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Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility ceiling. This affected 1 of 13 smoke compartments which could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the building construction was observed.

East Wing
At 11:58 a.m., there was an approximately 1 inch unsealed penetration around the sprinkler pipe in the Dietary Storage Room. One of two sprinklers had an escutcheon ring that was not flush to the ceiling.

Based on observation, the facility failed to maintain the integrity of the corridor walls as evidenced by penetrations in one wall. This could result in the spread of fire and smoke and increase the risk of harm to residents and staff in the event of a fire. This affected 1 of 13 smoke compartments.

Findings:
During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the walls were observed.

East Wing
At 2:55 p.m., there were four approximately 1/2 inch penetrations in the Med Surge East Wing Pyxis Storage area. The penetrations were in the north wall above the Pyxis unit.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke, as evidenced by a corridor door that was impeded from closing. This affected 1 of 13 smoke compartments and had the potential to allow the migration of smoke in the event of a fire.

Findings:

During the facility tour with Staff 1 and Staff 2 on March 12, 2012, the corridor doors were observed.

East Wing
At 11:50 a.m., the self-closing corridor door to the Kitchen dry storage room was impeded from closing. There was a bungee cord tied around the door handle and connected to a storage rack.

During an interview at 11:52 a.m., Staff 1 and 2 confirmed the door was impeded from closing by the bungee cord tied around the door handle.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in two smoke barrier walls. This affected 4 of 13 smoke compartments, and could result in the spread of smoke or fire to other smoke compartments.

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.

Findings:

During a facility tour with Staff 1, Staff 2, and Staff 3 on March 12, 2012, the smoke barrier walls were observed.

East Wing
At 3:25 p.m., there was an approximately 1/2 inch unsealed conduit in the East smoke barrier wall near the Elevator lobby. Staff 1 confirmed the finding.

At 3:48 p.m., there was an approximately 1 inch unsealed penetration, inside a 2 inch conduit, around purple colored wires. The conduit was at the top of the pipe, in the East smoke barrier wall, near LDRP Room 4. Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier. This was evidenced by smoke barrier, cross-corridor, fire doors that were equipped with latching hardware, but failed to latch when closed. This affected 5 of 13 smoke compartments, and could result in the spread of smoke and/or fire.

Findings:

During fire alarm testing with Staff 1, Staff 2, Staff 3, and TRL Staff 1 on March 13, 2012, the smoke barrier doors were observed and tested.

West Wing
At 8:26 a.m., the north leaf, of the smoke barrier doors near Room 280, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

At 8:32 a.m., the north leaf, of the smoke barrier doors near Room 298, failed to latch after activation of the fire alarm system. Staff 1 and Staff 2 confirmed the finding.

At 8:40 a.m., the east leaf, of the elevator smoke barrier doors near the second floor Electrical Room, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

East Wing
At 9:17 a.m., the south leaf, of the smoke barrier doors near LDRP 4, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

At 9:35 a.m., the east leaf, of the smoke barrier doors near the first floor Mail Room, failed to latch after activation of the fire alarm system. Staff 1 and Staff 2 confirmed the finding.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with NFPA 10. This was evidenced by one fire extinguisher that was impeded from access. This affected 1 of 13 smoke compartments and could result in a delay to access the fire extinguisher, in the event of a fire.

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.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the portable fire extinguishers were observed.

East Wing
At 11:23 a.m., there was a portable fire extinguisher that was impeded by a counter, in the Gross Room.

Based on observation and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire. This was evidenced by items that were stored in the corridor exit access. This could result in a delay in evacuation in the event of a fire, or other emergency, and affected 2 of 13 smoke compartments.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the exit corridors were observed.

East Wing
At 2:55 p.m., there were 2 patient transport chairs, one wheelchair and a telemetry machine in the exit corridor near the Med Surge Pyxis Storage area. The items were in the corridor for over 60 minutes without being moved.

During an interview at 2:58 p.m., Staff 6 stated "we always store our stuff here."

Based on document review, the facility failed to maintain the relative humidity level for 2 of 6 Operating Rooms (OR). This was evidenced by documentation that the humidity levels were below 35% during February 2012. This increased the risk of fire and harm to patients. This affected 1 of 13 smoke compartments.

Findings:

During document review with Staff 1 and Staff 2 on March 13, 2012, the humidity logs of the OR were reviewed for the month of February 2012.

East Wing
At 11:00 a.m., the following information was provided from the humidity log for the month of February:

In OR 6 on February 20, the humidity was 32. On February 21, the humidity was 32, and on February 22, the humidity was 31.

In OR 4 on February 16, the humidity was 32. On February 17, the humidity was 30. From February 20 through February 24, the humidity was 25. On February 27, the humidity was 34, on February 28, the humidity was 31, and on February 29, the humidity was 33.

Based on observation, the facility failed to maintain electrical wiring and equipment, as evidenced by utilizing extension cords. This could result in an increased risk of electrical fire and potential injury to patients and staff. This affected 2 of 13 smoke compartments.

NFPA 70, National Electric Code, 1999 Edition
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

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the electrical system was observed.

At 11:17 a.m., there was an orange extension cord that was in use in the House Supervisor Office located in the Mail Room.

At 1:23 p.m., there was a orange extension cord plugged into a Workstation on Wheels in the Gastroenterology Endoscopy (GI) Pulmonary Lab.



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Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility ceiling. This affected 1 of 13 smoke compartments which could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the building construction was observed.

East Wing
At 11:58 a.m., there was an approximately 1 inch unsealed penetration around the sprinkler pipe in the Dietary Storage Room. One of two sprinklers had an escutcheon ring that was not flush to the ceiling.

Based on observation, the facility failed to maintain the integrity of the corridor walls as evidenced by penetrations in one wall. This could result in the spread of fire and smoke and increase the risk of harm to residents and staff in the event of a fire. This affected 1 of 13 smoke compartments.

Findings:
During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the walls were observed.

East Wing
At 2:55 p.m., there were four approximately 1/2 inch penetrations in the Med Surge East Wing Pyxis Storage area. The penetrations were in the north wall above the Pyxis unit.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke, as evidenced by a corridor door that was impeded from closing. This affected 1 of 13 smoke compartments and had the potential to allow the migration of smoke in the event of a fire.

Findings:

During the facility tour with Staff 1 and Staff 2 on March 12, 2012, the corridor doors were observed.

East Wing
At 11:50 a.m., the self-closing corridor door to the Kitchen dry storage room was impeded from closing. There was a bungee cord tied around the door handle and connected to a storage rack.

During an interview at 11:52 a.m., Staff 1 and 2 confirmed the door was impeded from closing by the bungee cord tied around the door handle.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by penetrations in two smoke barrier walls. This affected 4 of 13 smoke compartments, and could result in the spread of smoke or fire to other smoke compartments.

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.

Findings:

During a facility tour with Staff 1, Staff 2, and Staff 3 on March 12, 2012, the smoke barrier walls were observed.

East Wing
At 3:25 p.m., there was an approximately 1/2 inch unsealed conduit in the East smoke barrier wall near the Elevator lobby. Staff 1 confirmed the finding.

At 3:48 p.m., there was an approximately 1 inch unsealed penetration, inside a 2 inch conduit, around purple colored wires. The conduit was at the top of the pipe, in the East smoke barrier wall, near LDRP Room 4. Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier. This was evidenced by smoke barrier, cross-corridor, fire doors that were equipped with latching hardware, but failed to latch when closed. This affected 5 of 13 smoke compartments, and could result in the spread of smoke and/or fire.

Findings:

During fire alarm testing with Staff 1, Staff 2, Staff 3, and TRL Staff 1 on March 13, 2012, the smoke barrier doors were observed and tested.

West Wing
At 8:26 a.m., the north leaf, of the smoke barrier doors near Room 280, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

At 8:32 a.m., the north leaf, of the smoke barrier doors near Room 298, failed to latch after activation of the fire alarm system. Staff 1 and Staff 2 confirmed the finding.

At 8:40 a.m., the east leaf, of the elevator smoke barrier doors near the second floor Electrical Room, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

East Wing
At 9:17 a.m., the south leaf, of the smoke barrier doors near LDRP 4, failed to latch after activation of the fire alarm system. Staff 1 confirmed the finding.

At 9:35 a.m., the east leaf, of the smoke barrier doors near the first floor Mail Room, failed to latch after activation of the fire alarm system. Staff 1 and Staff 2 confirmed the finding.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with NFPA 10. This was evidenced by one fire extinguisher that was impeded from access. This affected 1 of 13 smoke compartments and could result in a delay to access the fire extinguisher, in the event of a fire.

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.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the portable fire extinguishers were observed.

East Wing
At 11:23 a.m., there was a portable fire extinguisher that was impeded by a counter, in the Gross Room.

Based on observation and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire. This was evidenced by items that were stored in the corridor exit access. This could result in a delay in evacuation in the event of a fire, or other emergency, and affected 2 of 13 smoke compartments.

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the exit corridors were observed.

East Wing
At 2:55 p.m., there were 2 patient transport chairs, one wheelchair and a telemetry machine in the exit corridor near the Med Surge Pyxis Storage area. The items were in the corridor for over 60 minutes without being moved.

During an interview at 2:58 p.m., Staff 6 stated "we always store our stuff here."

Based on document review, the facility failed to maintain the relative humidity level for 2 of 6 Operating Rooms (OR). This was evidenced by documentation that the humidity levels were below 35% during February 2012. This increased the risk of fire and harm to patients. This affected 1 of 13 smoke compartments.

Findings:

During document review with Staff 1 and Staff 2 on March 13, 2012, the humidity logs of the OR were reviewed for the month of February 2012.

East Wing
At 11:00 a.m., the following information was provided from the humidity log for the month of February:

In OR 6 on February 20, the humidity was 32. On February 21, the humidity was 32, and on February 22, the humidity was 31.

In OR 4 on February 16, the humidity was 32. On February 17, the humidity was 30. From February 20 through February 24, the humidity was 25. On February 27, the humidity was 34, on February 28, the humidity was 31, and on February 29, the humidity was 33.

Based on observation, the facility failed to maintain electrical wiring and equipment, as evidenced by utilizing extension cords. This could result in an increased risk of electrical fire and potential injury to patients and staff. This affected 2 of 13 smoke compartments.

NFPA 70, National Electric Code, 1999 Edition
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

Findings:

During a tour of the facility with Staff 1 and Staff 2 on March 12, 2012, the electrical system was observed.

At 11:17 a.m., there was an orange extension cord that was in use in the House Supervisor Office located in the Mail Room.

At 1:23 p.m., there was a orange extension cord plugged into a Workstation on Wheels in the Gastroenterology Endoscopy (GI) Pulmonary Lab.



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