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Based on observation and interview, the facility failed to maintain their self-closing doors. This was evidenced by a door which failed to latch due to an obstruction. During a fire, this could allow smoke and flames to pass through the open door and harm patients, visitors, and staff. This affected the Penthouse of Tower 85.

Findings:

During a facility tour with hospital staff from 5/13/19 to 5/15/19, the self-closing doors were observed.

On 5/13/19, at 2:27 p.m., the door to Elevator rooms Two and Three, located in the Penthouse of Tower 85, failed to latch. It had a rag stuffed between the door and the jamb. ES2 said the Maintenance Staff probably put the rag there because the door cannot be unlocked and they needed access.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by a self-closing door which failed to close and latch. During a fire, this could allow smoke and flames to pass through the open door and harm patients, visitors, and staff. This affected one of five floors in Tower 85.

Findings:

During a facility tour with hospital staff from 5/13/19 to 5/15/19, the hazardous areas were observed.

On 5/13/19, at 4:21 p.m., the door to the Equipment room, located in the Third Floor 3200 corridor of the Tower 85, failed to self-close and latch. ES2 said the door needed adjustment.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by fire extinguishers that were improperly mounted and obstructed from view, and by fire extinguisher that was stored unsecured. This could result in the fire extinguisher being tampered with, accelerated ignition if it falls or is knocked over, malfunction, or delay in extinguishment in the event of a fire. This affected three floors in the "65" Tower and one floor in the "71" Tower.

NFPA 101, Life Safety Code, 2012 Edition

19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1

9.7.4 Manual Extinguishing Equipment.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

Findings:

During a tour of the facility and interview with the Hospital Staff from 5/13/19 through 5/15/19, the portable fire extinguishers were observed.

1. On 5/13/19 at 4:09 p.m., there was one fire extinguisher type "ABC" in a Gastrointestinal office located in the first floor of Tower 65 sitting on a metal table unsecured and freestanding. During a concurrent interview, the VP1 confirmed the finding and stated the suite was recently painted.

2. On 5/14/19 at 9:05 a.m., on the fifth floor of the Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not mounted to prevent tipping over.

3. At 9:23 a.m., in the Laboratory, located on the second floor of the Tower 71, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The enclosure was blocked by a utility cart. The fire extinguisher was freestanding inside the enclosure and not visible from outside. A member of the laboratory staff said there was no fire extinguisher inside the enclosure and upon inspection the surveyor found an extinguisher in the enclosure.

4. At 9:28 a.m., on the second floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible from outside.

5. At 9:32 a.m., in the Observation Unit, located on the second floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible from outside.

6. At 10:38 a.m., in the Secured Unit, located on the fifth floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible from outside.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by fire extinguishers that were improperly mounted and obstructed from view, and by fire extinguisher that was stored unsecured. This could result in the fire extinguisher being tampered with, accelerated ignition if it falls or is knocked over, malfunction, or delay in extinguishment in the event of a fire. This affected three floors in the "65" Tower and one floor in the "71" Tower.

NFPA 101, Life Safety Code, 2012 Edition

19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1

9.7.4 Manual Extinguishing Equipment.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) ln the bracket supplied by the extinguisher manufacturer
(3) ln a listed bracket approved for such purpose
(4) ln cabinets or wall recesses

Findings:
During a tour of the facility and interview with the
Hospital Staff from 5/13/19 through 5/15/19, the portable fire extinguishers were observed.

1. On 5/13/19 at 4:09 p.m., there was one fire extinguisher type "ABC" in a Gastrointestinal office located in the first floor of Tower 65 sitting on a metal table unsecured and freestanding. During a concurrent interview, the VP1 confirmed the finding and stated the suite was recently painted.
2. On 5/14/19 at 9:05 a.m., on the fifth floor of the Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and !he enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside !he enclosure and not mounted to prevent tipping over.
3. At 9:23 a.m., in the Laboratory, located on the second floor of the Tower 71, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The enclosure was blocked by a utility cart. The fire extinguisher was freestanding inside the enclosure and not visible from outside. A member of the laboratory staff said there was no fire extinguisher inside the enclosure and upon inspection the surveyor found an extinguisher in the enclosure.

4. At 9:28 a.m., on the second floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been rernoved and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible from outside.
5. At 9:32 a.rn., in the Observation Unit, located on the second floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been rernoved and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible frorn outside.
6. At 10:38 a.rn., in the Secured Unit, located on the fifth floor of Tower 65, the fire extinguisher was placed in a fire hose enclosure. The fire hose had been removed and the enclosure was repurposed to house the fire extinguisher. The fire extinguisher was freestanding inside the enclosure and not visible from outside.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by two corridor doors that failed to latch. This could result in the spread of smoke into the corridor in the event of fire. This affected the one floor in the Tower 65.

Finding:

During a tour of the facility and interview with the Hospital Staff from 5/13/19 through 5/15/19, the corridor doors were observed.

1. On 5/13/19 at 3:49 p.m., the door to a restroom in Cardio-Pulmonary located in the first floor of Tower 65 did not latch. Two attempts were made.

2. At 4:05 p.m., the door to the Gastrointestinal storage room located in the first floor of the Tower 65 did not latch. Two attempts were made. During a concurrent interview, the VP1 confirmed the finding and stated the door needs adjusting.

Based on observation and interview, the facility failed to maintain their Rubbish and Laundry Chutes. This was evidenced by missing or non-operable fire sprinklers at the top of the chutes. During a fire, this could cause a delay in extinguishment and could harm patients, visitors, and staff. This affected five of five floors in Tower 65.

NFPA 101, Life Safety Code, 2012 Edition

19.5.4 Rubbish Chutes, Incinerators, and Laundry Chutes.
19.5.4.3
Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with Section 9.7. (See Section 9.5.)

NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, 2009 Edition

5.2.6 Automatic Sprinklers.
5.2.6.1 Gravity Chute.
5.2.6.1.1
Gravity chutes shall be protected internally by automatic sprinklers.
5.2.6.1.2
This protection requires that a sprinkler be installed at or above the top service opening of the chute.

Findings:

During a facility tour with the Engineering Staff from 5/13/19 to 5/15/19, the rubbish and laundry chutes were observed.

1. On 5/14/19, at 9:02 a.m., in the Laundry Chute room, located on the fifth floor of Tower 65, the sprinkler head was missing from the sprinkler piping.

2. On 5/14/19, at 9:03 a.m., in the Trash Chute room, located on the fifth floor of the Tower 65 and adjacent to the Laundry Chute room, the sprinkler head was missing from the sprinkler piping and was capped off. ES1 said he thought both areas were sprinklered, but the sprinklers were just corroded.

Based on interview, the facility failed to ensure that staff had knowledge of the proper fire protection procedures, as evidenced by kitchen staff that could not determine the correct fire extinguisher to use for an electrical fire. This could result in the rapid spread of fire and injury to staff since the extinguishing agents in many Class K extinguishers are electrically conductive. This affected the basement of the "85" Tower.

NFPA 101 Life Safety Code, 2012 Edition

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures devices.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

5.1 General Requirements. The selection of fire extinguishers for a given situation shall be determined by the applicable requirements of Sections 5.2 through 5.6 and the following factors:
(1) Type of fire most likely to occur
(2) Size of fire most likely to occur
(3) Hazards in the area where the fire is most likely to occur
(4) Energized electrical equipment in the vicinity of the fire
(5) Ambient temperature conditions
(6) Other factors (See Section H.2.)
5.2 Classifications of Fires. Fires shall be classified in accordance with the guidelines specified in 5.2.1 through 5.2.5.
5.2.1 Class A Fires. Class A fires are fires in ordinary combustible materials, such as wood, cloth, paper, rubber, and many plastics.
5.2.2 Class B Fires. Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases.
5.2.3 Class C Fires. Class C fires are fires that involve energized electrical equipment.
5.2.4 Class D Fires. Class D fires are fires in combustible metals, such as magnesium, titanium, zirconium, sodium, lithium, and potassium.
5.2.5 Class K Fires. Class K fires are fires in cooking appliances that involve combustible cooking media (vegetable or
animal oils and fats).

Findings:

On 5/14/19, during a facility tour with the Engineering Staff, the surveyor interviewed kitchen staff to determine their knowledge and usage of life safety equipment.
At 1:45 9 p.m., Kitchen Staff One was asked which extinguisher she would use in an electrical fire. She directed the surveyor to the A/K type fire extinguisher, and said it was a universal type. The surveyor observed that type to be suitable for a trash fire, wood and paper (A), and cooking media (K), but not electrical equipment (C). The surveyor requested the most recent kitchen staff inservice training on fire extinguishers and hospital staff produced documentation of a fire drill on 7/21/18. The documentation identified proper use of a fire extinguisher but it did not identify different types or which type to use for which fire.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by power strips that were interconnected, power strips that were electrically overloaded, power strips that did not meet UL (Underwriters Laboratories) requirements, and by the use of extension cords. This could result in electrical hazards and cause fire and injury to patients.

NFPA 99 - Health Care Facilities Code, 2012 Edition
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4)*The electrical and mechanical integrity of the assembly is regularly verified and documented.
10.2.4.2.1 All adapters shall be listed for the purpose.

Findings:

During a facility tour with th Engineering Staff from 5/13/19 to 5/15/19, the electrical equipment were observed.

1. On 5/13/19, at 3:08 p.m., in the Nurse Manager office, located on the fifth floor, 5100 unit of Tower 85, three electrical devices were connected to a six-outlet power strip. The power strip was then connected to a six-outlet wall adapter, which was connected to the duplex receptacle wall outlet. ES2 said he spoke to a staff member from that office, but she did not know anything about it.

2. On 5/13/19, at 3:24 p.m., in the Employee Lounge, located on the fifth floor, 5100 unit of Tower 85, a microwave oven, toaster, and Keurig coffeemaker were connected to a power strip, which was then connected to the duplex receptacle wall outlet. The ampere (unit measuring electric current flow drawn by equipment) of the microwave was 13.75 A (amperes or amps0], the toaster was 15.00 A, and the Keurig was 12.50 A. The devices totaled 41.25 A. The power strip was rated at 12 A. The maximum permissible is 9.00 A (12 x .75). The power strip was therefore overloaded by 32.25 A. ES2 said staff from Biomed or Engineering connected the appliances that way.

3. On 5/13/19, at 4:06 p.m., in the Team Health Medical office, located on the third floor of the "85" Tower, computers and computer equipment were connected to four APC non-UL power strips. ES2 said he was not sure who installed non-UL power strips, as those are not handed out, just hospital-grade ones.

4. On 5/13/19, at 4:08 p.m., also in the Team Health Medical office, an extension cord was connected between a microwave oven and a power strip. The power strip was connected to the duplex receptacle wall outlet.

Based on observation and interview, the facility failed to properly secure the medical gas cylinders. This was evidenced by the failure to secure the oxygen cylinders to prevent movement and tipping over caused by seismic activity. This could result in damage to the medical gas equipment during a disaster. This affected one floor in the Tower 2007.

NFPA 101, Life Safety Code, 2012 Edition

19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition

11.6 Operation and Management of Cylinders

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm- not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb.) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Findings:

During a tour of the facility and interview with the Engineering Staff from 5/13/19 through 5/15/19, the medical gas cylinder storage room was observed.

1. On 5/13/19 at 3:59 p.m., there were 60 oxygen "E" type cylinders stored in the medical gas storage room located in the first floor of Tower 2007. The cylinders were stacked horizontally on mobile carts. Each cart was equipped with wheels and two swinging doors. The cart doors were not in a closed position and the cylinders were not chained or secured to prevent them from falling off on the ground.
During a concurrent interview, the VP1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the zone valve boxes in the hyperbaric room. This was evidenced by the failure to maintain the oxygen panel visible and accessible at all times. This could result in a delay to shut off the oxygen source from the obstructed panel. This affected the one floor in the Tower 65.

NFPA 101, Life Safety Code, 2012 Edition

8.7.5* Hyperbaric Facilities. All occupancies containing hyperbaric facilities shall comply with NFPA 99, Health Care Facilities Code, Chapter 20, unless otherwise modified by other provisions of this Code.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition

14.2.1.4.4.1 Hyperbaric oxygen systems for acute and non-acute care connected directly to a hospital's oxygen system shall comply with Section 5.1, as applicable, except as noted in 14.2.1.4.4.2.

14.2.1.6 Hyperbaric Medical Air System Requirements.

14.2.1.6.1 Where medical air systems are installed for hyperbaric use, the hyperbaric area(s) or facility shall be treated as a separate zone.

14.2.1.6.2 Chapter 5 requirements shall apply to the medical air system for hyperbaric use, from the source of supply to the first in-line valve located downstream of the zone valve(s).

5.1.4*Valves

5.1.4.8.4 Zone valve boxes shall be installed where they are visible and accessible at all times.

Findings:

During a tour of the facility and interview with the Hospital Staff from 5/13/19 through 5/15/19, the hyperbaric oxygen system was observed.

On 5/14/19 at 11:39 a.m., the oxygen panel in the hyperbaric chamber room located in the first floor of Tower 65 was not visible. One of four hyperbaric chambers blocked the panel and there was a patient inside the chamber receiving treatment at the time of the survey. In addition, there was approximately 1-foot clearance between the panel and chamber. During a concurrent interview, the DC1 confirmed the finding and stated the hyperbaric room was equipped with two shutoff valves.