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Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the First floor main phone room has six pipe chases that were not fire resistant and penetrated the corridor walls.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the following corridor doors:

Tower forth floor

1. Door 4-434, staff lounge, rated door closing device removed
2. Door 4-432, Cardiothoracic surgery services, rated door closing device removed
3. Door 4-423, rated door closing device removed
4. Nurse Manager, rated door with a hold open device, door closing device disconnected
5. Room 449 Nurse Sub station, rated door closing device removed
6. Door 4-423, Cardiac rehab and chest pain coordinator, door closing device removed

Tower third floor

1. Door 3-335, office rated door closing device removed

Tower second floor

1. MSICA Room 20, rated door with a closing device, held open with a an impediment

First floor, EMS, rated door closing device removed

OR

1. OR staff lounge, rated door closing device removed

Women's Center

1. OR one, door latch broken, taped open and will not positively latch

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas. And failed to keep the laundry room dryer clean

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors. Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "


Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager ,observed the dryer in the EVS laundry room had an excessive amount of lint in the dryer drum assemblies, to include complete coverage of the wiring harness, coverage of lint was approximately one half to six inches deep. Observation of the following doors in hazardous areas are;


Tower forth floor

1. Bio-Med work shop, rated 1-1/2 hr. door, closing device removed
2. Room 404, converted to a storage room, door does not have a closing device
3. Door 4-05, Pharmacy, rated door closing device removed

Tower third floor

1. Door 3-326 Pharmacy office, rated 1-1/2 hr. door, closing device removed

Tower second floor

1. Door 2-234, Nurse sub station charting and medication, 1 hr. rated door, closing device removed
2. Room 222, converted to a storage room, door does not have a closing device

Tower first floor

1. Medical records, storage room measuring 72 sq. ft. does not have a door closing device

OR

1. Janitors closet across from room 8, door closing device removed
2. Anesthesia, rated door on a closing device removed

Radiology

1. Xray # 5, door on a closing device will not positively latch when tested

Women's Center

1. Admin Ast. room, rated 1-1/2 hr. door, closing device removed

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.
Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.2.8 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the exit discharge lighting from the Women's Center north east exit was illuminated by a single-bulb light fixture. All designated exits shall have two bulb fixtures.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.

In an emergency the failure of the one bulb will result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing. And failed to maintain the sprinkler heads from obstructions

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "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 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."


Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager, observations include the following findings:

Tower forth floor

1. Room 485, 2 of 4 sprinklers, paint escutcheon plate gap greater than 1 inch
2. Room 486. 1 of 3 sprinklers lint
3. Room 431, 1 sprinkler lint
4. Room 434, 1 of 2 sprinklers gap greater than 1 inch in the escutcheon plate
5. North nurse station, 2 of 2 sprinklers lint and paint
6. Nurse manager room, 2 of 2 escutcheon Plates missing

Tower third floor

1. Staff locker, 1 of 2 sprinklers lint

Tower second floor

Ortho nurse station, 3 of 4 sprinklers lint

First floor

1. Storage, across from plant op's, escutcheon plate gap greater than 1//8 inch, obstructions within 18" of sprinkler heads

OR

1. Central sterilization, 4 of 11 sprinklers paint/lint gap greater than 1/8 inch, escutcheon plate

MED-oncology

West sub Nursing station, 1 or 3 sprinklers lint

Kitchen

1. Walk in freezer 2 of 2 sprinkler escutcheon plates missing


During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.



Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients. Obstructions within 18 inches of the sprinklers head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on Observation the facility failed to provide self-closing metal containers in all designated smoking areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.4 "Smoking regulations shall be adopted and shall include not less than the following provisions:
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager ,observations include the following designated smoking areas. None of the smoking areas had self-closing metal containers, which ashtrays can be emptied.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failure to provide metal containers for the disposal of cigarette butts could result in a fire which could cause harm to patients.

Based on observation the facility failed to mount an electrical light switch's and 110 electrical outlets five feet above the floor in the oxygen storage rooms. And failed to separate 5 ft. from combustibles.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed wall mounted electric light switch's/and 110 electrical outlets in the oxygen storage rooms. The electrical switch's were less than 5 ft. from stored oxygen to include combustible materials less than 5 ft. in the following locations:

Tower forth floor

1. Clean utility, 3 E O2 bottles
2. 4 E clean utility, 7 E O2 bottles
3. Room 404, 3 E O2 bottles

Tower second floor

1. Room 222 , 2 E O2 bottles

Tower third floor

1. C-Arm storage room, 1 E O2 bottle
2. Room 314, 1 E O2 bottle
3. Clean utility, 4 E O2 bottles
4. Door 4-412, 11 E O2 bottles

ED Medical gases

1. 15 E O2 bottles
2. Equipment storage, 3 E O2 bottles

Cardiac Cath Lab

1. 3 E O2 bottles, to include 7 unsecured compressed medical gases

Women's Center

1. Storage room, 4 E O2 bottles and 1 medical air not secured

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to mount a light switch/ electrical outlet five feet above the floor and separate combustibles 5 ft to prevent an accident/or possible fire could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, the facility failed to provide receptacle face plates, and facility failed to provide protection from electrical shock at the electrical panel..


NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters ,Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface." NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the electrical panels, missing blanks,refrigerator plugged into power strip, missing J-box cover and broken electrical outlet covers in the following locations:

Tower forth floor

1. Elec 401, panel 4L-L missing blank
2. South Nurses station refrigerator plugged into power strip

Tower second floor

1. 2 North electrical room, panel 2 L-L missing 1 of 79 blanks

First floor

1. Electrical room by Pharmacy, panel Lin 1E1, missing 1 of 84 blanks
2. MDF room J-box cover missing

Women's Center

1. Room 12, broken 4-Plex electrical cover
2. Room 7, broken 4-Plex electrical cover

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the First floor main phone room has six pipe chases that were not fire resistant and penetrated the corridor walls.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the following corridor doors:

Tower forth floor

1. Door 4-434, staff lounge, rated door closing device removed
2. Door 4-432, Cardiothoracic surgery services, rated door closing device removed
3. Door 4-423, rated door closing device removed
4. Nurse Manager, rated door with a hold open device, door closing device disconnected
5. Room 449 Nurse Sub station, rated door closing device removed
6. Door 4-423, Cardiac rehab and chest pain coordinator, door closing device removed

Tower third floor

1. Door 3-335, office rated door closing device removed

Tower second floor

1. MSICA Room 20, rated door with a closing device, held open with a an impediment

First floor, EMS, rated door closing device removed

OR

1. OR staff lounge, rated door closing device removed

Women's Center

1. OR one, door latch broken, taped open and will not positively latch

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas. And failed to keep the laundry room dryer clean

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors. Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "


Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager ,observed the dryer in the EVS laundry room had an excessive amount of lint in the dryer drum assemblies, to include complete coverage of the wiring harness, coverage of lint was approximately one half to six inches deep. Observation of the following doors in hazardous areas are;


Tower forth floor

1. Bio-Med work shop, rated 1-1/2 hr. door, closing device removed
2. Room 404, converted to a storage room, door does not have a closing device
3. Door 4-05, Pharmacy, rated door closing device removed

Tower third floor

1. Door 3-326 Pharmacy office, rated 1-1/2 hr. door, closing device removed

Tower second floor

1. Door 2-234, Nurse sub station charting and medication, 1 hr. rated door, closing device removed
2. Room 222, converted to a storage room, door does not have a closing device

Tower first floor

1. Medical records, storage room measuring 72 sq. ft. does not have a door closing device

OR

1. Janitors closet across from room 8, door closing device removed
2. Anesthesia, rated door on a closing device removed

Radiology

1. Xray # 5, door on a closing device will not positively latch when tested

Women's Center

1. Admin Ast. room, rated 1-1/2 hr. door, closing device removed

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.
Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.2.8 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the exit discharge lighting from the Women's Center north east exit was illuminated by a single-bulb light fixture. All designated exits shall have two bulb fixtures.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.

In an emergency the failure of the one bulb will result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing. And failed to maintain the sprinkler heads from obstructions

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "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 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."


Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager, observations include the following findings:

Tower forth floor

1. Room 485, 2 of 4 sprinklers, paint escutcheon plate gap greater than 1 inch
2. Room 486. 1 of 3 sprinklers lint
3. Room 431, 1 sprinkler lint
4. Room 434, 1 of 2 sprinklers gap greater than 1 inch in the escutcheon plate
5. North nurse station, 2 of 2 sprinklers lint and paint
6. Nurse manager room, 2 of 2 escutcheon Plates missing

Tower third floor

1. Staff locker, 1 of 2 sprinklers lint

Tower second floor

Ortho nurse station, 3 of 4 sprinklers lint

First floor

1. Storage, across from plant op's, escutcheon plate gap greater than 1//8 inch, obstructions within 18" of sprinkler heads

OR

1. Central sterilization, 4 of 11 sprinklers paint/lint gap greater than 1/8 inch, escutcheon plate

MED-oncology

West sub Nursing station, 1 or 3 sprinklers lint

Kitchen

1. Walk in freezer 2 of 2 sprinkler escutcheon plates missing


During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.



Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients. Obstructions within 18 inches of the sprinklers head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on Observation the facility failed to provide self-closing metal containers in all designated smoking areas.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.4 "Smoking regulations shall be adopted and shall include not less than the following provisions:
(4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager ,observations include the following designated smoking areas. None of the smoking areas had self-closing metal containers, which ashtrays can be emptied.

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failure to provide metal containers for the disposal of cigarette butts could result in a fire which could cause harm to patients.

Based on observation the facility failed to mount an electrical light switch's and 110 electrical outlets five feet above the floor in the oxygen storage rooms. And failed to separate 5 ft. from combustibles.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed wall mounted electric light switch's/and 110 electrical outlets in the oxygen storage rooms. The electrical switch's were less than 5 ft. from stored oxygen to include combustible materials less than 5 ft. in the following locations:

Tower forth floor

1. Clean utility, 3 E O2 bottles
2. 4 E clean utility, 7 E O2 bottles
3. Room 404, 3 E O2 bottles

Tower second floor

1. Room 222 , 2 E O2 bottles

Tower third floor

1. C-Arm storage room, 1 E O2 bottle
2. Room 314, 1 E O2 bottle
3. Clean utility, 4 E O2 bottles
4. Door 4-412, 11 E O2 bottles

ED Medical gases

1. 15 E O2 bottles
2. Equipment storage, 3 E O2 bottles

Cardiac Cath Lab

1. 3 E O2 bottles, to include 7 unsecured compressed medical gases

Women's Center

1. Storage room, 4 E O2 bottles and 1 medical air not secured

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to mount a light switch/ electrical outlet five feet above the floor and separate combustibles 5 ft to prevent an accident/or possible fire could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, the facility failed to provide receptacle face plates, and facility failed to provide protection from electrical shock at the electrical panel..


NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters ,Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface." NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

Findings Include:

On May 23 and 24, 2012, the surveyor, accompanied by the Assistant Chief Executive Officer, Senior Project Manager, Plant Operations Manager and the Risk Manager , observed the electrical panels, missing blanks,refrigerator plugged into power strip, missing J-box cover and broken electrical outlet covers in the following locations:

Tower forth floor

1. Elec 401, panel 4L-L missing blank
2. South Nurses station refrigerator plugged into power strip

Tower second floor

1. 2 North electrical room, panel 2 L-L missing 1 of 79 blanks

First floor

1. Electrical room by Pharmacy, panel Lin 1E1, missing 1 of 84 blanks
2. MDF room J-box cover missing

Women's Center

1. Room 12, broken 4-Plex electrical cover
2. Room 7, broken 4-Plex electrical cover

During the exit conference on May 24, 2012 the above findings were again acknowledged by the Chief Executive Officer, Assistant Executive Officer, Chief Operating Officer, Senior Project Manager,Plant Operations Manager and the Risk Manager.


Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.