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Based on observation, the facility failed to maintain the integrity of their building. This was evidenced by one unsealed penetration in a facility wall. This affected one of two floors and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff, the walls and ceilings in the facility were observed.

Main Hospital:

1. On 6/5/12 at 9:18 a.m., there was one approximately four inch by one inch unsealed penetration in the wall of Waiting Room 110.26. The penetration was located in the wall adjacent to the corridor door.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by one corridor door that failed to latch when in the closed position. This affected all patients, and could result in a delay in containing smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Urgent Care Clinic:

1. On 6/6/12 at 8:16 a.m., the door to the Server Closet failed to latch when in the closed position. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

Based on observation, the facility failed to maintain the integrity of their building. This was evidenced by one unsealed penetration in a facility wall. This affected one of two floors and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff, the walls and ceilings in the facility were observed.

Main Hospital:

1. On 6/5/12 at 8:33 a.m., there was one approximately four inch by one inch unsealed penetration in the wall of the Soiled Utility Room 101.56. The penetration was located in the back wall of the room.

Based on observation, the facility failed to maintain their emergency lights and exit equipped with battery back-up. This was evidenced by two emergency lights/exit sign combination units equipped with battery back-up that failed to illuminate when tested. This affected one of two floors, and could result in a delayed evacuation in the event of an emergency due to limited egress visibility.

Findings:

During a facility tour with staff, the emergency lighting units and exit signs were observed.

Main Hospital:

1. On 6/4/12 at 1:44 p.m., one emergency light/exit sign combination unit near Room 207 and one emergency light/exit sign combination unit near Room 219 were observed. The emergency light/exit signs were tested by pressing the test buttons on the combination units. Both emergency light/exit sign combination units failed to illuminate when the test buttons for the devices were pressed.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm chime that failed to emit an audible sound when the fire alarm system was activated. This affected all patients, and could result in a delayed notification of a fire.

NFPA 72, 1999 edition
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.

Findings:

During a facility tour with staff, the fire alarm system notification devices were observed.

Urgent Care Clinic:

1. On 6/6/12 at 8:35 a.m., the fire alarm system was tested. The facility had one chime/strobe combination device located inside Suite 109. The chime portion of the chime/strobe device failed to emit an audible sound when the fire alarm system was activated. The fire alarm chimes located outside Suite 109 could not be heard from all areas inside the suite.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by two sprinkler heads that had debris. This affected one of two floors, and could result in a delay to extinguish a fire due to an impaired sprinkler head.

NFPA 25, 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.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff, the automatic fire sprinklers in the facility were observed.

Main Hospital:

1. On 6/4/12 at 1:52 p.m., an automatic fire sprinkler head located in the Bathroom in Room 225 was observed to have a white plaster-like substance on the deflector plate.

2. On 6/4/12 at 2:24 p.m., an automatic fire sprinkler head located in the Soiled Utility Room across from the C-Section Room 228.01 had a piece of plastic bag on the deflector plate.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by the facility's fire extinguishers that had not had an annual service and inspection within the past twelve months. This affected two of two floors, and could result in a delay to extinguish a fire due to a malfunctioning fire extinguisher.

NFPA 10, 1998 edition
4-3 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 4-4.

Findings:

During a facility tour with staff, the facility's portable fire extinguishers were observed.

Main Hospital:

1. From 6/4/12 to 6/5/12, the portable fire extinguishers in the facility were observed. All fire extinguishers in the facility were equipped with tags that indicated the last time they had an annual service and inspection. The tags indicated that the fire extinguishers in the facility were last serviced on 5/25/11. The facility's fire extinguishers were approximately two weeks overdue for an annual service and inspection. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that the portable fire extinguishers are scheduled to be serviced and inspected in June, 2012.

Based on observation, the facility failed to maintain their storage of medical gas cylinders. This was evidenced by two medical gas cylinders that were free standing and unsecured. This affected one of two floors, and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the medical gas storage locations were observed.

Main Hospital:

1. On 6/4/12 at 4:08 p.m., two medical gas cylinders, located at the Medical Gas Manifold location, were observed to be free standing and unsecured.

Based on record review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels at their anesthetizing locations at thirty-five percent or above. This affected four of four anesthetizing locations, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

1. On 6/5/12 at 2:25 p.m., the relative humidity logs for the facility's anesthetizing locations were observed. Three of three Operating Rooms and one of one C-Section Rooms had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months. Operating Room 1 had recorded relative humidity levels below thirty-five percent on thirty-nine days during the past twelve months. Operating Room 2 had recorded relative humidity levels below thirty-five percent on sixty-three days during the past twelve months. Operating Room 3 had recorded relative humidity levels below thirty-five percent on seventy-one days during the past twelve months. The C-Section Room had recorded relative humidity levels below thirty-five percent on one hundred and six days during the past twelve months. The policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing locations was requested at that time. The policy indicated that the facility would maintain relative humidity levels at their anesthetizing locations between thirty and sixty percent relative humidity. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that they were not aware that relative humidity levels were required to be maintained at thirty-five percent or above.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the facility's use of extension cords as a substitute for permanent wiring and one electrical junction box that was missing a faceplate. This affected two of two floors, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the 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, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

1. On 6/5/12 at 8:47 a.m., a toaster oven in Staff Office Room 101.06 was plugged into a surge protected multi-outlet extension cord.

2. On 6/5/12 at 8:57 a.m., a refrigerator in the Respiratory Therapy Lounge was plugged into a surge protected multi-outlet extension cord.

3. On 6/5/12 at 9:11 a.m., a portable space heater in Staff Office Room 107.05 was plugged into a surge protected multi-outlet extension cord.

4. On 6/5/12 at 9:37 a.m., computer equipment in Radiology Room 111.27 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

5. On 6/5/12 at 9:53 a.m., a portable space heater in Staff Office Room 120.01 was plugged into a surge protected multi-outlet extension cord.

6. On 6/5/12 at 9:56 a.m., a portable space heater in the Receiving Office was plugged into a surge protected multi-outlet extension cord.

7. On 6/5/12 at 10:07 a.m., a portable air conditioning unit in the Laboratory was plugged into a surge protected multi-outlet extension cord.

8. On 6/5/12 at 10:23 a.m., a change machine and microwave oven near the Cafeteria Vending Machine Room were plugged into a non-surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord.


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Findings:

During a facility tour with staff, the electrical wiring and equipment in the facility were observed.

Main Hospital:

9. On 6/5/12 at 8:57 a.m., in the Occupational Therapy/Physical Therapy/Speech Therapy Room, an electrical box by the glass door and cycle was missing a cover. No electrical wires were exposed.

10. On 6/5/12 at 10:27 a.m., in the Cafeteria, a space heater at the cashier's station was plugged into a surge protector.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of five alcohol based hand rub dispensers over or adjacent to ignition sources. This affected two of two floors, and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

Main Hospital:

1. On 6/4/12 at 1:41 p.m., an alcohol based hand rub dispenser in Room 216 was mounted on the wall approximately two inches to the upper right of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 6/4/12 at 1:55 p.m., an alcohol based hand rub dispenser in Room 222 was mounted on the wall approximately two and a half feet above an electrical wall receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 6/4/12 at 2:17 p.m., an alcohol based hand rub dispenser in Sterile Processing Room 229 was mounted on the wall approximately two inches to the upper right of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

4. On 6/5/12 at 9:01 a.m., an alcohol based hand rub dispenser in the Intensive Care Unit near Room 3 was mounted on the wall approximately three feet above an electrical wall receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

5. On 6/5/12 at 9:21 a.m., an alcohol based hand rub dispenser in Room 110.23 was mounted on the wall approximately five inches to the upper left of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.