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During the survey tour on August 13, 2013 from 7:00am to 1:00pm, I observed the following penetrations that were not sealed and would allow smoke, heat, and fire to penetrate from one area to the another area. This would expose patients, visitors, and staff to the threat of smoke and fire.

The findings include, but are not limited to:

1. At 8:46am, I observed that room 236 has penetrations in the wall.
2. At 10:20am, I observed penetrations from the exterior sprinkler control room into the MRI areas.

These findings were observed and discussed with the Director of Plant Services.

The facility has failed to provide battery-powered emergency lighting in the Operating Room. This could allow for the OR surgeons to be in complete darkness for the 10 seconds that the generator delays to turn on. This could place patients and staff at risk of critical moments of darkness in a power outage.

The findings include, but are not limited to:

During the survey of the Operating Room on August 13, 2013 at 7:15am, I observed that the Endo Room in the OR was not equipped with battery-powered emergency lights.

This finding was observed and discussed with the Director of Plant Services.

The facility has failed to ensure that the required fire alarm devices have been installed where required. This could allow for a fire to go undetected until the smoke and heat has reached other areas of the hospital. This potentially can expose patients, visitors, and staff to the threat of smoke and fire.

The findings include, but are not limited to:

During the facility tour on August 12, 2013 at 3:24pm, I observed that the 5th floor (5-tower) sleeping room did not have a smoke detector.

This finding was observed and discussed with the Director of Plant Services.

Based on observations and staff interviews, the facility failed to maintain the proper operational condition of the sprinkler system. This has the potential of having a non-functional sprinkler system that would expose patients, visitors, and staff to a fire or smoke environment.

The findings include, but are not limited to:

During the facility survey on August 12, 2013 from 3:15pm to 4:15pm and continued on August 13, 2013 from 7:00am to 1:00pm, sprinkler deficiencies were observed in the following location(s):

August 13, 2013:
1. At 10:59am, I observed that the 1st floor Fire Alarm Control Panel room (ED157) did not have sprinkler coverage. All areas around this room did have sprinkler protection.
2. At 11:00am, I observed that the 1st floor Electrical closet across from ER southwest entrance did not have sprinkler coverage. All areas around this room did have sprinkler protection.
3. At 11:39am, I observed that the hazardous storage room basement was using the sprinkler piping for electrical grounding cables.
4. At 12:35am, I observed that the pharmacy staff restroom had sprinkler head escutcheon missing.

These findings were observed and discussed with the Director of Plant Services.

The facility has failed to restrict the use of portable electric heaters to the types of heaters specified in the Life Safety Code. This could expose patients, visitors, and staff to risk of fire due to overheating of portable heaters.

The findings include, but are not limited to:

Observations made during the facility survey on August 12, 2013 at 3:19pm, I observed that the Administration Reception desk was using an unapproved portable heater.

This finding was observed and discussed with the Director of Plant Services.

Observations made during the facility tour on August 13, 2013 revealed the following violations in the Operating Rooms. This could put patients and staff at risk of fire conditions.

The findings include, but are not limited to:

1. At 7:20, I observed that Operating Room #3 did not have a medical gas shut off outside of the room as required. The shut off valve was discovered to be inside of the operating room. All other operating rooms have the shut off valve outside of the operating room.
2. The facility has provided letter of intent to use the Categorical Waiver for Humidity Levels as required by C.M.S.

These findings were observed and discussed with the Director of Plant Services.

The facility has failed to maintain premises free of electrical hazards. This could provide for electrical fire and expose staff and patients to threat of fire.

The findings include, but are not limited to:

Observations made during the facility survey on August 12, 2013 from 3:15pm to 4:15pm and continued on August 13, 2013 from 7:00am to 1:00pm, revealed electrical hazards in the following location(s):

August 12, 2013:
1. At 3:53pm, I observed that the ACU Director office has refrigerator plugged into a power strip.
2. At 3:53pm, I observed that the ACU Director office has a power strip daisy chained into another power strip.
3. At 4:06pm, I observed that the 4th floor nurses lounge on 4 center has a microwave plugged into a power strip.
4. At 4:15pm, I observed that hte 4th floor Director 4 Center office has a refrigerator plugged into a power strip.

August 13, 2013:
1. At 7:35am, I observed PACU break room to have a microwave plugged into a power strip.
2. At 8:05am, I observed 3rd floor cath lab storage to have an unapproved blue power tap/ extension cord.
3. At 8:07am, I observed 3rd floor Housekeeping storage/break room to have a microwave on a power strip.
4. At 8:10am, I observed Housekeeping Manager's office to have an orange extension cord for the refrigerator.
5. At 8:30am, I observed that the Meaningful Use Clinical office has an outlet with no cover plate.
6. At 9:04am, I observed the Physical Therapy Accute to have an extension cord for coffee maker into a power strip.
7. At 9:05am, I observed the Physical Therapy Accute to have a microwave and a refrigerator on a power strip.
8. At 9:20am, I observed the Director of Respitory on 2nd floor to have a a brown extension cord that serves tv/dvd equipment plugged into a white extension cord for a razor.
9. At 9:21am, I observed the Rehab office 2nd floor to have microwave and refrigerator into a power strip.
10. At 10:16am, I observed the Gift shop to have a power strip plugged into a power strip that also had a large flower refrigerator on it.
11. At 10:17am, I observed that the Gift shop storage room had an extension cord plugged into another extension cord that served 3 lamps.
12. At 10:37am, I observed that the ER 1st floor diectation area has a power strip that is incorrectly mounted and is dangling, putting stress on cords.
13. At 11:31am, I observed that the Accounting -Accounts Payable desk has a refrigerator into a power strip.
14. At 11:31am, I observed that the Accounting-Accounts Payable 2nd desk has a power strip plugged into another power strip, and then plugged into a 3rd power strip.
15. At 12:10pm, I observed the Plant Services Office to have a power strip plugged into another power strip.
16. At 12:11pm, I observed that the BIO Med area has a power strip plugged into another power strip.
17. At 12:35pm, I observed that the Pharmacy staff lounge restroom has a microwave into a power strip and that power strip is improperly mounted causing it to dangle adding stress to cords.
18. At 12:40pm, I observed BIO Lab Supervisor's office to have a refrigerator into a power strip and a 2nd power strip in this office is improperly mounted causing it to be dangling and adding stress to cords.

These findings were observed and discussed with the Director of Plant Services.

The facility failed to maintain the proper distance for alcohol based hand sanitizers (ABHS) from an electrical source. This potentially allows a fire ignition source that exposes patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility survey on August 12, 2013 from 3:15pm to 4:15pm and continued on August 13, 2013 from 7:00am to 1:00pm, improper mounting of alcohol based hand rub was observed in the following location(s):

August 12, 2013:
1. At 3:52pm, I observed that the ABHS in 4th floor ICU med room was to close too an electrical unit.
August 13, 2013:
1. At 7:29am, I observed that the ABHS in the surgery holding room was too close to an electrical unit.
2. At 8:57am, I observed that room 238 has ABHS too close to electrical switch.

These findings were observed and discussed with the Director of Plant Services.