latching hardware was missing.

5. At 2:21 p.m., the north self-closing corridor door to the Clean Linen Closet 2 west on the second floor was not latching when tested. The latching hardware was missing.









27961

Based on observation, the facility failed to maintain their corridor doors to resist the passage of smoke as evidenced by corridor doors which failed to positive latch upon closure, and by a corridor door that was impeded from closing. This could result in the spread of smoke and fire throughout the facility, and increase the risk of injury to the occupants due to smoke and fire. This affected two of three floors within the facility.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/2013 through 2/27/13, the corridor doors were observed.

On 2/25/2013:
1. At 10:15 a.m., there were two unsealed pipes in the smoke barrier wall above the Northwest double doors of ICU on the third floor. One pipe was round and approximately 2 ? inches in diameter, and the other pipe was round and approximately ? inch in diameter. There were white and blue wires coming through the unsealed pipes.

2. At 1:25 p.m., there was an approximately three inch by two inch unsealed penetration in the smoke barrier wall near the nurse manager's desk on the third floor. There were white and blue wires coming through the unsealed penetration.









27961

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, the facility failed to maintain their smoke barriers as evidenced by unsealed penetrations in the smoke barrier walls. This affected one of three floors within the facility, and could result in the spread of smoke and fire to other smoke compartments.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/2013, the facility's smoke barrier walls were observed.

On 2/26/2013:
2. At 2:10 p.m., the west smoke barrier door near the Radiology Manager Office on the first floor was not latching when tested.

3. At 2:38 p.m., the north smoke barrier door near the Cafeteria in the Basement was not latching when tested.





27961

NFPA 80 Standard for Fire Doors and Fire Windows (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire for a minimum of 20 minutes as evidenced by doors that failed to positive latch, and doors with the Underwriter Laboratory (UL) rating that was painted over. This affected two of three floors, and created the potential for the spread of smoke and fire to other compartments.

Findings:

During testing of the fire alarm system with the Hospital Staff on 2/25/2013 through 2/27/13, the smoke barrier doors were tested and observed.

On 2/25/2013:
1. At 11:45 A.M., the Underwriters Laboratory rating on the smoke barrier doors by the Copy room on the first floor was painted over. The door rating could not be identified.

NFPA 101?, Life Safety Code?, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas
(a) Wiring, Regular Voltage.
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).

NFPA 70 National Electrical Code, 1999 Edition, An International Electrical Code (Trademark) Series
517-63. Grounded Power Systems in Anesthetizing Locations
(a) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e).

700-12
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the on the equipment or shall be permitted to have terminals for remote lamps or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Based on observation and interview, the facility failed to maintain their emergency lighting as evidenced by emergency lighting units that failed to illuminate when tested, no record of maintenance and testing for six of six emergency exit lights, and no battery backup emergency lighting in five of five Operating Rooms. This had the potential for delaying evacuation, and causing injury to patients and staff in the event of an emergency. This affected three floors and the basement.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/13 through 2/27/13, the emergency lighting was observed and tested, and hospital staff was interviewed.

On 2/25/2013:
1. At 10:45 A.M., emergency light #14 in the corridor by the Case Management office on the first floor failed to illuminate when tested.

2. At 11:23 A.M., emergency light #9 in the corridor by Medical Records on the first floor failed to illuminate when tested.

3. At 3:45 P.M., the emergency light testing log failed to list annual and monthly testing for six exit lights that contained battery backup. When interviewed, the Facility Manager stated that they forgot to add the exit signs to the monthly and annual testing log.

On 2/26/2013:
4. At 2:00 P.M., five of five operating rooms had a second light source that failed to illuminate when tested. When interviewed, the Facility Manager stated that those lights were probably abandoned, and they would install battery backup emergency lighting in all five operating rooms.

On 2/27/2013:
5. At 9:35 A.M., five new emergency lights were observed in the operating rooms and the invoice from the vendor for the installation was provided.

6. At 9:40 A.M., the "Battery Powered Egress Light and Exit Sign Testing" log was updated to include six exit signs and five new emergency backup lights in the operating rooms.

On 2/25/2013:
3. At 2:30 P.M., the fire drill records indicate that the facility failed to have a fire drill for 2nd quarter April, May and/or June 2012 NOC shift.





27961

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Based on document review and interview, the facility failed to have a fire drill for 2nd quarter April, May and/or June 2012 for the NOC shift, and the facility failed to prepare staff members to respond to emergency situations. This was evidenced by no documentation of a fire drill for the NOC shift in the 2nd quarter, 2012, by staff members that did not know how to demonstrate how to open a locked bathroom door, and by staff members that did not know the facility's policy regarding the use of the acronym "RACE". This affected two of three floors, and could result in facility staff not being prepared to respond to a fire emergency.

Findings:

During document review and a tour of the facility with the Hospital Staff on 2/25/2013, through 2/27/13, records were reviewed, and hospital staff employees were interviewed.

On 2/25/2013:
1. At 10:47 a.m., staff members 1a through 6a were interviewed and asked to describe what actions they would take if the discovered a fire, and to explain the acronym "RACE" (Rescue, Alarm, Contain, and Extinguish). Two of six staff (staff 3a and 4a ) were unable to describe RACE and the Code word (Code Red).

2. At 10:52 a.m., staff members 2a through 4a were interviewed and asked if they could demostrate how to open a locked bathroom door to evacuate a person out of the room in the event of a fire emergency. Two of four staff (Staff 2a and 3a), were not able to open the locked door in the event of an emergency. The door can be unlocked with a small key or a coin.

On 2/25/2013:
1. At 10:20 A.M., heat detector #BHD14 in Purchasing, Basement level, was hanging down from the ceiling by a wire approximately four inches in length.

On 2/27/2013:
2. At 9:15 A.M., the facility provided documentation from February, 2010, for the sensitivity testing of 191 system based smoke detectors. When interviewed, the Facility Manager was asked if there was any other documentation of the last time the sensitivity testing had been performed, and staff stated that this was the only documentation they had that sensitivity testing had ever been performed on the smoke detectors.






27961

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 72 (1999 Edition), 7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.
(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section_____."
(8) Functional Test of Detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem, corrected/success-fully retested, device abandoned in place)

Based on document review and interview, the facility failed to maintain their smoke detectors as evidenced by the failure to provide documentation of sensitivity testing for 191 smoke detectors and, a heat detector that was hanging down from the ceiling. This affected three floors and a basement and had the potential for smoke detector failure.

Findings:

During the document review with the Hospital Staff on 2/25/13 through 2/27/13, the smoke detector sensitivity report was reviewed, and Hospital Staff were interviewed.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
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.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by the Inspector's Test Valve failing to activate the fire alarm system within 90 seconds during a flow test. This affected three of three floors and the basement. This could result in the failure of the sprinkler system in the event of a fire, increasing the risk of harm to the patients.

Findings:

During testing of the fire alarm system with the Engineering Operations Manager on 2/26/2013, the sprinkler system was tested, and staff was interviewed.

On 2/26/2013:
Penthouse Suite
1. At 3:05 p.m., the Inspector's Test Valve, a simulation of water flowing from the sprinkler system, activated the fire alarm system in 117 seconds.

2. At 3:07 p.m., the Engineering Operations Manager said during an interview that they were initiating a fire watch until the fire alarm system could be restored.

3. At 3:30 p.m., the Inspector's Test Valve was tested again, and activated the fire alarm system in 20 seconds. The fire watch was cancelled.

On 2/25/2013:
1. At 10:40 A.M., in the Case Manager/Business Office hallway on the first floor, there was a sprinkler head that was missing an escutcheon ring.

2. At 11:30 A.M., the spare sprinkler box did not contain spare sprinklers for every type of sprinkler head installed at the facility.





27961

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based
Fire Protection Systems, 1998 Edition
2-2.1 Sprinklers.
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.

2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinkler heads with missing escutcheon rings, sprinkler heads that were not free of debris, and the failure to supply the proper number and type of spare sprinkler heads. This could result in the fire sprinkler system not functioning as designed, and increased risk of injury to patients and staff. This affected three of three floors and the basement.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/13 through 2/27/13, the automatic sprinkler system was observed.

On 2/26/2013:
3. At 9:45 a.m., in the generator area outside, there were 3 of 6 sprinkler heads in the ceiling overhang near the generator that were covered with paint.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
6.1.2 The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly "quick check" or inspection in order to follow the inspection procedure as outlined in Section 6.2. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer's service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 6.3.
6.2.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
6.2.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
6.2.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file or by an electronic method that provides a permanent record.

Based on observation and interview, the facility failed to maintain their fire extinguishers as evidenced by the facility's failure to provide complete maintenance records for the fire extinguishers. This increased the risk of a fire extinguisher failing, and increased risk of injury to the patients due to smoke and fire. This affected the roof, and three floors.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/13 through 2/27/13, the fire extinguishers were observed, and staff was interviewed.


On 2/25/2013:

At 9:50 a.m., in the Chiller Room on the roof there were two fire extinguishers that were not inspected during the month of January, 2013. The fire extinguisher was last serviced on 12/20/2012. When interviewed, the Lead Engineer said that the inspection card attached to the fire extinguisher was not signed for January and February.

Based on document review, observation and interview, the facility failed to follow their smoking policy as evidenced by a smoking area set up in a non-designated area. This affected three floors and the Basement.

Findings:

During document review with the Hospital Staff on 2/25/13 through 2/27/13, the facility's smoking policy was reviewed, and the Director of Plan Operations interviewed.

Surveyor 27961

On 2/26/13:

At 9:45 A.M., a table and chairs, a smoking receptacle and a sign that indicated the area was used for smoking was observed on the back loading deck. The table and chairs were placed up against the hospital wall next to the "High Voltage" panel. When interviewed, the Director of Plant Operations was asked if that was a designated smoking area, and staff stated that it was not. The facility's smoking policy was reviewed, and stated any designated smoking area will be 25 feet from the hospital.

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, Standard for 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.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
12-4.1.1.4 Rules and Regulations.
(a) Hospital authorities and professional staff shall jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption, rules and regulations shall be prominently posted in the operating room suite. Positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement.

Based on document review and interview, the facility failed to maintain the relative humidity level equal to or greater than 35%. This was evidenced by documentation that some of the humidity levels for Operating Rooms 1, 2, 3, 4 and 5 for the months of November and December, 2012 and January and February, 2013, fell below the required level of 35%, and the facility failed to provide a written policy and procedure for the Operating Room Relative Humidity and what to do in the event the relative humidity fell below the facility's standard. This failure could result in an increased risk of fire in the operating rooms, resulting in potential harm to patients and staff. This affected three floors and the Basement.

Findings:

During document review with Hospital Staff on 2/25/13 through 2/27/13, the humidity levels of Operating Room 1,2,3,4 and 5 were reviewed, and staff was interviewed.

Surveyor 27961

On 2/25/13:
At 3:45 P.M., the humidity logs were reviewed and stated "Humidity Range 30% to 60%". The facility's policy and procedure was reviewed, and stated "Engineering will read and record humidity reading in all operating rooms every morning. Relative humidity range is 30% -- 60% and a temperature range of 68 - 73 C in all anesthetizing locations will be maintained." When interviewed, the Facility Manager stated that they would call the vendor out to fix the humidity levels when they were not able to do so. The log and vendor receipts were reviewed, and documentation for all operating rooms where relative humidity fell below 35% had been corrected was not provided. Vendor receipts for some of the days the relative humidity fell below 35% was provided for 12/4/12, 1/7/13, 1/18/13, 2/8/13, and the log sheets contained corrections for some of the dates that were affected. When asked if surgeries were continued on the dates when no correction had been noted, the Hospital Staff stated that they did not know.

The policy and procedure did not state what would be done if the relative humidity fell outside the range listed in the policy. The log sheet did not specifically state what the relative humidity was on the days it fell below 30%. The log stated " <30% rh " and had an initial next to it and did not specifically list what the relative humidity was.

Operating Room 1, 2, 3, 4, and 5:
Humidity levels documented on 11/01/12 for OR 4 was 32%.
Humidity levels documented on 11/02/12 for OR 4 was 32%.
Humidity levels documented on 11/03/12 for OR 4 was 30%.
Humidity levels documented on 11/04/12 for OR 4 was 30%.
Humidity levels documented on 11/05/12 for OR 4 was 30%.
Humidity levels documented on 11/06/12 for OR 4 was 30%.
Humidity levels documented on 11/10/12 for OR 4 was 32%.

Humidity levels documented on 12/18/12 for OR 1 was 30%.
Humidity levels documented on 12/20/12 for OR 1 was <30%.
Humidity levels documented on 12/21/12 for OR 1 was 30%.
Humidity levels documented on 12/28/12 for OR 1 was 34%.

Humidity levels documented on 12/11/12 for OR 2 was 32%.
Humidity levels documented on 12/19/12 for OR 2 was 30%.
Humidity levels documented on 12/20/12 for OR 2 was <30%.
Humidity levels documented on 12/27/12 for OR 2 was 32%.

Humidity levels documented on 12/28/12 for OR 3 was 32%.
Humidity levels documented on 12/29/12 for OR 3 was 32%.

Humidity levels documented on 12/12/12 for OR 4 was 34%.
Humidity levels documented on 12/14/12 for OR 4 was 32%.
Humidity levels documented on 12/15/12 for OR 4 was 32%.
Humidity levels documented on 12/16/12 for OR 4 was 32%.
Humidity levels documented on 12/17/12 for OR 4 was 30%.
Humidity levels documented on 12/20/12 for OR 4 was <30%.
Humidity levels documented on 12/21/12 for OR 4 was <30%.
Humidity levels documented on 12/28/12 for OR 4 was 32%.
Humidity levels documented on 12/29/12 for OR 4 was 30%.
Humidity levels documented on 12/19/12 for OR 5 was 30%.
Humidity levels documented on 12/20/12 for OR 5 was <30%.
Humidity levels documented on 12/21/12 for OR 5 was <30%.
Humidity levels documented on 12/28/12 for OR 5 was 30%.
Humidity levels documented on 12/29/12 for OR 5 was 32%.

Humidity levels documented on 01/03/13 for OR 1 was 34%.
Humidity levels documented on 01/04/13 for OR 1 was 34%.
Humidity levels documented on 01/06/13 for OR 1 was 34%.
Humidity levels documented on 01/13/13 for OR 1 was 34%.
Humidity levels documented on 01/14/13 for OR 1 was 32%.
Humidity levels documented on 01/15/13 for OR 1 was 30%.
Humidity levels documented on 01/16/13 for OR 1 was 34%.
Humidity levels documented on 01/17/13 for OR 1 was 34%.
Humidity levels documented on 01/18/13 for OR 1 was 32%.
Humidity levels documented on 01/19/13 for OR 1 was 32%.
Humidity levels documented on 01/20/13 for OR 1 was 32%.
Humidity levels documented on 01/21/13 for OR 1 was 32%.
Humidity levels documented on 01/22/13 for OR 1 was 34%.
Humidity levels documented on 01/23/13 for OR 1 was 34%.

Humidity levels documented on 01/01/13 for OR 2 was 32%.
Humidity levels documented on 01/02/13 for OR 2 was 30%.
Humidity levels documented on 01/03/13 for OR 2 was 30%.
Humidity levels documented on 01/04/13 for OR 2 was <30%.
Humidity levels documented on 01/05/13 for OR 2 was 34%.
Humidity levels documented on 01/12/13 for OR 2 was 34%.
Humidity levels documented on 01/13/13 for OR 2 was 32%.
Humidity levels documented on 01/14/13 for OR 2 was 30%.
Humidity levels documented on 01/15/13 for OR 2 was <30%.
Humidity levels documented on 01/16/13 for OR 2 was <30%.
Humidity levels documented on 01/17/13 for OR 2 was <30%.
Humidity levels documented on 01/18/13 for OR 2 was 26%.
Humidity levels documented on 01/19/13 for OR 2 was 32%.
Humidity levels documented on 01/20/13 for OR 2 was 30%.
Humidity levels documented on 01/21/13 for OR 2 was 32%.
Humidity levels documented on 01/22/13 for OR 2 was <30%.
Humidity levels documented on 01/23/13 for OR 2 was <30%.
Humidity levels documented on 01/29/13 for OR 2 was 32%.
Humidity levels documented on 01/30/13 for OR 2 was 34%.

Humidity levels documented on 01/01/13 for OR 3 was 30%.
Humidity levels documented on 01/02/13 for OR 3 was 30%.
Humidity levels documented on 01/03/13 for OR 3 was 32%.
Humidity levels documented on 01/04/13 for OR 3 was 32%.
Humidity levels documented on 01/13/13 for OR 3 was 34%.
Humidity levels documented on 01/14/13 for OR 3 was 30%.
Humidity levels documented on 01/15/13 for OR 3 was 30%.
Humidity levels documented on 01/16/13 for OR 3 was 32%.
Humidity levels documented on 01/17/13 for OR 3 was 32%.
Humidity levels documented on 01/18/13 for OR 3 was 30%.
Humidity levels documented on 01/19/13 for OR 3 was 32%.
Humidity levels documented on 01/20/13 for OR 3 was 32%.
Humidity levels documented on 01/21/13 for OR 3 was 32%.
Humidity levels documented on 01/22/13 for OR 3 was 30%.
Humidity levels documented on 01/23/13 for OR 3 was 30%.
Humidity levels documented on 01/29/13 for OR 3 was 34%.

Humidity levels documented on 01/01/13 for OR 4 was 34%.
Humidity levels documented on 01/02/13 for OR 4 was 34%.
Humidity levels documented on 01/03/13 for OR 4 was 30%.
Humidity levels documented on 01/04/13 for OR 4 was <30%.
Humidity levels documented on 01/05/13 for OR 4 was 32%.
Humidity levels documented on 01/06/13 for OR 4 was 30%.
Humidity levels documented on 01/07/13 for OR 4 was 32%.
Humidity levels documented on 01/12/13 for OR 4 was <30%.
Humidity levels documented on 01/13/13 for OR 4 was <30%.
Humidity levels documented on 01/14/13 for OR 4 was <30%.
Humidity levels documented on 01/15/13 for OR 4 was <30%.
Humidity levels documented on 01/16/13 for OR 4 was <30%.
Humidity levels documented on 01/17/13 for OR 4 was 30%.
Humidity levels documented on 01/18/13 for OR 4 was 30%.
Humidity levels documented on 01/19/13 for OR 4 was 32%.
Humidity levels documented on 01/20/13 for OR 4 was 32%.
Humidity levels documented on 01/21/13 for OR 4 was 32%.
Humidity levels documented on 01/22/13 for OR 4 was 30%.
Humidity levels documented on 01/23/13 for OR 4 was 34%.

Humidity levels documented on 01/03/13 for OR 5 was 30%.
Humidity levels documented on 01/04/13 for OR 5 was 30%.
Humidity levels documented on 01/10/13 for OR 5 was 30%.
Humidity levels documented on 01/11/13 for OR 5 was 32%.
Humidity levels documented on 01/12/13 for OR 5 was 32%.
Humidity levels documented on 01/13/13 for OR 5 was 30%.
Humidity levels documented on 01/14/13 for OR 5 was 30%.
Humidity levels documented on 01/15/13 for OR 5 was <30%.
Humidity levels documented on 01/16/13 for OR 5 was 30%.
Humidity levels documented on 01/17/13 for OR 5 was 30%.
Humidity levels documented on 01/18/13 for OR 5 was 30%.
Humidity levels documented on 01/19/13 for OR 5 was 30%.
Humidity levels documented on 01/20/13 for OR 5 was 32%.
Humidity levels documented on 01/21/13 for OR 5 was 30%.
Humidity levels documented on 01/22/13 for OR 5 was <30%.
Humidity levels documented on 01/23/13 for OR 5 was 30%.

Humidity levels documented on 02/16/13 for OR 1 was <30%.
Humidity levels documented on 02/20/13 for OR 1 was 34%.
Humidity levels documented on 02/24/13 for OR 1 was <30%.

Humidity levels documented on 02/16/13 for OR 2 was <30%.
Humidity levels documented on 02/22/13 for OR 2 was 32%.
Humidity levels documented on 02/23/13 for OR 2 was 32%.
Humidity levels documented on 02/24/13 for OR 2 was <30%.
Humidity levels documented on 02/25/13 for OR 2 was <30%.
Humidity levels documented on 02/26/13 for OR 2 was 32%.

Humidity levels documented on 02/16/13 for OR 3 was <30%.
Humidity levels documented on 02/20/13 for OR 3 was 34%.
Humidity levels documented on 02/24/13 for OR 3 was <30%.
Humidity levels documented on 02/25/13 for OR 3 was 30%.
Humidity levels documented on 02/26/13 for OR 3 was 34%.

Humidity levels documented on 02/15/13 for OR 4 was <30%.
Humidity levels documented on 02/20/13 for OR 4 was 32%.
Humidity levels documented on 02/23/13 for OR 4 was 34%.
Humidity levels documented on 02/24/13 for OR 4 was <30%.
Humidity levels documented on 02/25/13 for OR 4 was <30%.
Humidity levels documented on 02/26/13 for OR 4 was 32%.

Humidity levels documented on 02/16/13 for OR 5 was <30%.
Humidity levels documented on 02/20/13 for OR 5 was 32%.
Humidity levels documented on 02/24/13 for OR 5 was 32%.
Humidity levels documented on 02/25/13 for OR 5 was <30%.
Humidity levels documented on 02/26/13 for OR 5 was 32%.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.

(a) Type I and Type II essential electrical system power sources shall be classified as Type 10, Class X, Level 1generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.
(b) Type III essential electrical system power sources shall be classified as Type 10, Class X, Level 2 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-2.4* Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a)* Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures
5-2.5 The EPS equipment shall be installed in a location that will permit ready accessibility and adequate [minimum of 30 in. (76 cm)] working space around the unit for inspection, repair, maintenance, cleaning, or replacement.

Based on observation and interview, the facility failed to ensure that their generator was stored in a location that will permit ready accessibility and adequate working space. This was evidenced by items stored next to the generator. This could result in the failure to access the generator in the event of an emergency, and affected three floors and the basement.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/13 through 2/27/13, the generator was observed, and the Facility Manager and Director of Plant Operations were interviewed.


On 2/25/13:
At 10:05 A.M., the diesel generator was stored next to a barbeque covered in plastic, paint containers, drop clothes, plastic chairs and other hospital equipment. When interviewed, the Facility Manager stated that the area did not look like that two weeks ago, and would be cleaned up in the next 24 hours.

On 2/25/13:
2. At 10:29 a.m., on the third floor, there was no electrical cover plate over the electrical outlet in Room 320 and behind bed A.

3. At 11:17 a.m., on the third floor, there were 3 of 42 circuits in the "on" position in the electrical Panel 3BB in the ICU electrical rooms that were unmarked to their purpose. Circuits 20, 24, and 29, were not identified to their use. At 11:19 a.m., the Lead Engineer was interviewed, and stated that they did not know what the circuits were connected to.

4. At 2:01 p.m., on the second floor, there was a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord in the Nursing Staffing Office.

5. At 2:40 p.m., on the second floor, there was a small refrigerator that was plugged into a surge protected multi-outlet extension cord and not directly into an electrical outlet in the Case Management Office.





27961

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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 the fixed wiring of a structure

Based on observation and interview, the facility failed to maintain their wiring and electrical equipment. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, one surge protected multi-outlet extension cord that was plugged into a another surge protected multi-outlet extension cord, unmarked circuit breakers, a missing outlet cover, and broken outlet covers. This affected two of three floors, and could result in an electrical fire and potential harm to patients.

Findings:

During a tour of the facility with the Hospital Staff on 2/25/13 through 2/27/13, the facility's electrical wiring and equipment was observed.


On 2/25/2013:
1. At 9:00 A.M., in the Basement, there was a cracked cable cover with a cable wire running through it in the wall across from the elevators.

Based on document review and interview, the facility failed to include notification to the authority having jurisdiction that the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period in their written fire watch policy. This affected three floors and the basement, and could result in a delay in notification to the authority having jurisdiction.

During document review with the Hospital Staff on 2/25/13 through 2/27/13, the facility's policies and procedures were reviewed, and staff was interviewed.

On 2/25/13:
At 4:00 P.M., the automatic sprinkler system fire watch policy and procedure was reviewed and failed to include language stating the facility would contact the authority having jurisdiction (Department of Public Health) per the NFPA 101 regulation. When interviewed, the Facility Manager stated that they did not know the Department of Public Health needed to be notified, but would update the policy to include that language.

Based on document review and interview, the facility failed to include notification to the authority having jurisdiction that the fire alarm system is out of service for more than 4 hours in a 24 hour period in their written fire alarm system fire watch policy. This affected three floors and the basement, and could result in a delay in notification to the authority having jurisdiction.


During document review with the Hospital Staff on 2/25/13 through 2/27/13, the facility's policies and procedures were reviewed, and staff was interviewed.

On 2/25/13:
At 4:00 P.M., the fire alarm system fire watch policy and procedure was reviewed and failed to include language stating the facility would contact the authority having jurisdiction (Department of Public Health) per the NFPA 101 regulation. When interviewed, the Facility Manager stated that they did not know the Department of Public Health needed to be notified, but would update the policy to include that language.