HospitalInspections.org

Based on observation and document review, the facility failed to maintain openings in occupancy separations. This was evidenced by double doors located at a 2-hour fire barrier wall separation that were not labeled to show that they had a minimum fire rating of 90 minutes (1 1/2 hour). This reduced the appropriate fire protection that could result in injury to the patients during a fire. This affected the separation between Original Hospital Building (BLD#01846) and the Utility/Central Plant #1 Building (BLD#01852).

NFPA 101, Life Safety Code, 2000 Edition
19.1.2.1 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
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.
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition.
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with the Director of Facilities Management and the Director of Patient Experience on 6/9/15, the facility's occupancy separation barriers were observed.

07 Utility/Central Plant #1 (BLD#01852)
At 8:59 a.m., the double doors that opened into the corridor from the chiller room in the Utility/Central Plant #1 Building were not labeled to identify the fire rating of the doors. The floor plans that were provided by the Manager of Plant Maintenance showed that the doors were located at the 2-hour fire rated wall separation between the Utility/Central Plant #1 Building and the Original Hospital Building (BLD#01846). The occupancy separations are required to have the appropriate fire protection rating that includes a 2-hour fire rated wall separation and 90-minutes (1.5 hours) fire rated doors.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the ceiling and walls which could allow the spread of smoke in the event of a fire. This affected 1 of 7 smoke compartments in the Wings 700/800/900 (BLD#01851) and the Original Hospital Building (BLD#01846).

NFPA 101 Life Safety Code, 2000 Edition.
19.1.1.3 Total Concept. All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by
appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling
programs for the isolation of fire, transfer of occupants to
areas of refuge, or evacuation of the building

Findings:

During a tour of the facility with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15 and 6/10/15, the ceiling and walls were observed.

06 Wings 700/800/900 (BLD#01851)
1. On 6/8/15, at 3:43 p.m., there was a one half inch penetration around four communication wires in the ceiling of the coding office.

01 Original Hospital (BLD#01846)
2. On 6/10/15, at 1:30 p.m., there was an approximately three inch penetration in the wall adjoining EVS and the old kitchen.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by areas in the hospital that failed to have visibly marked exits. This failure affected the Original Hospital Building (BLD#01846) and had the potential to delay the exit from the hospital in the event of an emergency evacuation.

NFPA 101 Life Safety Code 2000 Edition.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with Director of Facilities Management on 6/10/15, the egress path and emergency evacuation plans were observed.

01 Original Hospital (BLD#01846)
1. At 1:18 p.m., there were no exit signs in the Finance Office measuring approximately 3000-3500 square feet.
2. At 1:25 p.m., there were no exit signs in the Business/Education Office measuring approximately 2000 square feet.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation and interview, the facility failed to ensure the fire alarm system was maintained in reliable condition. This was evidenced by visual alarm devices that failed to function when the system was tested. This failure affected the Original Hospital Building (BLD#01846) and had the potential to delay the notification of staff in the event of a fire.

NFPA 72 National fire Alarm Code, 1999 Edition.
4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

Findings:

During a tour of the facility with the Manager of Plant Maintenance on 6/9/15, the fire alarm system was tested and visual alarm indicators were observed.

01 Original Hospital (BLD#01846)
At 9:55 a.m., there were two strobe fire alarm indicators that failed to function in the Behavioral Health Unit North when the system was tested and activated.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to ensure that their fire extinguishers were easily accessible. This was evidenced by a fire extinguisher mounted above the required height. This failure affected the 1st Floor in the North Hospital Tower (BLD#01850) and had the potential to delay the removal of the fire extinguishers from their mount causing potential delay in extinguishing a fire.

NFPA 101, 1999 Edition. Life Safety Code.
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, 1998 Edition. Standard for Portable Fire Extinguishers.
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 1/2 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 Director of Facilities Management on 6/10/15, the fire extinguishers were observed.

05 North Hospital Tower (BLD#01850)
At 8:53 a.m., there was a fire extinguisher labeled #129, mounted approximately 5 ft. 4 inches in the Cardio Pulmonary Department.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation and record review, the facility failed to enforce their policy of non-smoking in the hospital campus. This was evidenced by the disposal of cigarette butts on the hospital campus. This failure affected the 1st Floor in North Hospital Tower and had the potential to aid in the ignition of combustible material near by.

Findings:

During a tour of the facility with Director of Facilities Management on 6/10/15, the designated smoking areas were observed.

05 North Hospital Tower (BLD#01850)
At 7:50 a.m., there were approximately thirty cigarette butts discarded on the ground on the north west side of the hospital. This area was not a designated smoking area and no safety type ashtray was provided. A kitchen staff member was seen smoking in this location on 6/9/15 at approximately 1:10 p.m. The facility had a non smoking campus policy in their policy and procedure manual.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on record review and interview, the facility failed to test and inspect all their fire/smoke dampers to ensure proper function. This was evidenced by records that showed that not all fire/smoke dampers had been tested. This had the potential for the damper to not function during a fire and could result in the spread of smoke and fire, increasing the risk of injury to patients, staff, and visitors. This affected the Original Hospital Building (BLD#01846), the South Hospital Tower (BLD#01849), the North Hospital Tower (BLD#01850), and the Wings 700/800/900 (BLD#01851).

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2 Heating, Ventilating, and Air Conditioning.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
3-4.5.1 All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.

Findings:

During record review with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15, the fire/smoke damper maintenance records were reviewed.

At 10:45 a.m., the damper inspection and test records, dated 1/15/10, showed that 102 dampers were not accessible and therefore not tested. The dampers were located in the following locations:
1. 26 in the 1st Floor Tower (BLD#01849 & 01850).
2. 19 in the 2nd Floor Tower (BLD#01849 & 01850).
3. 20 in the 3rd Floor Tower (BLD#01849 & 01850).
4. 22 in the 4th Floor Tower (BLD#01850).
5. 4 in the 5th Floor Tower (BLD#01850).
6. 1 in the Roof East Campus (BLD#01846).
7. 3 in the Middle Campus (BLD#01851).
8. 2 in NCU North (BLD#01846).
9. 5 in PHP/Volunteer Center (BLD#01846).

At 10:55 a.m., the Manager of Plant Maintenance stated that the 102 dampers that were not accessible had not been tested.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain their cooking facility in accordance with NFPA 96, 1998 Edition. This was evidenced by failing to display a current label indicating the date the ventilation system in the kitchen was cleaned. This had the potential for the failure to maintain the exhaust system and result in an increased risk of fire. This affected the 1st Floor in the North Hospital Tower (BLD#01850).

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
8-3.1* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person acceptable to the authority having jurisdiction in accordance with Table 8-3.1.
8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Findings:

During the facility tour with the Manager of Plant Maintenance and the Director of Patient Experience on 6/9/15, the kitchen's exhaust systems were observed.

05 North Hospital Tower (BLD#01850)
At 9:05 a.m., the facility failed to display the label from the servicing company that marked the most current date that the ventilation system was cleaned for the back kitchen. The label was dated 10/8/14 and the report showed a date of 5/13/15.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on record review and interview, the facility failed to maintain their piped in medical gas system in accordance with NFPA 99, 1999 Edition. This was evidenced by a medical gas piping system installed in the facility that did not have a complete compliance inspection record. This failure could increase the risk of injury to patients. This affected the 3rd Floor in the South Hospital Tower (BLD#01849) and the 2nd and 4th Floors in the North Hospital Tower (BLD#01850).

NFPA 99 Health Care Facilities, 1999 Edition
4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Findings:

During record review with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15, the records for the inspection of the piped medical gas system were reviewed.

At 2:45 p.m., the inspection reports, dated 2/21/14 and 2/3/15, showed that the piped medical gas system did not have acceptable purity readings for the oxygen outlets in the following locations:
1. 2 of 4 in Nursery 2B, 2nd Floor, North Hospital Tower (BLD#01850).
2. 1 of 2 in ICU Room 12, 3rd Floor, South Hospital Tower (BLD#01849).
3. 1 of 2 in ICU Room 15, 3rd Floor, South Hospital Tower (BLD#01849).
4. 1 of 2 in ICU Room 17, 3rd Floor, South Hospital Tower (BLD#01849).
5. 1 of 1 in Room 407, 4th Floor, North Hospital Tower (BLD#01850).
6. 1 of 1 in Room 409, 4th Floor, North Hospital Tower (BLD#01850).
7. 1 of 1 in Room 411, 4th Floor, North Hospital Tower (BLD#01850).
8. 1 of 1 in Room 414, 4th Floor, North Hospital Tower (BLD#01850).
9. 1 of 1 in Room 416, 4th Floor, North Hospital Tower (BLD#01850).

On 6/10/15, at 2:15 p.m., the Director of Facilities Management was interviewed and he stated that the company that tested the piped medical gas system had re-tested the system on 6/10/15. They found acceptable purity readings at all above locations and concluded that the initial report contained errors that were due to computer system entry.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain fixed eye wash stations. This was evidenced by an eye wash station that did not have adequate water flow. This had the potential to delay its use during an emergency and cause injury. This affected the 2nd Floor on the South Hospital Tower (BLD#01849)

Findings:

During the facility tour with the Director of Facilities Management and the Director of Patient Experience on 6/9/15, the facility's occupancy separation barriers were observed.

04 South Hospital Tower (BLD#01849)
At 3:30 p.m., the fixed eye wash station by the Nurses Station in the Neonatal Intensive Care Unit-NICU did not have enough water flow to affectively drench or flush the eyes. The Director of Facilities Management stated that the water valve located underneath the station had been turned down.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by a broken cover plate to an electrical outlet. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to visitors and staff. This affected the Original Hospital Building (BLD#01846)

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. 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.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (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.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.

Findings:

During the facility tour with the Manager of Plant Maintenance on 6/9/15, the the electrical equipments and devices were observed.

01 Original Hospital (BLD#01846)
At 1:09 p.m., the dual receptacle wall outlet in the Housekeeping Office had a broken cover plate.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation and document review, the facility failed to maintain openings in occupancy separations. This was evidenced by double doors located at a 2-hour fire barrier wall separation that were not labeled to show that they had a minimum fire rating of 90 minutes (1 1/2 hour). This reduced the appropriate fire protection that could result in injury to the patients during a fire. This affected the separation between Original Hospital Building (BLD#01846) and the Utility/Central Plant #1 Building (BLD#01852).

NFPA 101, Life Safety Code, 2000 Edition
19.1.2.1 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
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.
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition.
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with the Director of Facilities Management and the Director of Patient Experience on 6/9/15, the facility's occupancy separation barriers were observed.

07 Utility/Central Plant #1 (BLD#01852)
At 8:59 a.m., the double doors that opened into the corridor from the chiller room in the Utility/Central Plant #1 Building were not labeled to identify the fire rating of the doors. The floor plans that were provided by the Manager of Plant Maintenance showed that the doors were located at the 2-hour fire rated wall separation between the Utility/Central Plant #1 Building and the Original Hospital Building (BLD#01846). The occupancy separations are required to have the appropriate fire protection rating that includes a 2-hour fire rated wall separation and 90-minutes (1.5 hours) fire rated doors.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the ceiling and walls which could allow the spread of smoke in the event of a fire. This affected 1 of 7 smoke compartments in the Wings 700/800/900 (BLD#01851) and the Original Hospital Building (BLD#01846).

NFPA 101 Life Safety Code, 2000 Edition.
19.1.1.3 Total Concept. All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by
appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention and the planning, training, and drilling
programs for the isolation of fire, transfer of occupants to
areas of refuge, or evacuation of the building

Findings:

During a tour of the facility with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15 and 6/10/15, the ceiling and walls were observed.

06 Wings 700/800/900 (BLD#01851)
1. On 6/8/15, at 3:43 p.m., there was a one half inch penetration around four communication wires in the ceiling of the coding office.

01 Original Hospital (BLD#01846)
2. On 6/10/15, at 1:30 p.m., there was an approximately three inch penetration in the wall adjoining EVS and the old kitchen.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by areas in the hospital that failed to have visibly marked exits. This failure affected the Original Hospital Building (BLD#01846) and had the potential to delay the exit from the hospital in the event of an emergency evacuation.

NFPA 101 Life Safety Code 2000 Edition.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with Director of Facilities Management on 6/10/15, the egress path and emergency evacuation plans were observed.

01 Original Hospital (BLD#01846)
1. At 1:18 p.m., there were no exit signs in the Finance Office measuring approximately 3000-3500 square feet.
2. At 1:25 p.m., there were no exit signs in the Business/Education Office measuring approximately 2000 square feet.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation and interview, the facility failed to ensure the fire alarm system was maintained in reliable condition. This was evidenced by visual alarm devices that failed to function when the system was tested. This failure affected the Original Hospital Building (BLD#01846) and had the potential to delay the notification of staff in the event of a fire.

NFPA 72 National fire Alarm Code, 1999 Edition.
4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

Findings:

During a tour of the facility with the Manager of Plant Maintenance on 6/9/15, the fire alarm system was tested and visual alarm indicators were observed.

01 Original Hospital (BLD#01846)
At 9:55 a.m., there were two strobe fire alarm indicators that failed to function in the Behavioral Health Unit North when the system was tested and activated.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to ensure that their fire extinguishers were easily accessible. This was evidenced by a fire extinguisher mounted above the required height. This failure affected the 1st Floor in the North Hospital Tower (BLD#01850) and had the potential to delay the removal of the fire extinguishers from their mount causing potential delay in extinguishing a fire.

NFPA 101, 1999 Edition. Life Safety Code.
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, 1998 Edition. Standard for Portable Fire Extinguishers.
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 1/2 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 Director of Facilities Management on 6/10/15, the fire extinguishers were observed.

05 North Hospital Tower (BLD#01850)
At 8:53 a.m., there was a fire extinguisher labeled #129, mounted approximately 5 ft. 4 inches in the Cardio Pulmonary Department.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation and record review, the facility failed to enforce their policy of non-smoking in the hospital campus. This was evidenced by the disposal of cigarette butts on the hospital campus. This failure affected the 1st Floor in North Hospital Tower and had the potential to aid in the ignition of combustible material near by.

Findings:

During a tour of the facility with Director of Facilities Management on 6/10/15, the designated smoking areas were observed.

05 North Hospital Tower (BLD#01850)
At 7:50 a.m., there were approximately thirty cigarette butts discarded on the ground on the north west side of the hospital. This area was not a designated smoking area and no safety type ashtray was provided. A kitchen staff member was seen smoking in this location on 6/9/15 at approximately 1:10 p.m. The facility had a non smoking campus policy in their policy and procedure manual.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on record review and interview, the facility failed to test and inspect all their fire/smoke dampers to ensure proper function. This was evidenced by records that showed that not all fire/smoke dampers had been tested. This had the potential for the damper to not function during a fire and could result in the spread of smoke and fire, increasing the risk of injury to patients, staff, and visitors. This affected the Original Hospital Building (BLD#01846), the South Hospital Tower (BLD#01849), the North Hospital Tower (BLD#01850), and the Wings 700/800/900 (BLD#01851).

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2 Heating, Ventilating, and Air Conditioning.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
3-4.5.1 All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
5-1.2 Records shall be maintained on acceptance test results and shall be available for inspection.

Findings:

During record review with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15, the fire/smoke damper maintenance records were reviewed.

At 10:45 a.m., the damper inspection and test records, dated 1/15/10, showed that 102 dampers were not accessible and therefore not tested. The dampers were located in the following locations:
1. 26 in the 1st Floor Tower (BLD#01849 & 01850).
2. 19 in the 2nd Floor Tower (BLD#01849 & 01850).
3. 20 in the 3rd Floor Tower (BLD#01849 & 01850).
4. 22 in the 4th Floor Tower (BLD#01850).
5. 4 in the 5th Floor Tower (BLD#01850).
6. 1 in the Roof East Campus (BLD#01846).
7. 3 in the Middle Campus (BLD#01851).
8. 2 in NCU North (BLD#01846).
9. 5 in PHP/Volunteer Center (BLD#01846).

At 10:55 a.m., the Manager of Plant Maintenance stated that the 102 dampers that were not accessible had not been tested.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain their cooking facility in accordance with NFPA 96, 1998 Edition. This was evidenced by failing to display a current label indicating the date the ventilation system in the kitchen was cleaned. This had the potential for the failure to maintain the exhaust system and result in an increased risk of fire. This affected the 1st Floor in the North Hospital Tower (BLD#01850).

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
8-3.1* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person acceptable to the authority having jurisdiction in accordance with Table 8-3.1.
8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

Findings:

During the facility tour with the Manager of Plant Maintenance and the Director of Patient Experience on 6/9/15, the kitchen's exhaust systems were observed.

05 North Hospital Tower (BLD#01850)
At 9:05 a.m., the facility failed to display the label from the servicing company that marked the most current date that the ventilation system was cleaned for the back kitchen. The label was dated 10/8/14 and the report showed a date of 5/13/15.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on record review and interview, the facility failed to maintain their piped in medical gas system in accordance with NFPA 99, 1999 Edition. This was evidenced by a medical gas piping system installed in the facility that did not have a complete compliance inspection record. This failure could increase the risk of injury to patients. This affected the 3rd Floor in the South Hospital Tower (BLD#01849) and the 2nd and 4th Floors in the North Hospital Tower (BLD#01850).

NFPA 99 Health Care Facilities, 1999 Edition
4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Findings:

During record review with the Director of Facilities Management and the Manager of Plant Maintenance on 6/8/15, the records for the inspection of the piped medical gas system were reviewed.

At 2:45 p.m., the inspection reports, dated 2/21/14 and 2/3/15, showed that the piped medical gas system did not have acceptable purity readings for the oxygen outlets in the following locations:
1. 2 of 4 in Nursery 2B, 2nd Floor, North Hospital Tower (BLD#01850).
2. 1 of 2 in ICU Room 12, 3rd Floor, South Hospital Tower (BLD#01849).
3. 1 of 2 in ICU Room 15, 3rd Floor, South Hospital Tower (BLD#01849).
4. 1 of 2 in ICU Room 17, 3rd Floor, South Hospital Tower (BLD#01849).
5. 1 of 1 in Room 407, 4th Floor, North Hospital Tower (BLD#01850).
6. 1 of 1 in Room 409, 4th Floor, North Hospital Tower (BLD#01850).
7. 1 of 1 in Room 411, 4th Floor, North Hospital Tower (BLD#01850).
8. 1 of 1 in Room 414, 4th Floor, North Hospital Tower (BLD#01850).
9. 1 of 1 in Room 416, 4th Floor, North Hospital Tower (BLD#01850).

On 6/10/15, at 2:15 p.m., the Director of Facilities Management was interviewed and he stated that the company that tested the piped medical gas system had re-tested the system on 6/10/15. They found acceptable purity readings at all above locations and concluded that the initial report contained errors that were due to computer system entry.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain fixed eye wash stations. This was evidenced by an eye wash station that did not have adequate water flow. This had the potential to delay its use during an emergency and cause injury. This affected the 2nd Floor on the South Hospital Tower (BLD#01849)

Findings:

During the facility tour with the Director of Facilities Management and the Director of Patient Experience on 6/9/15, the facility's occupancy separation barriers were observed.

04 South Hospital Tower (BLD#01849)
At 3:30 p.m., the fixed eye wash station by the Nurses Station in the Neonatal Intensive Care Unit-NICU did not have enough water flow to affectively drench or flush the eyes. The Director of Facilities Management stated that the water valve located underneath the station had been turned down.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by a broken cover plate to an electrical outlet. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to visitors and staff. This affected the Original Hospital Building (BLD#01846)

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. 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.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (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.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.

Findings:

During the facility tour with the Manager of Plant Maintenance on 6/9/15, the the electrical equipments and devices were observed.

01 Original Hospital (BLD#01846)
At 1:09 p.m., the dual receptacle wall outlet in the Housekeeping Office had a broken cover plate.

The above findings were acknowledged during the exit conference on 6/10/15 by the hospital staff.