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Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program for the preventative maintenance services for the Automatic Transfer Switch B, to ensure that services are furnished annually per the manufacturers' recommendations for the Automatic Transfer Switch B.

Failure to develop a comprehensive program that identifies opportunities for improvement may result in compromised patient outcomes in relationship to life safety equipment.

Findings:

During an interview, on 1/15/16 at 9:30 a.m., Administrative Staff B and Administrative Staff C stated the TMS equipment inventory maintenance service software did not provide the hospital with an automatic reminder for the recommended annual preventative maintenance for the Automatic Transfer Switch B, installed in 1992. Administrative Staff B and Administrative Staff C stated plant maintenance staff rely on the white board in the department to remind staff to contact the vendor to provide the annual recommended preventative maintenance for the Automatic Transfer Switch B. Administrative Staff B and Administrative Staff C stated the maintenance schedule for the Automatic Transfer Switch B was monitored through the Property, Utilities, Fire and Life Safety Subcommittee (PUFS). Administrative Staff B and Administrative Staff C stated the PUFS committee reported to the Safety Committee. Administrative Staff B and Administrative Staff C stated the hospital did not have a current contract with the vendor to provide the annual recommended preventative maintenance to the Automatic Transfer Switch B. Administrative Staff B and Administrative Staff C stated prior to June 2015 the manufacturer had not been contacted and had not completed the recommended preventative maintenance.

During an administrative record review of the Safety Committee and the Property, Utilities, Fire and Life Safety Subcommittee meeting minutes for 2015, the minutes did not specifically identify the Automatic Transfer Switch B requiring preventive maintenance from 1992 through June 2015.

During an interview, on 12/30/15 at 10:45 a.m., Administrative Staff B and Administrative Staff C stated the hospital did not have a report summarizing the quality and performance of the hospital's TMS equipment inventory and maintenance services performed or required maintenance due.

Based on observations, interviews and document reviews, the hospital failed to ensure staff was trained in the use of the "supersled" for transporting patients out of the multi-level hospital in the event of a real-world emergency evacuation. A "supersled" is a vertical evacuation device hospital staff would use to safely and quickly evacuate non-ambulatory patients down flights of stairs. This lack of preparedness had the potential the most fragile patients would not be able to be removed from a dangerous situation.

Findings:

The hospital's multi-levels included the second floor- Labor and Delivery, Mother and Baby, a Neonatal Intensive Care Unit (NICU-specializing in the care of ill or premature newborn infants), and the third floor- Critical Services (Seriously ill patients are cared for by specially trained staff). Review of the document titled, "A learning module in Supersled-Vertical Evacuation Device" documented the "supersleds" were housed in four locations, two on each floor- the second floor Utility Closet 2181A and 2192A and the third floor Utility Closet 3181A and 3180A.

During an Observational Tour and concurrent interviews of the "Mother and Baby" Unit, on 1/13/16 at 9 a.m., Unlicensed Nurse K was asked, in the event of an emergency, where would she find the equipment to evacuate a patient down the stairwell if the elevator was inoperable. Unlicensed Nurse K walked to the elevator to the location she believed contained the "supersleds." Unlicensed Nurse K stated she thought the "supersleds" were right across from the elevator.

During the same observational tour Licensed Nurse L was asked the same question. Licensed Nurse L did not go directly to the locked Utility Closet (2181A- Emergency Patient Evacuation Equipment) along the main hallway that housed the "supersleds". When queried which individual(s) were responsible for the keys to access the closet housing the "supersleds" Licensed Nurse L stated she was unsure who was responsible.

During an observation, with concurrent interviews, of the Critical Care Services on 1/14/16 at 2 p.m., Licensed Nurse M was asked in the event of an emergency where she would find the equipment to evacuate a patient down the (third floor) stairwell if the elevator was inoperable. Licensed Nurse M walked to the first room in the main hallway where she did not locate the "supersleds". When asked who was responsible for the key, staff stated, "the Lead." Licensed Nurse N, when aware of the request to obtain the "supersled" retrieved a set of keys from a drawer in the Critical Care Services and went to the elevator. When unable to locate the closet housing the "supersleds", hospital administrative staff assisted Licensed Staff M and Licensed Nurse N in locating the "supersled(s)". The set of keys initially retrieved from the Critical Care Services did not open the third floor Utility Closet labeled 3181A- Emergency Patient Evacuation Equipment. The second set of keys retrieved from the Critical Care Services for 3181A made the "supersleds" available.

During an interview, on 1/14/16 at 1:40 p.m., Administrative Staff A and O provided documents and indicated "all" staff were trained by reviewing the module titled, "Supersled-Vertical Evacuation Device." Administrative Staff A and O corroborated the training received was the one-time training module and a return demonstration was not completed by staff to ensure staff's ability to implement proper care and protection for patients, guests, and staff. Administrative Staff A stated there was not a policy and procedure or guidelines written addressing the "supersleds".

K3 BUILDING: 01- Hospital
K6 PLAN APPROVAL: 1975 & 1992
K7 SURVEY UNDER: 2000 EXISTING

STRUCTURE TYPE: TYPE V (000) (ONE STORY BUILDING) &
TYPE II (222) (THREE STORY BUILDING) CONSTRUCTIONS,
FULLY SPRINKLERED

The following reflects the findings of the California Department of Public Health, during a Complaint Validation Life Safety Code Survey, using the NFPA 101, 2000 edition (existing) of the Life Safety Code for Health Care Facilities and in accordance with 42 CFR 482.41(b)(1) for General Acute Care Hospitals.

Representing the California Department of Public Health:
27994
31203

Census: 104

The facility elected to utilize the Categorical Waiver allowing for the use of Clean Waste and Patient Record Recycling Containers up to 96 gallons in size and will conform to the applicable provisions of the NFPA 101 2012 Edition Section 18/19.7.5.7.2 of the Life Safety Code as permitted by Centers for Medicare & Medicaid Services (CMS) Survey & Certification (S&C) Letter 13-58-LSC, dated 8-30-13

The facility elected to utilize the Categorical Waiver which allows increasing the amount of wall space covered by combustible decorations and will conform to the applicable provisions of the NFPA 101 2012 Edition Section 18/19.7.5.6 of the Life Safety Code as permitted by Centers for Medicare & Medicaid (CMS) Services Survey & Certification (S&C) Letter 12-21-LSC, dated 3-9-12.

The facility elected to utilize the Categorical Waiver option allowing a centralized computer system to substitute one of the Category 1 medical gas master alarms, in accordance with all applicable 1999 NFPA medical gas master alarm provisions and with section 5.1.9.4 of the 2012 NFPA 99, as permitted by the Centers for Medicare & Medicaid Services (CMS) Survey & Certification Letter S&C: 13-58-LSC, dated 8-30-13.

The facility elected to utilize the Categorical Waiver allowing hospitals with new and existing ventilation systems supplying anesthetizing locations, as defined by the 1999 edition of NFPA 99, to operate with a RH level of =20 percent and will conform to the applicable provisions of the ASHRAE Standard 170, 2008 edition Addendum D, NFPA 99 2012 edition, and 1999 edition of NFPA 99, as permitted by Centers for Medicare & Medicaid Services (CMS) Survey & Certification (S&C) Letter 13-25-LSC, dated 4-19-13.

The facility elected to utilize the Categorical Waiver allowing previously restricted items to be placed in the corridor and will conform to the applicable provisions of the NFPA 101 2012 Edition Section 18/19.2.3 and 18/19.2.3.4 of the Life Safety Code as permitted by Centers for Medicare & Medicaid Services (CMS) Survey & Certification (S&C) Letter 12-21-LSC, dated 3-9-12.

The facility elected to utilize the Categorical Waiver option allowing one of the required means of egress from a suite to be through another suite, one of the two required exit access doors from a suite to be into an exit stair, passageway, or exterior door, and an increase in sleeping room suite size up to 10,000 square feet in accordance with all applicable 2000 LSC suite provisions and with sections 18/19.2.5.7 of the 2012 LSC, as permitted by the Centers for Medicare & Medicaid Services (CMS) Survey & Certification Letter S&C: 13-58-LSC, dated 8-30-13.

The facility elected to utilize the Categorical Waiver option allowing a reduction in frequency of testing requirements for vane-type and pressure switch type waterflow alarm devices and electric motor-driven pump assemblies in accordance with all applicable 1998 NFPA 25 testing provisions (as referenced in section 9.7.5 of the 2000 LSC) and with sections 5.3 and 8.3 of the 2011 NFPA 25, as permitted by the Centers for Medicare & Medicaid Services (CMS) Survey & Certification Letter S&C: 13-58-LSC, dated 8-30-13.


K12
Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in walls and ceilings. This affected two of three floors and could result in the passage of smoke and/or fire to other areas.

8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as
follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with Administrative Staff B, the walls and ceilings were observed.

THIRD FLOOR
1. On 1/13/16 at 8:47 a.m., there was an approximately three inch by two inch unsealed penetration with wires traveling through it in the ceiling in Room 3180A. This finding was confirmed by Administrative Staff B.
2. On 1/13/16 at 9:36 a.m., there were four approximately ¼ inch diameter unsealed penetrations in the wall in Room 3164. This finding was confirmed by Administrative Staff B.

FIRST FLOOR
3. On 1/13/16 at 3:11 p.m., there was an approximately ½ inch wide by one inch long penetration near the side of the escutcheon ring in the UPS Room located in the Radiology Department. This finding was confirmed by Administrative Staff B.
4. On 1/13/16 at 3:13 p.m., there was an approximately ½ inch diameter unsealed penetration with data wires traveling through it the ceiling in the CT Control Room located in the Radiology Department. This finding was confirmed by Administrative Staff B.

K18
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by doors that failed to latch and by doors that were held open by rubber wedges and kick down type door stops. This affected two of three floors and could result in the passage smoke and/or fire.

Findings:

During a tour of the facility with Administrative Staff B, Administrative Staff J, and Licensed Staff H, the corridor doors were observed.

THIRD FLOOR
1. On 1/13/16 at 8:48 a.m., the door to Room 3180A was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested two times and failed to latch each time. This finding was confirmed by Administrative Staff B.

2. On 1/13/16 at 9:10 a.m., the door to Room 3131 was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested two times and failed to latch each time. This finding was confirmed by Administrative Staff B.

3. On 1/13/16 at 9:15 a.m., the door to Room 3132 was equipped with a self-closing device and was held open by a rubber wedge. This finding was confirmed by Administrative Staff B.

4. On 1/13/16 at 9:42 a.m., the door to Room 3198 was equipped with a self-closing device and was held open by a rubber wedge. The room was left unattended. This finding was confirmed by Administrative Staff B.

FIRST FLOOR
5. On 1/13/16 at 11:06 a.m., two doors in the Cardio Rehab, Room 1815C and Room 1815E, were equipped with self-closing devices that were held open by kick down door stops. This finding was confirmed by Administrative Staff B.

6. On 1/13/16 at 11:31 a.m., the door to the Doctor's office in the Emergency Department was equipped with a self-closing device and was held open by a rubber wedge. This finding was confirmed by Licensed Staff H and Administrative Staff B.

7. On 1/13/16 at 1:39 p.m., the door to the Electrical Room located in the Pharmacy Department was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested three times and failed each time. This finding was confirmed by Administrative Staff B.

8. On 1/13/16 at 3:36 p.m., the self-closing door to the Lab Supervisor's Office failed to latch.

9. On 1/14/16 at 2:04 p.m., the door to Form Storage near Room 1626 located in the Same Day Surgery Department, was equipped with a self-closing device that was missing the arm hinge. This made the self-closing device inoperable. This finding was confirmed by Administrative Staff J.

K20
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6. 19.3.1.1.

Based on observation and interview, the facility failed to maintain a vertical opening as evidenced by an unsealed penetration in a wall. This affected one of three floors and could result in the passage smoke and/or fire.

Findings:

During a tour of the facility with Administrative Staff B, the vertical openings were observed.

THIRD FLOOR
On 1/13/16 at 9:19 a.m., the shaft for hot water on the third floor located in Room 3188, had an approximately two inch diameter penetration in the wall. When asked, Administrative Staff B stated that the shaft was a two-hour fire rated wall and confirmed the finding.

K27
Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7

Based on observation and interview, the facility failed to maintain the fire rated doors as evidenced by fire rated doors that failed to fully close and latch and doors that failed to release from their magnetic hold-open devices. This affected one of three floors, and could result in the spread of smoke and or fire.


NFPA 101, Life Safety Code, 2000 edition
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a tour of the facility with Administrative Staff B, the facility's fire doors were observed.

THIRD FLOOR
1. On 1/13/16 at 2:14 p.m., a 20 minute fire-rated door between ICU A and B failed to close upon activation of the fire alarm system. The double fire doors released from the magnetic device and the right door closed, but the left door remained open. Upon interview, Administrative Staff B stated that the closing device might just need adjusting and confirmed the finding.

2. On 1/13/16 at 2:23 p.m., the 20 minute fire-rated doors to the Family Lounge Room 3191 on the third floor were held open by a magnetic hold-open device. When the fire alarm system was activated, the left leaf door failed to latch.

3. On 1/13/16 at 2:24 p.m., the 20 minute fire-rated doors on the third floor were held open by magnetic hold-open devices. When the fire alarm system was activated, the left leaf door failed to release near Room 3191 Family Lounge and the Elevator.

K46
Emergency lighting of at least 1 1/2 hour duration is provided automatically in accordance with 7.9., 18.2.9.1, 19.2.9.1.

Based on observation, document review, and interview, the facility failed to maintain and provide emergency lights in its anesthetizing locations. This was evidenced by failure to provide a battery-powered emergency light in one procedure room and by the failure to document testing for the emergency lights. This affected two of three floors, and could result in a loss of lighting during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer if the generator fails to start).

NFPA 101, 2000 edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
19.2.9 Emergency Lighting
Emergency lighting shall be provided in accordance with section 7.9
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. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 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.

NFPA 99, 1999 edition
3-3.2.1.2, All Patient Care Areas. (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)

Findings:

During tour, document review, and interview with the Administrative Staff, Chief of Engineering (COE), and Engineering Staff, the emergency lights were observed and documents were reviewed.

1. On 1/13/16 at 3 p.m., there was no emergency light provided in the Procedure Room 1 in the Cath Lab. During an interview at 3:10 p.m., Engineering Staff 1 stated he was not sure if Procedure Room 1 had battery back-up emergency lights. During an interview on 1/14/16 at 10:30 a.m., Administrative Staff B confirmed that there was no battery-powered emergency lighting in the Procedure Room 1 in Cath Lab.

2. On 1/15/16 at 9:20 a.m., there were back-up emergency lighting units in L&D OR 1 and 2, and Cath Lab Procedure Room 2. A review of the preventive maintenance (PM) log failed to indicate that any monthly or annual testing was performed in the L&D and Cath Lab. During an interview at 9:35 a.m., the COE stated that engineering does test the emergency lighting units in L&D and the Cath Lab, but that it was not documented in the PM log.

K47
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1, 19.2.10.1
(Indicate N/A in one story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Based on observation, document review, and interview, the facility failed to maintain its exit signs. This was evidenced by failure to test exit signs for 90 minutes annually. This affected one of three floors, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000 edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
NFPA 101, 7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
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 1 1/2 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.

Findings:

During tour, document review, and interview with the COE, the exit signs were observed and documents were reviewed.

On 1/15/16 at 10 a.m., the facility was observed with exit signs that were equipped with a test button. A review of the PM log for the exit signs failed to indicate that any annual testing was performed. During an interview at 10:30 a.m., the COE stated that the exit signs were on generator power. During an interview on 1/19/15 at 9:12 a.m., the COE stated that they were aware that there were exit signs with battery back-up in the Cath Lab, Laboratory, Pharmacy, and Emergency Department. The COE further stated that the exit signs were tested at the time same as the monthly generator run, but that there was no annual PM log for the testing.

K50
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms.
18.7.1.2, 19.7.1.2

Based on document review and interview, the facility failed to ensure that all staff were familiar with procedures during fire drills. This was evidenced by the failure to document which staff participated during each fire drill. This affected three of three floors, and could potentially result in some staff being untrained and unable to respond quickly in the event of an emergency.

NFPA 101, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.2.3 All health care occupancy personnel shall be
instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:
During document review and interview with Administrative Staff, the fire drill records were reviewed.
On 1/15/16 at 10 a.m., the facility performed fire drills by sending out training scenarios to all hospital management teams. During the fire drills, the different departments would fill out the "Fire Drill/Incident Observation Report". On the report, there were nine questions that needed to be completed. The report did not indicate which staff had participated or if all staff were instructed on the fire procedures. During an interview at 10:15 a.m., Administrative Staff B confirmed that the report did not indicate which Staff had participated and trained on the fire procedure.


K51
A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system is by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas may be omitted provided that manual pull stations are within 200 feet of nurse's stations. Pull stations are located in the path of egress. Electronic or written records of tests are available. A reliable second source of power is provided. Fire alarm systems are maintained in accordance with NFPA 72 and records of maintenance are kept readily available. There is remote annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6


Based on observation, the facility failed to maintain the manual fire alarm system as evidenced by a manual pull station that was obstructed from access. This affected one of three floors and could result in a delay in access to the manual pull station and a delay in alarm activation in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
9.6.2 Signal Initiation.
9.6.2.6* Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Findings:

During a tour of the facility with Administrative Staff B and Licensed Staff H, the fire alarm manual pull stations were observed.

FIRST FLOOR
On 1/13/16 at 11:59 a.m., the access to the manual pull station near Room 1159 in the Emergency Department was obstructed by an EKG machine that was parked directly in front of it. Licensed Staff H moved the EKG machine and confirmed the finding.


K54
All required smoke detectors, including those activating door hold open devices, are approved, maintained, inspected and tested in accordance with the manufacturer's specifications. 9.6.1.3

Based on observation and interview, the facility failed to maintain its smoke detectors. This was evidenced by a smoke detector that was covered with masking tape. This affected one of three floors and could result in a delay in notification in the event of a fire.


Findings:

During observation and interview with Administrative Staff J and Engineering Staff 2, the smoke detectors were observed.

FIRST FLOOR
On 1/14/16 at 10:02 a.m., the smoke detector in the Nitrogen/Med Gas Room (Room 106) near Central Supply was covered with blue masking tape. Upon interview, Engineer Staff 2 stated, that they were unsure why it was covered with masking tape. This finding was confirmed by Administrative Staff J and Engineering Staff 2.

K62
Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5


Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by failure to maintain the minimum clearance between the deflector and the top of storage of 18 inches or greater, by an escutcheon ring that was not flush with ceiling, by an inspector test valve that did not have an identification sign, by a sprinkler that was missing an escutcheon ring, and by a post indicator valve that was missing a protective window. This could lead to the sprinklers malfunctioning in the event of a fire, and affected three of three floors.


NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 13, Installation of Sprinkler System, 1999 Edition
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm)
between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 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.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.
2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

Findings:

During a tour of the facility with Administrative Staff B, the sprinklers were observed.


SECOND FLOOR
1. On 1/13/16 at 10:04 a.m., the sprinkler across from Bed A in Room 2101 had approximately seven inches of clearance between the deflector and two paper bags on top of the shelf. This finding was confirmed by Administrative Staff B.

FIRST FLOOR
2. On 1/13/16 at 11:03 a.m., the sprinkler in Room 1815D located in the Cardio Rehab had approximately twelve inches of clearance between the deflector and cardboard boxes on top of the shelf. This finding was confirmed by Administrative Staff B.

3. On 1/13/16 at 2:59 p.m., one of eight sprinklers was missing an escutcheon ring, in Cath Lab Procedure Room 1.

4. On 1/13/16 at 3:41 p.m., a post indicator valve was missing a protective glass window at the Fire Island area.

THIRD FLOOR
5. On 1/13/16 at 2:04 p.m., the northwest stairway inspector test (ITV) valve on the third floor was missing an identification sign to indicate that valve was the ITV.

K64
Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by a fire extinguisher that was obstructed from access. This could result in a delay in access to the portable fire extinguishers in the event of a fire and affected one of three floors.

NFPA 101, Life Safety Code, 2000 Edition
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 installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers,1998 Edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with Administrative Staff B, the Fire Extinguishers were observed.

THIRD FLOOR
On 1/13/16 at 8:51 a.m., the access to the fire extinguisher near Room 3190 was obstructed by a wheelchair that was parked directly in front of it. Administrative Staff B moved the wheelchair in order to access the inspection tag on the fire extinguisher. This finding was confirmed by Administrative Staff B.

FIRST FLOOR
On 1/13/16 at 3:39 p.m., the door to the recessed cabinet fire extinguisher in the Lab Break Room was obstructed by a trash bin that prevented the door from swinging open all the way.

K70
Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F (100 degrees C). 18.7.8, 19.7.8

Based on observation, document review, and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by the failure to follow the manufacturer's instructions and insure that the heaters met the temperature requirements. This affected one of three floors in the hospital, and could result in the ignition of fire.

NFPA 101, 2000 edition
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1 9.1.2. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 70, 1999 edition
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

NFPA 99, 1999 edition
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by who ' s labeling the manufacturer indicates compliance with appropriate standards or per