HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of their walls and ceilings. This was evidenced by unsealed penetrations at eleven locations. This affected one of eight buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the walls and ceilings were observed.

Main Hospital:

1. On 11/2/10 at 10:03 a.m., there was one approximately one half inch wide and twelve approximately one eighth inch wide unsealed penetrations in the wall of the closet H2052.

2. On 11/2/10 at 1:40 p.m., there were two approximately one half inch wide unsealed penetrations in the wall of staff office HB103. The penetrations were in the portion of the wall between two desks in that office.

3. On 11/2/10 at 2:00 p.m., there was on approximately one half inch wide unsealed penetration in the wall of Nuclear Medicine HB160. The penetration was located on the wall near the countertop in that room.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the walls and ceiling were observed throughout the facility.

11/1/10 - Penthouse
At 11:47 a.m., there was an approximate 2 inch penetration in the Fan Room. The penetration was around an approximately 5 inch pipe on the left wall.
During an interview, facility staff stated the penetrations are a result of a new regulator that was installed approximately a month.

At 11:58 a.m., there was an approximately 1 inch round penetration in the ceiling in the Fan Room. During an interview, facility staff stated that this was the result of a conduit that was removed and a smoke detector relocated.

11/1/10 - Fifth Floor
At 2:03 p.m., there was an approximately ? inch penetration around 3 grey and 1 tan wires in the ceiling in the communication closet (H5054).

11/1/10 - Fourth Floor
At 4:29 p.m., there was an approximately 1 inch penetration in the ceiling in the communication room (H4056).

11/2/10 - Third Floor
At 8:18 a.m., there was an approximately 3 inch penetration around a pipe on the left wall in the electrical panel room (H3021). The penetration was around a pipe. There was an approximately 2 ? x 4 inch penetration exposing insulation in the same area.

At 8:41 a.m., there was an approximately ? inches round, cut out, penetration in the break room, above the door (H3049).

At 8:52 a.m., there were seven approximately 1/8 to ? inch penetrations and an approximately 12 x 18 inch cut out square penetration in the key room. The penetrations were in the right wall. During an interview, facility staff stated that this was a result of new construction currently in progress.

At 8:56 a.m., there was an approximately 3 inch unsealed pipe in the ceiling in room H3057.
During an interview, facility staff stated that this is a result of the construction currently in progress and cables need to be pulled from the 5th floor to the basement for the patient monitoring.

Based on observation, the facility failed to maintain their doors. This was evidenced by twenty-nine corridor doors that were obstructed from closing or latching. This affected one of eight buildings and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the doors in the facility were observed.

Main Hospital:

1. On 11/2/10 at 9:32 a.m., the corridor door to room 215 (H2006) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 11/2/10 at 1:57 p.m., the corridor door to the Treadmill/Holter room HB157 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the floor transition.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the doors were observed and tested throughout the facility.

Main Hospital
11/1/10 - Fifth Floor
At 1:41 p.m., there was a walker and a garbage can impeding the door from closing to Room 512.

At 1:46 p.m., the door between the Nurse ' s office and the Annex Office closed but failed to latch. The door was equipped with a self-closing device.

At 1:58 p.m., the corridor door to the housekeeping closet (H5051) closed but failed to latch. The door was equipped with a self-closing device.

At 2:15 p.m., there was an over the bed table impeding the corridor door from closing to Room 527.

At 2:17 p.m., the corridor door to Room 529 (H5031) failed to fully close and latch. The door was equipped with a self-closing device.

11/1/10 - 4th Floor
At 3:43 p.m., the corridor door to Room 403 (H4070) was impeded from closing by a privacy curtain.

At 4:09 p.m., the corridor door to Room 418 was impeded from closing by a walker.

At 4:24 p.m., the corridor door to the Dialysis Storage Room (H4060) closed but failed to latch. The door was equipped with a self-closing device.

11/2/10 - 3rd Floor
At 7:56 a.m., the door to AHN Office (3101) was impeding from closing by a yellow door stopper and a chair.

At 8:46 a.m., the corridor door to Room 322 was impeded from closing by a privacy curtain.

11/2/10 - 1st Floor
At 9:49 a.m., the corridor door to Room 115 was impeded from closing by a garbage can.

At 9:51 a.m., the corridor door to Room 117 was impeded from closing by a sleep chair.

At 9:53 a.m., the corridor door to Room 120 was impeded from closing by a garbage can.

At 9:54 a.m., the corridor door to Room 121 was impeded from closing by a garbage can.

At 10:43 a.m., the corridor door to the AHN Office (H1045-1) was held open by a garbage can.

At 10:48 a.m., the door to the housekeeping closet in the ICU failed to fully close and latch.

At 11:04 a.m., the corridor door to the communication room, across Room 164 failed to fully close and latch. The door was equipped with a self-closing device.

At 11:26 a.m., the closet door inside the Lab closed but failed to latch. The door was missing the latching mechanism.

At 2:36 p.m., one of two doors to the Triage was obstructed from closing by a desk ' s upper shelves. The shelves did not allow the closure of the door.

At 2:42 p.m., the door between the Triage and the Charge Nurse ' s Room closed but failed to latch.

At 4:14 p.m., the corridor door to the restroom (H1128) did not fully close and latch. The door was equipped with a self-closing service.

11/3/10 - 1st Floor
At 7:40 a.m., the corridor to the Service League Room (H1095), closed but failed to latch.

At 7:58 a.m., the corridor door to the Case Management Office (H1051), failed to fully close and latch. The door was equipped with a self-closing device.

At 11:06 a.m., the corridor door to Porter's Closet failed to fully close and latch. The door was equipped with a self-closing device.

At 11:11 a.m., two of two corridor doors did not fully close and latch. The doors were equipped with self-closing devices.

At 11:12 a.m., the corridor door to the Mannitol Room closed but failed to latch. The door was equipped with a self-closing device.

At 11:15 a.m., the corridor door to the OR storage room did not have a latching mechanism.

Based on observation, the facility failed to maintain a door in a smoke barrier. This was evidenced by one smoke barrier door that was held open by an unapproved device. This affected one of six floors in the Main Hospital and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 11/2/10, the smoke barrier doors were observed.

Main Hospital:

On 11/2/10 at 11:01 a.m., the smoke barrier door adjacent to the stairwell (HB001) was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a wooden door wedge.

Based on observation, the facility failed to maintain an exit. This was evidenced by one location in the facility that did not have an exit directional sign posted that would direct patients to the nearest exit. This affected one of eight buildings and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff on 11/3/10, the facility's exits and egress paths were observed.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:40 p.m., the hallway door near the staff break room was observed. The door separated the Cardiovascular Diagnostic Center from another occupancy. The door was one of two remotely located egress paths in the facility. There was no exit signs in the area indicating that door would lead to an exit.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in five smoke barrier walls throughout the facility. This affected four of six floors in the Main Hospital and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes 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 of the 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 for 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's smoke barrier walls were observed.

Main Hospital:

On 11/1/10 at 3:45 p.m., the smoke barrier wall near the 3rd floor stairway H3044 was observed. There was one approximately one inch wide unsealed penetration in the portion of wall above the ceiling. Three cables were running through the penetration.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the smoke barrier walls were observed.

11/1/10 - 5th Floor
At 1:03 p.m., there was an approximately 12 x 18 inch square, cut out, penetration in the smoke barrier wall by the Nutrition Station. The penetration was on the right side of the smoke barrier wall.

At 1:17 p.m., there was an approximately 1 x 3-4 inch penetration in the smoke barrier wall by the electrical panel FAPAD13. The penetration was underneath an approximately 3 - 4 inch pipe that had a bundle of green and white cables going through the pipe. Above the 3 - 4 inch pipe there was an approximately ? inch penetration around a pipe sleeve that had a bundle of purple wires.

11/1/10 - 4th Floor
At 2:41 p.m., there was an approximately 1 x 3 inch penetration in the smoke barrier wall by the Pulmonary Function Lab. The penetration was above a black pipe.

11/2/10 - 1st Floor
At 1:59 p.m., there was an approximately ? inch unsealed pipe sleeve in the smoke barrier wall by the Physician ' s Reading Room, between Registration and Diagnostic Imaging.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by two smoke barrier doors that were obstructed from closing or latching when the doors were released from their hold-open devices. This affected two of six floors in the Main Hospital and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the smoke barrier doors in the facility were observed.

Main Hospital:

On 11/2/10 at 10:39 a.m., the smoke barrier doors HB117 were equipped with self-closing devices and hold-open devices. The doors were released from the their hold-open devices and allowed to close. One of two door leafs of the smoke barrier doors failed to close. The door was obstructed from closing by a gurney positioned directly in the swing path of the door.



28602

During the facility tour with facility staff on 11/1/10 to 11/4/10, the smoke barrier doors were observed and tested.

11/3/10 - 1st Floor
At 10:19 a.m., the smoke barrier doors by the CT Scanner Room closed but failed to latch. The right door leaf failed to latch after activation of the Fire Alarm System.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one door to a hazardous area that was obstructed from latching and one hazardous area that was not equipped with a self-closing door. This affected two of eight buildings and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the hazardous areas in the facility were observed.

Main Hospital:

On 11/2/10 at 1:22 p.m., the corridor double doors to the Histology/Cytology Lab (HB077-2) were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two doors failed to latch. The door was obstructed from latching by the other door leaf.

Nancy Ausonio Mammography Center:

On 11/3/10 at 3:37 p.m., the soiled linen/biohazard waste room was observed. There was one large biohazard waste receptacle located inside the room. The door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by one emergency lighting unit that failed to illuminate when tested. This affected one of six floors in the Main Hospital and could result in a delayed evacuation in the event of an emergency due to limited visibility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the emergency lighting units in the facility were observed.

Main Hospital:

On 11/2/10 at 2:06 p.m., the emergency lighting unit in EKG Test Room HB163-2 was tested by pressing the test button on the unit. The lighting unit failed to illuminate when the test button for the device was pressed.

Based on observation, the facility failed to maintain their emergency exit signs. This was evidenced by one emergency exit sign that failed to remain illuminated when tested. This affected one of six floors in the Main Hospital and could result in a delayed evacuation in the event of an emergency due to limited exit sign visibility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the emergency lighting units in the facility were observed.

Main Hospital:

On 11/2/10 at 10:57 a.m., the emergency exit sign above the Cafeteria door HB135 was tested by pressing the test button on the unit. The exit sign failed to remain illuminated when the test button for the device was pressed.

Based on observation, the facility failed to maintain the integrity of the fire alarm system in accordance with the NFPA 72. This was evidenced by the failure of the manual pull alarm and two smoke detectors to activate an audible/visual alarm. This failure could result in a delay in notifying clients and staff in the event of a fire, affecting the entire building.

NFPA 101, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

Findings:

During fire alarm testing with facility staff on 11/3/10, a manual pull alarm and smoke detectors were tested.

MRI offsite building -
At 1:40 p.m., the smoke detector was tested. The smoke detector failed to activate an audible alarm and the strobe lights.

At 1:47 p.m., the manual pull alarm was tested. The manual pull alarm failed to activate an audible alarm and the strobe lights.

During an interview, facility staff stated that the smoke detector and manual pull alarm have always activated an audible alarm and strobe lights. Staff contacted personnel supervising main panel and were informed that the alarms were received at the main panel, at the Hospital.

During an interview, facility staff supervising main panel stated that the fire alarm system was disconnected from the main panel at the Hospital and would stand alone. Staff stated that the computers need to be updated at the main panel.

At 2:08 p.m. the smoke detector and the manual pull alarm were tested again and the audible alarm and the strobes were activated.

On 11/4/10, at 11:00 a.m., when reviewing the alarm activation reports, "Alarm Log Ad Hoc Report", there were no records of the alarm activation between 1:58 p.m., and 3:22 p.m., to indicate a signal was transmitted to the monitoring company.

Based on observation and interview, the facility failed to maintain their tamper valves. This was evidenced by one tamper valve that was moved from the open position to the closed position and failed to initiate an audible alarm and visual signal at the fire alarm control panel. This affected one of eight buildings and could result in a delayed notification of a suspension in water supply to the sprinkler system.

NFPA 101, 2000 edition
9.7.2.1 Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the automatic fire sprinkler system was observed.

Main Hospital:

On 11/3/10 at 9:26 a.m., the tamper valve (1.17.39) located in the soiled utility room on the 4th floor was turned from the open position to the closed position. The facility's fire alarm control panel did not receive an audible alarm or visual indicator that indicated the tamper valve was in the closed position. Fire Alarm Vendor 1 was interviewed at that time. Fire Alarm Vendor 1 indicated that the tamper switch was not aligned properly and that the switch itself was dirty and corroded.

Based on observation, record review, and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the two inspector's test valves that failed to initiate the fire alarm system, the facility's failure to have a current five year certification on two sprinkler systems, missing or misalignment of escutcheon fittings, sprinklers that were obstructed, and sprinkler heads and fittings that had accumulation of debris. This affected three of eight buildings and could result in a failure of the automatic fire sprinkler system.

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 1998 edition
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
9-4.1.2 Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-4.2.1 Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.
9-4.3.1.4 and 9-4.4.1.5 Strainers, filters, restricted orifices, and diaphragm chambers shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-5.1.2, 9-5.2.2, and 9-5.3.2 A full flow test shall be conducted on each valve at 5- year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be made in accordance with the manufacturer ' s instructions.

Findings:

During record review and a facility tour with staff from 11/1/10 to 11/4/10, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 11/2/10 at 9:51 a.m., the sprinkler head in closet H2027 had white paint on it. The sprinkler was missing an escutcheon fitting.

2. On 11/2/10 at 10:45 a.m., the sprinkler located in the janitor's closet in the kitchen (HB125) did not have eighteen inches around its deflector plate. The sprinkler deflector plate was level with the hard top ceiling. The sprinkler was missing an escutcheon fitting.

3. On 11/2/10 at 10:59 a.m., the sprinkler in the closet (HB0) was missing an escutcheon fitting.

4. On 11/3/10 at 8:42 a.m., the inspector's test valve located in the soiled utility room on the 5th floor was tested. The inspector's test valve did not activate the entire fire alarm system within ninety seconds. The doors wired to the fire alarm system released from their hold-open devices at the fifty-five second mark and the main fire alarm control panel received the signal within ninety seconds. The inspector's test valve was flowing water for one hundred and five seconds and did not activate the fire alarm strobes and chimes.

5. On 11/3/10 at 9:46 a.m., the inspector's test valve located in the soiled utility room on the 3rd floor was tested. The inspector's test valve did not activate the entire fire alarm system within ninety seconds. The main fire alarm control panel received the signal at the thirty-five second mark. The inspector's test valve was flowing water for one hundred and twenty-two seconds and did not activate the fire alarm strobes and chimes.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:45 p.m., the facility's automatic fire sprinkler system riser was tagged with a five year certification label dated 5/22/02. A current five year certification report for the automatic fire sprinkler system at that location was requested. The facility indicated that they would need time to search for that report. A five year certification for the automatic fire sprinkler system at that site was sent via electronic mail on 11/8/10. The five year report was dated 11/8/10. No documentation was viewed that indicated the facility had a five year certification on their automatic fire sprinkler system completed between 5/22/02 to 11/8/10. The facility was due for a five year certification on their automatic fire sprinkler system on 5/22/07.



28602

During the facility tour with facility staff on 11/1/10 to 11/4/10, the sprinkler heads were observed throughout the building.

11/1/10 - 5th Floor
At 1:32 p.m., there was an approximately ? inch gap between the escutcheon ring and the ceiling in clean utility room, exposing an approximately ? inch penetration.

At 1:35 p.m., the escutcheon ring in the soiled linen room had dust and lint buildup.

At 1:57 p.m., the escutcheon ring in the housekeeping closet (H5051) had dust and lint buildup.

11/1/10 - 4th Floor
At 4:08 p.m., the escutcheon ring was missing in Room 418 exposing an approximately 3 inch penetration. The sprinkler head was pushed up into the ceiling.

At 4: 26 p.m., the escutcheon ring was missing in the housekeeping room (H4052), exposing an approximately ? x 1 ? inch penetration at the ceiling.

11/2/10 - 3rd Floor
At 9:03 a.m., there was an approximately ? to 1 inch penetration the right side of the escutcheon ring in the housekeeping closet.

At 9:07 a.m., there was an approximately 1/8 to ? inch penetration around the escutcheon ring in Room 343. The penetration was at the ceiling.

At 10:08 a.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in restroom H1062.

At 10:09 a.m., there was an approximately ? to 1 inch gap between the escutcheon ring and the ceiling in restroom H1063, exposing an approximately ? inch penetration around the sprinkler pipe.

At 2:28 p.m., there was an approximately 1/8 x 1 inch penetration around the escutcheon ring, at the ceiling, in the Lab and Procedure Room, at the door entrance.

At 2:52 p.m., 1 of 4 escutcheon rings was missing in the Cath Lab Computer Room.

At 2:59 p.m., 1 of 2 escutcheon rings was missing in the Cath Lab Control Room.

At 3:58 p.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in the ES Closet, across the Ultra Sound Room.

11/3/10 - 1st Floor
At 7:50 a.m., 1 of 2 escutcheon rings was missing in the Meditation Room (H1089), exposing an approximately a ? inch penetration around the sprinkler pipe.

At 7:58 a.m., 2 of 7 escutcheon rings were missing in Level II, RN area, above the unit assistant ' s desk, exposing an approximately ? penetrations around the sprinkler pipes.

At 10:52 a.m., there was an approximately 1/4 inch gap between the escutcheon ring and the ceiling in the Sub Sterile Room, exposing an approximately ? inch penetration.

At 10:57 a.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in the OR scheduling office, exposing an approximately ? inch penetration.

At 10:59 a.m., the escutcheon ring was missing in the hallway in the OR, in front of OR 6, exposing an approximately 1 inch penetration around sprinkler head.

At 11:03 a.m., there was an approximately ? inch gap between the escutcheon ring and the ceiling in OR 6, exposing an approximately ? inch penetration.

At 11:04 a.m., there was an approximately ? to ? inch gap between 2 of 5 escutcheon rings, exposing approximately ? inch penetrations.

At 11:05 a.m., the escutcheon ring was missing in the Porter ' s Closet, exposing an approximately ? to ? inch penetration in the ceiling.

At 11:10 a.m., there was an approximately 1 to 1 ? inch gap between the escutcheon ring and the ceiling in the Biohazard Room in the OR department, exposing an approximately ? inch penetration.

11/3/10 - Cardiac Rehab
At 2:57 p.m., there was an approximately ? x 1 ? inch penetration around 1 of 5 escutcheon rings in the hallway by the copy room area.

At 2:59 p.m., there was a missing escutcheon ring at the entrance door, exposing an approximately ? inch penetration at the ceiling.

At 3:02 p.m., there was storage within 4 inches of the deflector in the exercise room closet. There were 2 racks with CDs.

At 3:20 p.m., the 5 year certification for the sprinkler system was requested.

11/4/10 - Cardiac Rehab
At 9:05 a.m., the 5 year certification for the sprinkler system was requested.

11/8/10
At 9:45 a.m., the facility provided a 5 year certification for the sprinkler system dated 11/5/10, conducted the day after the validation was completed. The 5 year cerfication indicated the system had failed.

At 12:48 p.m., the facility provided this information via e-mail: "We have been unable to locate a previous 5-year certification. I will continue to look - but, we will probably have to go forward without a previous certification".

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by two fire extinguishers that have not had an annual service and inspection within the past twelve months, one fire extinguisher that was not mounted, and one fire extinguisher that was obstructed. This affected one of six floors in the Main Hospital and could result in a delay to extinguish a fire in the event of an emergency.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
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).
4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's portable fire extinguishers were observed.

Main Hospital:

1. On 11/2/10 at 10:35 a.m., the fire extinguisher in the staff office HB118 was resting on the floor near the door to that room. There were no mounting brackets on the walls in the area. The service tag for the fire extinguisher was dated January 2009. The fire extinguisher was nine months overdue for an annual service and inspection.

2. On 11/2/10 at 10:49 a.m., the class K fire extinguisher in the Basement level kitchen was observed. The fire extinguisher had its access obstructed a cart that had a food preparation device stored on top of it.

3. On 11/2/10 at 11:08 a.m., the fire extinguisher mounted on the wall in the Basement level New Pharmacy entrance was observed. The service tag on the fire extinguisher was dated September 2008. The fire extinguisher was thirteen months overdue for an annual service and inspection.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by items stored in the corridor and in front of smoke barrier doors. This affected four of six floors in the Main Hospital and could result in a delayed evacuation due to an impeded means of egress.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's egress paths were observed.

Main Hospital:

On 11/2/10 at 9:54 a.m., the smoke barrier doors H2030 were observed. A food service cart was positioned directly in front of one side of the smoke barrier doors and a surgery preparation cart was positioned directly in front of the other side of the smoke barrier doors. The carts needed to be moved to completely open the smoke barrier doors.



28602

During the facility tour and interview with facility staff on 11/1/10 and 11/4/10, the means of egress were observed.

11/1/10 - 5th floor
At 2:13 p.m., there were 3 Work Stations on Wheels between Room H5024 and the Nurse's Office. During an interview, Staff 2 stated that the work stations are normally stored there.

11/2/10 -
At 3:02 p.m., there were 3 metal storage shelves, 6 to 7 ft, outside the Cath Lab in the corridor. Staff 2 stated that these shelves are always stored at this location due to the lack of storage.

11/3/10 -
At 10:54 a.m., there was a clean linen cart with 3 shelves, 1 trash container, and 1 soiled linen container in the corridor next to OR 3. OR staff stated these items are always stored there.

Based on observation, the facility failed to maintain their oxygen storage locations. This was evidenced by one liquid oxygen supply enclosure that was not equipped with a lock, three oxygen storage areas that did not have signs indicating oxygen was stored at those locations, and one oxygen E cylinder that was free standing and unsecured. This affected two of eight buildings and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Enclosures for supply systems shall be provided with doors or gates. If the enclosure is outside and/or remote from the single treatment facility, it shall be kept locked. If the storage area is within the single treatment facility (i.e., is not remote), it shall be permitted to be locked.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the oxygen storage locations were observed.

Main Hospital:

1. On 11/2/10 at 9:46 a.m., there were seventeen oxygen E cylinders stored inside the storage room H2032-1. There was no signs on the outside of the room indicating that oxygen was being stored at that location.

2. On 11/2/10 at 1:28 p.m., the liquid oxygen supply system enclosure was observed. The enclosure was located outside near the north end of the campus. There was no lock on the enclosure to prevent from unauthorized access or tampering.



28602

During the facility tour with facility Staff on 11/1/10 to 11/4/10, the oxygen storage areas were observed.

NFPA 99, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

11/1/10 - 4th Floor

At 4:22 p.m., there were 10 E oxygen cylinders stored in a rack, 3 E oxygen cylinders secured to the wall, and one liquid oxygen cylinder secured to the wall in Room H 4047. There was no sign on the door indicating oxygen was stored in the room.

11/2/10 - 1st Floor

At 10:03 a.m., there were 12 E oxygen cylinders stored in a rack in the Utility Room. There were 11 E oxygen cylinders full and 1 empty. The full and empty cylinders were mixed. There was no sign on the door indicating oxygen was stored in the room.

11/3/10 - Offsite MRI Building

At 1:25 p.m., there was 1 E oxygen cylinder unsecured in the sedation waiting area. The cylinder was standing in close proximity to a patient bed.

Based on record review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to adopt and have a documented policy and procedure for monitoring the relative humidity levels at their anesthetizing location and the facility's failure to maintain the relative humidity level at thirty-five percent or above. This affected eight of eight anesthetizing locations in the Main Hospital and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review from 11/1/10 to 11/4/10, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

On 11/4/10 at 8:45 a.m., the relative humidity logs for the facility's anesthetizing locations were observed. Eight of Eight anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months. The policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing locations was requested at that time. Engineering Staff 2 indicated that the facility does not have a documented policy or procedure for monitoring relative humidity levels. Engineering Staff 2 indicated that the facility follows the Association of preOperative Registered Nurses (AORN) guidelines. AORN guidelines suggest relative humidity levels be maintained at twenty to sixty percent for anesthetizing locations.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of unapproved extension cords as a substitute for permanent wiring, extension cords plugged into other extension cord, high powered appliances that were plugged into extension cords, electrical panelboards that did not have three feet of clearance, and electrical receptacles that were missing faceplates. This affected three of eight buildings and could result in an electrical fire to occur.

NFPA 70, 1999 edition
110-26(a)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.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's electrical equipment and wiring were observed.

Main Hospital:

1. On 11/2/10 at 9:15 a.m., computer equipment in the Mother Baby staff office H2108 was plugged into two surge protected multi-outlet extension cords that were plugged into one surge protected multi-outlet extension cord.

2. On 11/2/10 at 9:25 a.m., computer equipment in the Audio Visual room H2117 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord.

3. On 11/2/10 at 9:42 a.m., two portable space heaters in staff office H2033-1 were each plugged into separate surge protected multi-outlet extension cords.

4. On 11/2/10 at 9:43 a.m., computer equipment in staff office H2033-1 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

5. On 11/2/10 at 10:34 a.m., computer equipment in staff office HB118 was plugged into two surge protected multi-outlet extension cords that were both plugged into another surge protected multi-outlet extension cord.

6. On 11/2/10 at 10:46 a.m., two electrical panelboards located in the kitchen near room HB125 did not have three feet of clearance. The panelboards were obstructed by two food service carts positioned directly in front of them.

7. On 11/2/10 at 1:36 p.m., telephone equipment in staff office HB097 was plugged into a maroon non-surge protected multi-outlet extension cord.

8. On 11/2/10 at 1:42 p.m., computer equipment in staff office HB098 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

9. On 11/2/10 at 1:43 p.m., a portable space heater in staff office HB098 was plugged into a surge protected multi-outlet extension cord. The portable space heater was positioned under a table and had a small recycle receptacle positioned directly in front of it.

10. On 11/2/10 at 1:49 p.m., computer equipment in Registration Management was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

11. On 11/2/10 at 1:50 p.m., a miniature refrigerator in Registration Management was plugged into a surge protected multi-outlet extension cord.

12. On 11/2/10 at 1:51 p.m., a clock in Registration Management was plugged into a yellow non-surge protected extension cord.

13. On 11/2/10 at 2:02 p.m., two miniature refrigerators in staff office area HB161 were plugged into one surge protected multi-outlet extension cord that was plugged into one black non-surge protected extension cord.

14. On 11/2/10 at 2:13 p.m., computer equipment in staff office HB171 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:35 p.m., an electrical wall receptacle in the Hot Lab room was missing a faceplate.

Sleep Lab:

On 11/3/10 at 2:47 p.m., an electrical wall receptacle in the Telecommunications room was missing a faceplate.



28602

During the facility tour with facility staff on 11/1/10 to 11/3/10, the electrical wiring and connections were observed.

11/1/10 - 4th Floor
At 4:02 p.m., there was a heavy duty orange extension cord with three plugs connected to the wall. The extension cord was connecting a surge protector that was connecting a radio, desk light and a "Pyxis Connect Plus" machine.

11/2/10 - 3rd Floor
At 8:32 a.m., the electrical panel inside the copy room (H3038) did not have a 3 ft clearance. There was a book shelf and a copy machine directly in front of the electrical panel.

At 8:38 a.m., the refrigerator in the storage room (H3039) was plugged into an extension cord connected to the wall outlet.

At 8:42 a.m., the electrical panel in the equipment room (H3050) did not have a 3 ft clearance. There was a bassinet, and an ENT machine directly in front of the SB3 panel.

At 11:34 a.m., three electrical panels in the Lab area did not have a 3 ft clearance. A copy machine was directly in front of electrical panels LEC, LB, LEA and LD.

11/3/10 - 1st Floor
At 8:01 a.m., the 2 electrical panels in level II, across room 114 did not have a 3 ft clearance. There was a copy machine directly in front of the panels.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of five alcohol based hand rub dispensers over or adjacent to ignition sources. This affected three of eight buildings and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the alcohol based hand rub dispensers in the facility were observed.

Main Hospital:

On 11/2/10 at 2:09 p.m., an alcohol based hand rub dispenser in Endocrinology Exam Room 1 (HB168) was mounted on the wall approximately three inches to the upper right of a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

Sleep Lab:

1. On 11/3/10 at 2:43 p.m., an alcohol based hand rub dispenser in Room C was mounted on the wall approximately four inches to the upper right of a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

2. On 11/3/10 at 2:44 p.m., an alcohol based hand rub dispenser in Room B was mounted on the wall approximately four inches to the upper right of a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

3. On 11/3/10 at 2:45 p.m., an alcohol based hand rub dispenser in Room A was mounted on the wall approximately four inches to the upper left of a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

Nancy Ausonio Mammography Center:

On 11/3/10 at 3:34 p.m., an alcohol based hand rub dispenser in M.D. Office 1 was mounted on the wall approximately two and one half feet above an electrical receptacle. The hand rub was 62.5 percent ethyl alcohol by volume.

Based on observation and interview, the facility failed to maintain the integrity of their walls and ceilings. This was evidenced by unsealed penetrations at eleven locations. This affected one of eight buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the walls and ceilings were observed.

Main Hospital:

1. On 11/2/10 at 10:03 a.m., there was one approximately one half inch wide and twelve approximately one eighth inch wide unsealed penetrations in the wall of the closet H2052.

2. On 11/2/10 at 1:40 p.m., there were two approximately one half inch wide unsealed penetrations in the wall of staff office HB103. The penetrations were in the portion of the wall between two desks in that office.

3. On 11/2/10 at 2:00 p.m., there was on approximately one half inch wide unsealed penetration in the wall of Nuclear Medicine HB160. The penetration was located on the wall near the countertop in that room.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the walls and ceiling were observed throughout the facility.

11/1/10 - Penthouse
At 11:47 a.m., there was an approximate 2 inch penetration in the Fan Room. The penetration was around an approximately 5 inch pipe on the left wall.
During an interview, facility staff stated the penetrations are a result of a new regulator that was installed approximately a month.

At 11:58 a.m., there was an approximately 1 inch round penetration in the ceiling in the Fan Room. During an interview, facility staff stated that this was the result of a conduit that was removed and a smoke detector relocated.

11/1/10 - Fifth Floor
At 2:03 p.m., there was an approximately ? inch penetration around 3 grey and 1 tan wires in the ceiling in the communication closet (H5054).

11/1/10 - Fourth Floor
At 4:29 p.m., there was an approximately 1 inch penetration in the ceiling in the communication room (H4056).

11/2/10 - Third Floor
At 8:18 a.m., there was an approximately 3 inch penetration around a pipe on the left wall in the electrical panel room (H3021). The penetration was around a pipe. There was an approximately 2 ? x 4 inch penetration exposing insulation in the same area.

At 8:41 a.m., there was an approximately ? inches round, cut out, penetration in the break room, above the door (H3049).

At 8:52 a.m., there were seven approximately 1/8 to ? inch penetrations and an approximately 12 x 18 inch cut out square penetration in the key room. The penetrations were in the right wall. During an interview, facility staff stated that this was a result of new construction currently in progress.

At 8:56 a.m., there was an approximately 3 inch unsealed pipe in the ceiling in room H3057.
During an interview, facility staff stated that this is a result of the construction currently in progress and cables need to be pulled from the 5th floor to the basement for the patient monitoring.

Based on observation, the facility failed to maintain their doors. This was evidenced by twenty-nine corridor doors that were obstructed from closing or latching. This affected one of eight buildings and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the doors in the facility were observed.

Main Hospital:

1. On 11/2/10 at 9:32 a.m., the corridor door to room 215 (H2006) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 11/2/10 at 1:57 p.m., the corridor door to the Treadmill/Holter room HB157 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the floor transition.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the doors were observed and tested throughout the facility.

Main Hospital
11/1/10 - Fifth Floor
At 1:41 p.m., there was a walker and a garbage can impeding the door from closing to Room 512.

At 1:46 p.m., the door between the Nurse ' s office and the Annex Office closed but failed to latch. The door was equipped with a self-closing device.

At 1:58 p.m., the corridor door to the housekeeping closet (H5051) closed but failed to latch. The door was equipped with a self-closing device.

At 2:15 p.m., there was an over the bed table impeding the corridor door from closing to Room 527.

At 2:17 p.m., the corridor door to Room 529 (H5031) failed to fully close and latch. The door was equipped with a self-closing device.

11/1/10 - 4th Floor
At 3:43 p.m., the corridor door to Room 403 (H4070) was impeded from closing by a privacy curtain.

At 4:09 p.m., the corridor door to Room 418 was impeded from closing by a walker.

At 4:24 p.m., the corridor door to the Dialysis Storage Room (H4060) closed but failed to latch. The door was equipped with a self-closing device.

11/2/10 - 3rd Floor
At 7:56 a.m., the door to AHN Office (3101) was impeding from closing by a yellow door stopper and a chair.

At 8:46 a.m., the corridor door to Room 322 was impeded from closing by a privacy curtain.

11/2/10 - 1st Floor
At 9:49 a.m., the corridor door to Room 115 was impeded from closing by a garbage can.

At 9:51 a.m., the corridor door to Room 117 was impeded from closing by a sleep chair.

At 9:53 a.m., the corridor door to Room 120 was impeded from closing by a garbage can.

At 9:54 a.m., the corridor door to Room 121 was impeded from closing by a garbage can.

At 10:43 a.m., the corridor door to the AHN Office (H1045-1) was held open by a garbage can.

At 10:48 a.m., the door to the housekeeping closet in the ICU failed to fully close and latch.

At 11:04 a.m., the corridor door to the communication room, across Room 164 failed to fully close and latch. The door was equipped with a self-closing device.

At 11:26 a.m., the closet door inside the Lab closed but failed to latch. The door was missing the latching mechanism.

At 2:36 p.m., one of two doors to the Triage was obstructed from closing by a desk ' s upper shelves. The shelves did not allow the closure of the door.

At 2:42 p.m., the door between the Triage and the Charge Nurse ' s Room closed but failed to latch.

At 4:14 p.m., the corridor door to the restroom (H1128) did not fully close and latch. The door was equipped with a self-closing service.

11/3/10 - 1st Floor
At 7:40 a.m., the corridor to the Service League Room (H1095), closed but failed to latch.

At 7:58 a.m., the corridor door to the Case Management Office (H1051), failed to fully close and latch. The door was equipped with a self-closing device.

At 11:06 a.m., the corridor door to Porter's Closet failed to fully close and latch. The door was equipped with a self-closing device.

At 11:11 a.m., two of two corridor doors did not fully close and latch. The doors were equipped with self-closing devices.

At 11:12 a.m., the corridor door to the Mannitol Room closed but failed to latch. The door was equipped with a self-closing device.

At 11:15 a.m., the corridor door to the OR storage room did not have a latching mechanism.

Based on observation, the facility failed to maintain a door in a smoke barrier. This was evidenced by one smoke barrier door that was held open by an unapproved device. This affected one of six floors in the Main Hospital and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 11/2/10, the smoke barrier doors were observed.

Main Hospital:

On 11/2/10 at 11:01 a.m., the smoke barrier door adjacent to the stairwell (HB001) was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a wooden door wedge.

Based on observation, the facility failed to maintain an exit. This was evidenced by one location in the facility that did not have an exit directional sign posted that would direct patients to the nearest exit. This affected one of eight buildings and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff on 11/3/10, the facility's exits and egress paths were observed.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:40 p.m., the hallway door near the staff break room was observed. The door separated the Cardiovascular Diagnostic Center from another occupancy. The door was one of two remotely located egress paths in the facility. There was no exit signs in the area indicating that door would lead to an exit.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in five smoke barrier walls throughout the facility. This affected four of six floors in the Main Hospital and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes 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 of the 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 for 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's smoke barrier walls were observed.

Main Hospital:

On 11/1/10 at 3:45 p.m., the smoke barrier wall near the 3rd floor stairway H3044 was observed. There was one approximately one inch wide unsealed penetration in the portion of wall above the ceiling. Three cables were running through the penetration.



28602

During the facility tour and interview with facility staff on 11/1/10 to 11/4/10, the smoke barrier walls were observed.

11/1/10 - 5th Floor
At 1:03 p.m., there was an approximately 12 x 18 inch square, cut out, penetration in the smoke barrier wall by the Nutrition Station. The penetration was on the right side of the smoke barrier wall.

At 1:17 p.m., there was an approximately 1 x 3-4 inch penetration in the smoke barrier wall by the electrical panel FAPAD13. The penetration was underneath an approximately 3 - 4 inch pipe that had a bundle of green and white cables going through the pipe. Above the 3 - 4 inch pipe there was an approximately ? inch penetration around a pipe sleeve that had a bundle of purple wires.

11/1/10 - 4th Floor
At 2:41 p.m., there was an approximately 1 x 3 inch penetration in the smoke barrier wall by the Pulmonary Function Lab. The penetration was above a black pipe.

11/2/10 - 1st Floor
At 1:59 p.m., there was an approximately ? inch unsealed pipe sleeve in the smoke barrier wall by the Physician ' s Reading Room, between Registration and Diagnostic Imaging.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by two smoke barrier doors that were obstructed from closing or latching when the doors were released from their hold-open devices. This affected two of six floors in the Main Hospital and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the smoke barrier doors in the facility were observed.

Main Hospital:

On 11/2/10 at 10:39 a.m., the smoke barrier doors HB117 were equipped with self-closing devices and hold-open devices. The doors were released from the their hold-open devices and allowed to close. One of two door leafs of the smoke barrier doors failed to close. The door was obstructed from closing by a gurney positioned directly in the swing path of the door.



28602

During the facility tour with facility staff on 11/1/10 to 11/4/10, the smoke barrier doors were observed and tested.

11/3/10 - 1st Floor
At 10:19 a.m., the smoke barrier doors by the CT Scanner Room closed but failed to latch. The right door leaf failed to latch after activation of the Fire Alarm System.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one door to a hazardous area that was obstructed from latching and one hazardous area that was not equipped with a self-closing door. This affected two of eight buildings and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the hazardous areas in the facility were observed.

Main Hospital:

On 11/2/10 at 1:22 p.m., the corridor double doors to the Histology/Cytology Lab (HB077-2) were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two doors failed to latch. The door was obstructed from latching by the other door leaf.

Nancy Ausonio Mammography Center:

On 11/3/10 at 3:37 p.m., the soiled linen/biohazard waste room was observed. There was one large biohazard waste receptacle located inside the room. The door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by one emergency lighting unit that failed to illuminate when tested. This affected one of six floors in the Main Hospital and could result in a delayed evacuation in the event of an emergency due to limited visibility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the emergency lighting units in the facility were observed.

Main Hospital:

On 11/2/10 at 2:06 p.m., the emergency lighting unit in EKG Test Room HB163-2 was tested by pressing the test button on the unit. The lighting unit failed to illuminate when the test button for the device was pressed.

Based on observation, the facility failed to maintain their emergency exit signs. This was evidenced by one emergency exit sign that failed to remain illuminated when tested. This affected one of six floors in the Main Hospital and could result in a delayed evacuation in the event of an emergency due to limited exit sign visibility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the emergency lighting units in the facility were observed.

Main Hospital:

On 11/2/10 at 10:57 a.m., the emergency exit sign above the Cafeteria door HB135 was tested by pressing the test button on the unit. The exit sign failed to remain illuminated when the test button for the device was pressed.

Based on observation, the facility failed to maintain the integrity of the fire alarm system in accordance with the NFPA 72. This was evidenced by the failure of the manual pull alarm and two smoke detectors to activate an audible/visual alarm. This failure could result in a delay in notifying clients and staff in the event of a fire, affecting the entire building.

NFPA 101, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

Findings:

During fire alarm testing with facility staff on 11/3/10, a manual pull alarm and smoke detectors were tested.

MRI offsite building -
At 1:40 p.m., the smoke detector was tested. The smoke detector failed to activate an audible alarm and the strobe lights.

At 1:47 p.m., the manual pull alarm was tested. The manual pull alarm failed to activate an audible alarm and the strobe lights.

During an interview, facility staff stated that the smoke detector and manual pull alarm have always activated an audible alarm and strobe lights. Staff contacted personnel supervising main panel and were informed that the alarms were received at the main panel, at the Hospital.

During an interview, facility staff supervising main panel stated that the fire alarm system was disconnected from the main panel at the Hospital and would stand alone. Staff stated that the computers need to be updated at the main panel.

At 2:08 p.m. the smoke detector and the manual pull alarm were tested again and the audible alarm and the strobes were activated.

On 11/4/10, at 11:00 a.m., when reviewing the alarm activation reports, "Alarm Log Ad Hoc Report", there were no records of the alarm activation between 1:58 p.m., and 3:22 p.m., to indicate a signal was transmitted to the monitoring company.

Based on observation and interview, the facility failed to maintain their tamper valves. This was evidenced by one tamper valve that was moved from the open position to the closed position and failed to initiate an audible alarm and visual signal at the fire alarm control panel. This affected one of eight buildings and could result in a delayed notification of a suspension in water supply to the sprinkler system.

NFPA 101, 2000 edition
9.7.2.1 Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the automatic fire sprinkler system was observed.

Main Hospital:

On 11/3/10 at 9:26 a.m., the tamper valve (1.17.39) located in the soiled utility room on the 4th floor was turned from the open position to the closed position. The facility's fire alarm control panel did not receive an audible alarm or visual indicator that indicated the tamper valve was in the closed position. Fire Alarm Vendor 1 was interviewed at that time. Fire Alarm Vendor 1 indicated that the tamper switch was not aligned properly and that the switch itself was dirty and corroded.

Based on observation, record review, and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the two inspector's test valves that failed to initiate the fire alarm system, the facility's failure to have a current five year certification on two sprinkler systems, missing or misalignment of escutcheon fittings, sprinklers that were obstructed, and sprinkler heads and fittings that had accumulation of debris. This affected three of eight buildings and could result in a failure of the automatic fire sprinkler system.

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 1998 edition
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
9-4.1.2 Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-4.2.1 Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.
9-4.3.1.4 and 9-4.4.1.5 Strainers, filters, restricted orifices, and diaphragm chambers shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
9-5.1.2, 9-5.2.2, and 9-5.3.2 A full flow test shall be conducted on each valve at 5- year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be made in accordance with the manufacturer ' s instructions.

Findings:

During record review and a facility tour with staff from 11/1/10 to 11/4/10, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 11/2/10 at 9:51 a.m., the sprinkler head in closet H2027 had white paint on it. The sprinkler was missing an escutcheon fitting.

2. On 11/2/10 at 10:45 a.m., the sprinkler located in the janitor's closet in the kitchen (HB125) did not have eighteen inches around its deflector plate. The sprinkler deflector plate was level with the hard top ceiling. The sprinkler was missing an escutcheon fitting.

3. On 11/2/10 at 10:59 a.m., the sprinkler in the closet (HB0) was missing an escutcheon fitting.

4. On 11/3/10 at 8:42 a.m., the inspector's test valve located in the soiled utility room on the 5th floor was tested. The inspector's test valve did not activate the entire fire alarm system within ninety seconds. The doors wired to the fire alarm system released from their hold-open devices at the fifty-five second mark and the main fire alarm control panel received the signal within ninety seconds. The inspector's test valve was flowing water for one hundred and five seconds and did not activate the fire alarm strobes and chimes.

5. On 11/3/10 at 9:46 a.m., the inspector's test valve located in the soiled utility room on the 3rd floor was tested. The inspector's test valve did not activate the entire fire alarm system within ninety seconds. The main fire alarm control panel received the signal at the thirty-five second mark. The inspector's test valve was flowing water for one hundred and twenty-two seconds and did not activate the fire alarm strobes and chimes.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:45 p.m., the facility's automatic fire sprinkler system riser was tagged with a five year certification label dated 5/22/02. A current five year certification report for the automatic fire sprinkler system at that location was requested. The facility indicated that they would need time to search for that report. A five year certification for the automatic fire sprinkler system at that site was sent via electronic mail on 11/8/10. The five year report was dated 11/8/10. No documentation was viewed that indicated the facility had a five year certification on their automatic fire sprinkler system completed between 5/22/02 to 11/8/10. The facility was due for a five year certification on their automatic fire sprinkler system on 5/22/07.



28602

During the facility tour with facility staff on 11/1/10 to 11/4/10, the sprinkler heads were observed throughout the building.

11/1/10 - 5th Floor
At 1:32 p.m., there was an approximately ? inch gap between the escutcheon ring and the ceiling in clean utility room, exposing an approximately ? inch penetration.

At 1:35 p.m., the escutcheon ring in the soiled linen room had dust and lint buildup.

At 1:57 p.m., the escutcheon ring in the housekeeping closet (H5051) had dust and lint buildup.

11/1/10 - 4th Floor
At 4:08 p.m., the escutcheon ring was missing in Room 418 exposing an approximately 3 inch penetration. The sprinkler head was pushed up into the ceiling.

At 4: 26 p.m., the escutcheon ring was missing in the housekeeping room (H4052), exposing an approximately ? x 1 ? inch penetration at the ceiling.

11/2/10 - 3rd Floor
At 9:03 a.m., there was an approximately ? to 1 inch penetration the right side of the escutcheon ring in the housekeeping closet.

At 9:07 a.m., there was an approximately 1/8 to ? inch penetration around the escutcheon ring in Room 343. The penetration was at the ceiling.

At 10:08 a.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in restroom H1062.

At 10:09 a.m., there was an approximately ? to 1 inch gap between the escutcheon ring and the ceiling in restroom H1063, exposing an approximately ? inch penetration around the sprinkler pipe.

At 2:28 p.m., there was an approximately 1/8 x 1 inch penetration around the escutcheon ring, at the ceiling, in the Lab and Procedure Room, at the door entrance.

At 2:52 p.m., 1 of 4 escutcheon rings was missing in the Cath Lab Computer Room.

At 2:59 p.m., 1 of 2 escutcheon rings was missing in the Cath Lab Control Room.

At 3:58 p.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in the ES Closet, across the Ultra Sound Room.

11/3/10 - 1st Floor
At 7:50 a.m., 1 of 2 escutcheon rings was missing in the Meditation Room (H1089), exposing an approximately a ? inch penetration around the sprinkler pipe.

At 7:58 a.m., 2 of 7 escutcheon rings were missing in Level II, RN area, above the unit assistant ' s desk, exposing an approximately ? penetrations around the sprinkler pipes.

At 10:52 a.m., there was an approximately 1/4 inch gap between the escutcheon ring and the ceiling in the Sub Sterile Room, exposing an approximately ? inch penetration.

At 10:57 a.m., there was an approximately ? to ? inch gap between the escutcheon ring and the ceiling in the OR scheduling office, exposing an approximately ? inch penetration.

At 10:59 a.m., the escutcheon ring was missing in the hallway in the OR, in front of OR 6, exposing an approximately 1 inch penetration around sprinkler head.

At 11:03 a.m., there was an approximately ? inch gap between the escutcheon ring and the ceiling in OR 6, exposing an approximately ? inch penetration.

At 11:04 a.m., there was an approximately ? to ? inch gap between 2 of 5 escutcheon rings, exposing approximately ? inch penetrations.

At 11:05 a.m., the escutcheon ring was missing in the Porter ' s Closet, exposing an approximately ? to ? inch penetration in the ceiling.

At 11:10 a.m., there was an approximately 1 to 1 ? inch gap between the escutcheon ring and the ceiling in the Biohazard Room in the OR department, exposing an approximately ? inch penetration.

11/3/10 - Cardiac Rehab
At 2:57 p.m., there was an approximately ? x 1 ? inch penetration around 1 of 5 escutcheon rings in the hallway by the copy room area.

At 2:59 p.m., there was a missing escutcheon ring at the entrance door, exposing an approximately ? inch penetration at the ceiling.

At 3:02 p.m., there was storage within 4 inches of the deflector in the exercise room closet. There were 2 racks with CDs.

At 3:20 p.m., the 5 year certification for the sprinkler system was requested.

11/4/10 - Cardiac Rehab
At 9:05 a.m., the 5 year certification for the sprinkler system was requested.

11/8/10
At 9:45 a.m., the facility provided a 5 year certification for the sprinkler system dated 11/5/10, conducted the day after the validation was completed. The 5 year cerfication indicated the system had failed.

At 12:48 p.m., the facility provided this information via e-mail: "We have been unable to locate a previous 5-year certification. I will continue to look - but, we will probably have to go forward without a previous certification".

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by two fire extinguishers that have not had an annual service and inspection within the past twelve months, one fire extinguisher that was not mounted, and one fire extinguisher that was obstructed. This affected one of six floors in the Main Hospital and could result in a delay to extinguish a fire in the event of an emergency.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
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).
4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's portable fire extinguishers were observed.

Main Hospital:

1. On 11/2/10 at 10:35 a.m., the fire extinguisher in the staff office HB118 was resting on the floor near the door to that room. There were no mounting brackets on the walls in the area. The service tag for the fire extinguisher was dated January 2009. The fire extinguisher was nine months overdue for an annual service and inspection.

2. On 11/2/10 at 10:49 a.m., the class K fire extinguisher in the Basement level kitchen was observed. The fire extinguisher had its access obstructed a cart that had a food preparation device stored on top of it.

3. On 11/2/10 at 11:08 a.m., the fire extinguisher mounted on the wall in the Basement level New Pharmacy entrance was observed. The service tag on the fire extinguisher was dated September 2008. The fire extinguisher was thirteen months overdue for an annual service and inspection.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by items stored in the corridor and in front of smoke barrier doors. This affected four of six floors in the Main Hospital and could result in a delayed evacuation due to an impeded means of egress.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's egress paths were observed.

Main Hospital:

On 11/2/10 at 9:54 a.m., the smoke barrier doors H2030 were observed. A food service cart was positioned directly in front of one side of the smoke barrier doors and a surgery preparation cart was positioned directly in front of the other side of the smoke barrier doors. The carts needed to be moved to completely open the smoke barrier doors.



28602

During the facility tour and interview with facility staff on 11/1/10 and 11/4/10, the means of egress were observed.

11/1/10 - 5th floor
At 2:13 p.m., there were 3 Work Stations on Wheels between Room H5024 and the Nurse's Office. During an interview, Staff 2 stated that the work stations are normally stored there.

11/2/10 -
At 3:02 p.m., there were 3 metal storage shelves, 6 to 7 ft, outside the Cath Lab in the corridor. Staff 2 stated that these shelves are always stored at this location due to the lack of storage.

11/3/10 -
At 10:54 a.m., there was a clean linen cart with 3 shelves, 1 trash container, and 1 soiled linen container in the corridor next to OR 3. OR staff stated these items are always stored there.

Based on observation, the facility failed to maintain their oxygen storage locations. This was evidenced by one liquid oxygen supply enclosure that was not equipped with a lock, three oxygen storage areas that did not have signs indicating oxygen was stored at those locations, and one oxygen E cylinder that was free standing and unsecured. This affected two of eight buildings and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Enclosures for supply systems shall be provided with doors or gates. If the enclosure is outside and/or remote from the single treatment facility, it shall be kept locked. If the storage area is within the single treatment facility (i.e., is not remote), it shall be permitted to be locked.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the oxygen storage locations were observed.

Main Hospital:

1. On 11/2/10 at 9:46 a.m., there were seventeen oxygen E cylinders stored inside the storage room H2032-1. There was no signs on the outside of the room indicating that oxygen was being stored at that location.

2. On 11/2/10 at 1:28 p.m., the liquid oxygen supply system enclosure was observed. The enclosure was located outside near the north end of the campus. There was no lock on the enclosure to prevent from unauthorized access or tampering.



28602

During the facility tour with facility Staff on 11/1/10 to 11/4/10, the oxygen storage areas were observed.

NFPA 99, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

11/1/10 - 4th Floor

At 4:22 p.m., there were 10 E oxygen cylinders stored in a rack, 3 E oxygen cylinders secured to the wall, and one liquid oxygen cylinder secured to the wall in Room H 4047. There was no sign on the door indicating oxygen was stored in the room.

11/2/10 - 1st Floor

At 10:03 a.m., there were 12 E oxygen cylinders stored in a rack in the Utility Room. There were 11 E oxygen cylinders full and 1 empty. The full and empty cylinders were mixed. There was no sign on the door indicating oxygen was stored in the room.

11/3/10 - Offsite MRI Building

At 1:25 p.m., there was 1 E oxygen cylinder unsecured in the sedation waiting area. The cylinder was standing in close proximity to a patient bed.

Based on record review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to adopt and have a documented policy and procedure for monitoring the relative humidity levels at their anesthetizing location and the facility's failure to maintain the relative humidity level at thirty-five percent or above. This affected eight of eight anesthetizing locations in the Main Hospital and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review from 11/1/10 to 11/4/10, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

On 11/4/10 at 8:45 a.m., the relative humidity logs for the facility's anesthetizing locations were observed. Eight of Eight anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months. The policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing locations was requested at that time. Engineering Staff 2 indicated that the facility does not have a documented policy or procedure for monitoring relative humidity levels. Engineering Staff 2 indicated that the facility follows the Association of preOperative Registered Nurses (AORN) guidelines. AORN guidelines suggest relative humidity levels be maintained at twenty to sixty percent for anesthetizing locations.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of unapproved extension cords as a substitute for permanent wiring, extension cords plugged into other extension cord, high powered appliances that were plugged into extension cords, electrical panelboards that did not have three feet of clearance, and electrical receptacles that were missing faceplates. This affected three of eight buildings and could result in an electrical fire to occur.

NFPA 70, 1999 edition
110-26(a)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.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff from 11/1/10 to 11/4/10, the facility's electrical equipment and wiring were observed.

Main Hospital:

1. On 11/2/10 at 9:15 a.m., computer equipment in the Mother Baby staff office H2108 was plugged into two surge protected multi-outlet extension cords that were plugged into one surge protected multi-outlet extension cord.

2. On 11/2/10 at 9:25 a.m., computer equipment in the Audio Visual room H2117 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord.

3. On 11/2/10 at 9:42 a.m., two portable space heaters in staff office H2033-1 were each plugged into separate surge protected multi-outlet extension cords.

4. On 11/2/10 at 9:43 a.m., computer equipment in staff office H2033-1 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

5. On 11/2/10 at 10:34 a.m., computer equipment in staff office HB118 was plugged into two surge protected multi-outlet extension cords that were both plugged into another surge protected multi-outlet extension cord.

6. On 11/2/10 at 10:46 a.m., two electrical panelboards located in the kitchen near room HB125 did not have three feet of clearance. The panelboards were obstructed by two food service carts positioned directly in front of them.

7. On 11/2/10 at 1:36 p.m., telephone equipment in staff office HB097 was plugged into a maroon non-surge protected multi-outlet extension cord.

8. On 11/2/10 at 1:42 p.m., computer equipment in staff office HB098 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

9. On 11/2/10 at 1:43 p.m., a portable space heater in staff office HB098 was plugged into a surge protected multi-outlet extension cord. The portable space heater was positioned under a table and had a small recycle receptacle positioned directly in front of it.

10. On 11/2/10 at 1:49 p.m., computer equipment in Registration Management was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

11. On 11/2/10 at 1:50 p.m., a miniature refrigerator in Registration Management was plugged into a surge protected multi-outlet extension cord.

12. On 11/2/10 at 1:51 p.m., a clock in Registration Management was plugged into a yellow non-surge protected extension cord.

13. On 11/2/10 at 2:02 p.m., two miniature refrigerators in staff office area HB161 were plugged into one surge protected multi-outlet extension cord that was plugged into one black non-surge protected extension cord.

14. On 11/2/10 at 2:13 p.m., computer equipment in staff office HB171 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

Cardiovascular Diagnostic Center:

On 11/3/10 at 1:35 p.m., an electrical wall receptacle in the Hot Lab room was missing a faceplate.

Sleep Lab:

On 11/3/10 at 2:47 p.m., an electrical wall receptacle in the Telecommunications room was missing a faceplate.



28602

During the facility tour with facility staff on 11/1/10 to 11/3/10, the electrical wiring and connections were observed.

11/1/10 - 4th Floor
At 4:02 p.m., there was a heavy duty orange extension cord with three plugs connected to the wall. The extension cord was connecting a surge protector that was connecting a radio, desk light and a "Pyxis Connect Plus" machine.

11/2/10 - 3rd Floor
At 8:32 a.m., the electrical panel inside the copy room (H3038) did not have a 3 ft clearance. There was a book shelf and a copy machine directly in front of the electrical panel.

At 8:38 a.m., the refrigerator in the storage room (H3039) was plugged into an extension cord connected to the wall outlet.

At 8:42 a.m., the electrical panel in the equipment room (H3050) did not have a 3 ft clearance. There was a bassinet, and an ENT machine directly in front of the SB3 panel.

At 11:34 a.m., three electrical panels in the Lab area did not have a 3 ft clearance. A copy machine was directly in front of electrical panels LEC, LB, LEA and LD.

11/3/10 - 1st Floor
At 8:01 a.m., the 2 electrical panels in level II, across room 114 did not have a 3 ft clearance. There was a copy machine directly in front of the panels.