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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected 4 of 6 floors, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

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

1. On 5/23/11, at 2:53 p.m., there were three approximately 1/4 inch penetrations observed in the wall, next to an image plus screen, on the 5th floor of GI suite 2.
2. On 5/23/11, at 3:16 p.m., 1 of 2 escutcheon rings was not flushed against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, on the 4th floor in Room 406.
3. On 5/23/11, at 3:19 p.m., 1 of 1 escutcheon ring was shifted to one side. There was an approximately 1/8 inch penetration in the ceiling, on the 4th floor of the Linen closet 432.
4. On 5/23/11, at 3:30 p.m., 1 of 1 escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, on 2nd floor of EOC supplies/Oxygen supply 265.
5. On 5/24/11, at 9:11 a.m., there were two approximately 14 inch by 3 inch and a 12 inch by 12 inch cut out sheet rock in the wall and ceiling, in the Basement of IT support room.





29753

Findings:

1. On 5/23/11, at 2:50 p.m., the escutcheon plate on 1 of 4 sprinklers in the Operating Room (OR) Recovery Room on the fifth floor was not flush with the ceiling and exposed 3 half-inch penetrations in the Bed 1 area.

2. On 5/23/11, at 2:59 p.m., the sprinkler above the sterilizer in OR 1 on the fifth floor was not flush with the ceiling. There was an approximately 3 inch penetration.

3. On 5/23/11, at 3:14 p.m., the escutcheon plate in the staff locker room on the third floor was not flush with the ceiling. There was an approximately 3 inch penetration.

4. On 5/23/11, at 3:20 p.m., 1 of 2 escutcheon plates in Room 314 on the third floor was not flush with the ceiling and exposed an approximately 3 1/2 inch penetration.

5. On 5/23/11, at 3:25 p.m., there were 2 approximately 1/2 inch penetrations on the left wall behind the door of Room 341 on the third floor.

6. On 5/23/11, at 3:28 p.m., 1 of 3 escutcheon plates in Room 215 on the second floor was not flush with the ceiling and exposed an approximately 2 1/2 inch penetration.

7. On 5/24/11, at 9:11 a.m., there was no escutcheon plate on the sprinkler in the freezer in the basement kitchen. There was an approximately 3 inch penetration.

8. On 5/24/11, at 9:35 a.m., there was an approximately 3 inch penetration around the sprinkler pipe in the Social Services Office on the second floor.

Based on observation, the facility failed to maintain that corridors are able to resist the passage of smoke. This was evidenced by penetrations in the walls and ceilings. This affected 3 of 6 total floors and could result in the passage of smoke from one smoke compartment to the other.

Findings:

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

1. On 5/23/11, at 2:54 p.m., there were four approximately 1/4 inch penetrations in the right corridor wall, in the entrance to same day surgery room, on the 5th floor.
2. On 5/23/11, at 3:17 p.m., there was an approximately 1/4 inch penetration around a sink drain, in the nurse station corridor, on the 4th floor.
3. On 5/23/11, at 3:25 p.m., 1 of 3 escutcheon rings was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, by Room 332 corridor, on the 3rd floor.
4. On 5/25/11, at 10:41 a.m., 1 of 1 escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, by Room 307 corridor, on the 3rd floor.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed. This affected 2 of 6 floors, and could result in the inability to contain a fire to a room.

NFPA 80, 1999. Door opening and the surrounding area shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Findings:

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

1. On 5/23/11, at 2:59 p.m., the automatic roll down fire door in the same day surgery reception area was obstructed by a stack of scrap papers, on the 5th floor.
2. On 5/24/11, at 9 a.m., the automatic roll down fire door in the Business registration were obstructed by a signing pad and folders, on the 1st floor.

Based on observation, the facility failed to maintain their smoke barrier walls free from penetrations. This was evidenced by penetrations in several walls. This affected 3 of 6 total floors, and could result in the spread of fire and smoke to nearby smoke compartments.

NFPA 101, 8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube 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 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 of 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

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed.

1. On 5/25/11, at 10:46 a.m., there was an approximately 1/4 inch penetration on the top wall of a metal conduit, in the smoke barrier wall by Room 303, on the 3rd floor.
2. On 5/25/11, at 10:50 a.m., there were two approximately 1/4 inch penetrations around two metal conduits and 1/8 inch penetration around a metal conduit, in the smoke barrier wall by Room 302, on the 3rd floor.
3. On 5/25/11, at 11:07 a.m., there was an approximately 1/4 inch penetration around a 1/2 inch metal conduit pipe and a 1/8 inch penetration around a 2 inch pipe, in the smoke barrier wall, by the CT control 241, on the 2nd floor.
4. On 5/25/11, at 11:20 a.m., there were two approximately 1/8 inch penetration around a 1/2 inch conduit pipe and around a 3 inch drain line, in the smoke barrier wall by Cardiopulmomary unit waiting 151, on the 1st floor.

Based on observation and interview, the facility failed to provide emergency illumination. This was evidenced by a lack of battery-powered emergency lights in two operating rooms (OR). This affected 1 of 6 total floors, and could potentially result in a loss of normal and emergency lighting in the OR during surgical procedures if the generator fails to start.

NFPA 99 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 a tour of the facility with staff, the OR rooms were observed.
On 5/23/11, at 3:10 p.m., the facility failed to provide battery powered emergency lighting units in OR 1 and 2, on the 5th floor.

During an interview, at 3:15 p.m., the facility manager, head of OR nurse and chief engineer stated both OR rooms do not have a battery powered emergency lighting units.

Based on document review and interview, the facility failed to maintain its smoke detectors, as evidenced by the lack of approved smoke detector sensitivity tests conducted in compliance with NFPA 72, 1999 Edition. This affected 6 of 6 floors, and could result in smoke detector malfunction in the event of a fire.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a tour of the facility with staff, the smoke detector documentation was reviewed.

On 5/24/11, at 4:00 p.m., documentation revealed that a smoke detector sensitivity test was done in 2009, but not in accordance with NFPA 72, 1999 Edition. The Facilities Manager stated the contracted vendor "used magnets" instead of a method approved by NFPA 72, 1999 Edition.

Based on observation, the facility failed to maintain its automatic sprinkler system, as evidenced by debris on the sprinklers. This affected 5 of 6 floors, and could result in the sprinklers malfunctioning in the event of a fire.

Findings:

During a tour of the facility with staff, the sprinklers were observed.

1. On 5/23/11, at 2:51 p.m., there was debris on one of four sprinklers in the Fifth Floor OR Recovery Room.

2. On 5/23/11, at 2:58 p.m., there was debris on one of six sprinklers in the Fifth Floor OR to the left of the entrance door to the Recovery Room.

3. On 5/23/11, at 3:10 p.m., there was debris on one of three sprinklers, and paper towel wedged between the escutcheon plate and the ceiling on one of three sprinklers in Room 410.

4. On 5/23/11, at 3:19 p.m., there was debris on two of two sprinklers in Room 319.

5. On 5/24/11, at 9:05 a.m., there was debris on the sprinkler in Room 156.

6. On 5/24/11, at 9:10 a.m., there was debris on the sprinkler in the refrigerator in the kitchen.

7. On 5/24/11, at 9:15 a.m., there was debris on 11 of 13 sprinklers in the kitchen.




27994

NFPA 13, 1999. 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

Findings:

1. On 5/24/11, at 9:14 a.m., the facility spare sprinkler box that was located in the Basement did not contain a special spare sprinkler wrench.

Based on observation, the facility failed to maintain its fire extinguishers in accordance with NFPA 10, as evidenced by 2 of 23 fire extinguishers that were mounted higher than the regulated height, and by 1 of 23 fire extinguishers that was not mounted. This affected 3 of 6 floors, and could result in staff 's inability to readily access the fire extinguishers in the event of a fire, and by damage to the unsecured fire extinguisher.

NFPA 10, 1998 Edition

1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 ? ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

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

1. On 5/23/11, at 2:45 p.m., the portable fire extinguisher in the sixth floor Boiler Room was not mounted.

2. On 5/24/11, at 9:09 a.m., the K-type extinguisher in the basement kitchen, having a gross weight greater than 40 pounds, was mounted at approximately 63 inches above the floor.

3. On 5/24/11, at 2:55 p.m., the portable fire extinguisher in the first floor Lab was mounted at approximately 67 inches.



27994

NFPA 10, 1998. 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:

1. On 5/24/11, at 9:14 a.m., a recessed portable ABC fire extinguisher in the alcove area by Room 124 on the 1th floor, was missing an identification sign that indicated a portable fire extinguisher was available at the location.

Based on document review and interview, the facility failed to maintain its fire and smoke dampers, as evidenced by the lack of documentation stating that the failed fire and smoke dampers were repaired. This affected 2 of 6 floors, and could result in the spread of smoke and flames to other floors in the event of a fire.

Findings:

During a tour of the facility with staff, the fire and smoke damper documentation was reviewed.

On 5/24/11, at 4:00 p.m., a report titled "Coast Environmental Fire Damper Inspection" dated August 12, 2008, revealed that there were 6 failed dampers. The Facilities Manager stated the failed dampers were repaired, but could not produce documentation to prove the dampers were repaired.

Based on observation, the facility failed to provide proper storage for its medical gas in accordance with NFPA 99, as evidenced by the presence of an unsecured small-size oxygen tank in one of the rooms. This affected 1 of 6 floors, and could result in damage to the oxygen tank and subsequent explosion.

NFPA 99, 1999 Edition

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
25. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to therapy apparatus of sufficient size to render the entire assembly stable. Individual cylinder storage associated with patient care areas are not required to be stored in enclosures.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with staff, the medical gases and anesthetizing areas were observed.
On 5/23/11, at 3:40 p.m., there was a freestanding, unsecured oxygen tank in the second floor Treatment Center.

Based on observation and interview, the facility failed to maintain the emergency generator with all required components. The was evidenced by failing to provide an enunciator that provided an audible alarm for the generator. This affected 35 of 35 patients and could result in a delay in notification, in the event of an emergency.

NFPA 110, 3-5.6.1. A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 99 (1999 Edition) 3-4.1.1.15 Alarm Enunciator. A remote enunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The enunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source in operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110: 3-5.5.2)

Findings:

During a tour of the facility with staff, the generator was observed.

On 5/24/11, at 9:15 a.m., the diesel generator was located at the penthouse. The location of the generator was not continuously occupied and monitored by staff. The facility failed to provide an enunciator that provided an audible alarm for the emergency generator that is located at a work site readily observable by personnel if there was trouble with the generator.

During an interview, at 9:30 a.m., the facility manager stated he was never inform or heard of the installing a generator enunciator panel was require.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of an unapproved extension cord. This affected 1 of 6 floors, and could result in the increased risk of an electrical fire.

Findings:

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

1. On 5/23/11, at 3:31 p.m., a computer in the CT Control Room was plugged into a yellow extension cord.




27994

NFPA 70 National Electrical Code, 1999 Edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

Findings:

During the facility tour with staff, the electrical equipment and utilities were observed.
1. On 5/23/11, at 3:35 p.m., an electrical board panel was obstructed by a computer table within inches of the panel, on the 2nd floor of CT Control 241.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected 4 of 6 floors, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

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

1. On 5/23/11, at 2:53 p.m., there were three approximately 1/4 inch penetrations observed in the wall, next to an image plus screen, on the 5th floor of GI suite 2.
2. On 5/23/11, at 3:16 p.m., 1 of 2 escutcheon rings was not flushed against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, on the 4th floor in Room 406.
3. On 5/23/11, at 3:19 p.m., 1 of 1 escutcheon ring was shifted to one side. There was an approximately 1/8 inch penetration in the ceiling, on the 4th floor of the Linen closet 432.
4. On 5/23/11, at 3:30 p.m., 1 of 1 escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, on 2nd floor of EOC supplies/Oxygen supply 265.
5. On 5/24/11, at 9:11 a.m., there were two approximately 14 inch by 3 inch and a 12 inch by 12 inch cut out sheet rock in the wall and ceiling, in the Basement of IT support room.





29753

Findings:

1. On 5/23/11, at 2:50 p.m., the escutcheon plate on 1 of 4 sprinklers in the Operating Room (OR) Recovery Room on the fifth floor was not flush with the ceiling and exposed 3 half-inch penetrations in the Bed 1 area.

2. On 5/23/11, at 2:59 p.m., the sprinkler above the sterilizer in OR 1 on the fifth floor was not flush with the ceiling. There was an approximately 3 inch penetration.

3. On 5/23/11, at 3:14 p.m., the escutcheon plate in the staff locker room on the third floor was not flush with the ceiling. There was an approximately 3 inch penetration.

4. On 5/23/11, at 3:20 p.m., 1 of 2 escutcheon plates in Room 314 on the third floor was not flush with the ceiling and exposed an approximately 3 1/2 inch penetration.

5. On 5/23/11, at 3:25 p.m., there were 2 approximately 1/2 inch penetrations on the left wall behind the door of Room 341 on the third floor.

6. On 5/23/11, at 3:28 p.m., 1 of 3 escutcheon plates in Room 215 on the second floor was not flush with the ceiling and exposed an approximately 2 1/2 inch penetration.

7. On 5/24/11, at 9:11 a.m., there was no escutcheon plate on the sprinkler in the freezer in the basement kitchen. There was an approximately 3 inch penetration.

8. On 5/24/11, at 9:35 a.m., there was an approximately 3 inch penetration around the sprinkler pipe in the Social Services Office on the second floor.

Based on observation, the facility failed to maintain that corridors are able to resist the passage of smoke. This was evidenced by penetrations in the walls and ceilings. This affected 3 of 6 total floors and could result in the passage of smoke from one smoke compartment to the other.

Findings:

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

1. On 5/23/11, at 2:54 p.m., there were four approximately 1/4 inch penetrations in the right corridor wall, in the entrance to same day surgery room, on the 5th floor.
2. On 5/23/11, at 3:17 p.m., there was an approximately 1/4 inch penetration around a sink drain, in the nurse station corridor, on the 4th floor.
3. On 5/23/11, at 3:25 p.m., 1 of 3 escutcheon rings was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, by Room 332 corridor, on the 3rd floor.
4. On 5/25/11, at 10:41 a.m., 1 of 1 escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling, by Room 307 corridor, on the 3rd floor.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed. This affected 2 of 6 floors, and could result in the inability to contain a fire to a room.

NFPA 80, 1999. Door opening and the surrounding area shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Findings:

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

1. On 5/23/11, at 2:59 p.m., the automatic roll down fire door in the same day surgery reception area was obstructed by a stack of scrap papers, on the 5th floor.
2. On 5/24/11, at 9 a.m., the automatic roll down fire door in the Business registration were obstructed by a signing pad and folders, on the 1st floor.

Based on observation, the facility failed to maintain their smoke barrier walls free from penetrations. This was evidenced by penetrations in several walls. This affected 3 of 6 total floors, and could result in the spread of fire and smoke to nearby smoke compartments.

NFPA 101, 8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube 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 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 of 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

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed.

1. On 5/25/11, at 10:46 a.m., there was an approximately 1/4 inch penetration on the top wall of a metal conduit, in the smoke barrier wall by Room 303, on the 3rd floor.
2. On 5/25/11, at 10:50 a.m., there were two approximately 1/4 inch penetrations around two metal conduits and 1/8 inch penetration around a metal conduit, in the smoke barrier wall by Room 302, on the 3rd floor.
3. On 5/25/11, at 11:07 a.m., there was an approximately 1/4 inch penetration around a 1/2 inch metal conduit pipe and a 1/8 inch penetration around a 2 inch pipe, in the smoke barrier wall, by the CT control 241, on the 2nd floor.
4. On 5/25/11, at 11:20 a.m., there were two approximately 1/8 inch penetration around a 1/2 inch conduit pipe and around a 3 inch drain line, in the smoke barrier wall by Cardiopulmomary unit waiting 151, on the 1st floor.

Based on observation and interview, the facility failed to provide emergency illumination. This was evidenced by a lack of battery-powered emergency lights in two operating rooms (OR). This affected 1 of 6 total floors, and could potentially result in a loss of normal and emergency lighting in the OR during surgical procedures if the generator fails to start.

NFPA 99 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 a tour of the facility with staff, the OR rooms were observed.
On 5/23/11, at 3:10 p.m., the facility failed to provide battery powered emergency lighting units in OR 1 and 2, on the 5th floor.

During an interview, at 3:15 p.m., the facility manager, head of OR nurse and chief engineer stated both OR rooms do not have a battery powered emergency lighting units.

Based on document review and interview, the facility failed to maintain its smoke detectors, as evidenced by the lack of approved smoke detector sensitivity tests conducted in compliance with NFPA 72, 1999 Edition. This affected 6 of 6 floors, and could result in smoke detector malfunction in the event of a fire.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a tour of the facility with staff, the smoke detector documentation was reviewed.

On 5/24/11, at 4:00 p.m., documentation revealed that a smoke detector sensitivity test was done in 2009, but not in accordance with NFPA 72, 1999 Edition. The Facilities Manager stated the contracted vendor "used magnets" instead of a method approved by NFPA 72, 1999 Edition.

Based on observation, the facility failed to maintain its automatic sprinkler system, as evidenced by debris on the sprinklers. This affected 5 of 6 floors, and could result in the sprinklers malfunctioning in the event of a fire.

Findings:

During a tour of the facility with staff, the sprinklers were observed.

1. On 5/23/11, at 2:51 p.m., there was debris on one of four sprinklers in the Fifth Floor OR Recovery Room.

2. On 5/23/11, at 2:58 p.m., there was debris on one of six sprinklers in the Fifth Floor OR to the left of the entrance door to the Recovery Room.

3. On 5/23/11, at 3:10 p.m., there was debris on one of three sprinklers, and paper towel wedged between the escutcheon plate and the ceiling on one of three sprinklers in Room 410.

4. On 5/23/11, at 3:19 p.m., there was debris on two of two sprinklers in Room 319.

5. On 5/24/11, at 9:05 a.m., there was debris on the sprinkler in Room 156.

6. On 5/24/11, at 9:10 a.m., there was debris on the sprinkler in the refrigerator in the kitchen.

7. On 5/24/11, at 9:15 a.m., there was debris on 11 of 13 sprinklers in the kitchen.




27994

NFPA 13, 1999. 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

Findings:

1. On 5/24/11, at 9:14 a.m., the facility spare sprinkler box that was located in the Basement did not contain a special spare sprinkler wrench.

Based on observation, the facility failed to maintain its fire extinguishers in accordance with NFPA 10, as evidenced by 2 of 23 fire extinguishers that were mounted higher than the regulated height, and by 1 of 23 fire extinguishers that was not mounted. This affected 3 of 6 floors, and could result in staff 's inability to readily access the fire extinguishers in the event of a fire, and by damage to the unsecured fire extinguisher.

NFPA 10, 1998 Edition

1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 ? ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

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

1. On 5/23/11, at 2:45 p.m., the portable fire extinguisher in the sixth floor Boiler Room was not mounted.

2. On 5/24/11, at 9:09 a.m., the K-type extinguisher in the basement kitchen, having a gross weight greater than 40 pounds, was mounted at approximately 63 inches above the floor.

3. On 5/24/11, at 2:55 p.m., the portable fire extinguisher in the first floor Lab was mounted at approximately 67 inches.



27994

NFPA 10, 1998. 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:

1. On 5/24/11, at 9:14 a.m., a recessed portable ABC fire extinguisher in the alcove area by Room 124 on the 1th floor, was missing an identification sign that indicated a portable fire extinguisher was available at the location.

Based on document review and interview, the facility failed to maintain its fire and smoke dampers, as evidenced by the lack of documentation stating that the failed fire and smoke dampers were repaired. This affected 2 of 6 floors, and could result in the spread of smoke and flames to other floors in the event of a fire.

Findings:

During a tour of the facility with staff, the fire and smoke damper documentation was reviewed.

On 5/24/11, at 4:00 p.m., a report titled "Coast Environmental Fire Damper Inspection" dated August 12, 2008, revealed that there were 6 failed dampers. The Facilities Manager stated the failed dampers were repaired, but could not produce documentation to prove the dampers were repaired.

Based on observation, the facility failed to provide proper storage for its medical gas in accordance with NFPA 99, as evidenced by the presence of an unsecured small-size oxygen tank in one of the rooms. This affected 1 of 6 floors, and could result in damage to the oxygen tank and subsequent explosion.

NFPA 99, 1999 Edition

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
25. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to therapy apparatus of sufficient size to render the entire assembly stable. Individual cylinder storage associated with patient care areas are not required to be stored in enclosures.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with staff, the medical gases and anesthetizing areas were observed.
On 5/23/11, at 3:40 p.m., there was a freestanding, unsecured oxygen tank in the second floor Treatment Center.

Based on observation and interview, the facility failed to maintain the emergency generator with all required components. The was evidenced by failing to provide an enunciator that provided an audible alarm for the generator. This affected 35 of 35 patients and could result in a delay in notification, in the event of an emergency.

NFPA 110, 3-5.6.1. A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 99 (1999 Edition) 3-4.1.1.15 Alarm Enunciator. A remote enunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The enunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source in operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110: 3-5.5.2)

Findings:

During a tour of the facility with staff, the generator was observed.

On 5/24/11, at 9:15 a.m., the diesel generator was located at the penthouse. The location of the generator was not continuously occupied and monitored by staff. The facility failed to provide an enunciator that provided an audible alarm for the emergency generator that is located at a work site readily observable by personnel if there was trouble with the generator.

During an interview, at 9:30 a.m., the facility manager stated he was never inform or heard of the installing a generator enunciator panel was require.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of an unapproved extension cord. This affected 1 of 6 floors, and could result in the increased risk of an electrical fire.

Findings:

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

1. On 5/23/11, at 3:31 p.m., a computer in the CT Control Room was plugged into a yellow extension cord.




27994

NFPA 70 National Electrical Code, 1999 Edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

Findings:

During the facility tour with staff, the electrical equipment and utilities were observed.
1. On 5/23/11, at 3:35 p.m., an electrical board panel was obstructed by a computer table within inches of the panel, on the 2nd floor of CT Control 241.