HospitalInspections.org

Building 1:

Based on observation and interview, the facility failed to ensure projections (i.e. alcohol based hand rub dispensers) are not more than 4 inches from the corridor wall. The Centers for Medicaid Medicare Services (CMS) Final Rule issued on May 4, 2016 is enforcing 4" projections into the corridor per Americans with Disabilities Act (ADA) requirements. Projections too far into the corridors is likely to create problems with evacuation during an emergency, especially for those with disabilities that may require the use of handrails mounted along the walls, which presents the risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 05/30/17 at 8:30 am, during observation, alcohol based hand rub dispensers (ABHR's) located on the 5th floor projected from the wall six (6) inches.

B. On 05/30/17 at 8:30 am, during interview, the Accreditation and Regulatory Response Director stated the facility is in the process of replacing the ABHR's with ones that are 4 inches deep from the wall. She stated they recognized that the dispensers were projecting a bit too far past the handrail.

Building 3:

NFPA 101 Life Safety Code (2012 Edition)

7.2.2.5.4* Stairway Identification.
7.2.2.5.4.1 New enclosed stairs serving three or more stories and existing enclosed stairs serving five or more stories shall comply with 7.2.2.5.4.1(A) through 7.2.2.5.4.1(M).
(A) The stairs shall be provided with special signage within the enclosure at each floor landing.
(B) The signage shall indicate the floor level.
(C) The signage shall indicate the terminus of the top and bottom of the stair enclosure.
(D) The signage shall indicate the identification of the stair renclosure.
(E) The signage shall indicate the floor level of, and the direction to, exit discharge.
(F) The signage shall be located inside the enclosure approximately 60 in. (1525 mm) above the floor landing in a position
that is visible when the door is in the open or closed position.
(G) The signage shall comply with 7.10.8.1 and 7.10.8.2 of this Code.
(H) The floor level designation shall also be tactile in accordance with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities.
(I) The signage shall be painted or stenciled on the wall or on a separate sign securely attached to the wall.
(J) The stairway identification letter shall be located at the top of the sign in minimum 1 in. (25 mm) high lettering and shall be in accordance with 7.10.8.2.
(K)* Signage that reads NO ROOF ACCESS and is located under the stairway identification letter shall designate stairways
that do not provide roof access. Lettering shall be a minimum of 1 in. (25mm) high and shall be in accordance with 7.10.8.2.


Based on observation and interview, facility failed to ensure signage was posted (Tower 1), at the top of stair well # 5, to indicate (NO ROOF ACCESS). Not having signage to indicate there is no exit traveling upward from level 5 in stairwell #5, could result in the delay of occupants being evacuated from the stairwell in the event of a fire/emergency evacuation. This failed practice presents a likelihood of injury to all patients, staff and occupants located within the fifth (5th), floor of Tower 1. The findings are:

A. On 05/25/17 at 10:30 am, observation of no signage located in stairwell #5 (exiting the 5th floor, through the stairwell), to indicate that there is no exit up to the roof.

B. On 05/25/17 at 10:45 am, during interview, Security personnel stated "facility has security measures in place for the Birthing Unit located on level five (5), no re-entry is allowed back into this level from another level", although the signage should be in place. Acknowledging the finding.

Building 1:

Reference NFPA 72, 2010 Edition

Section 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.


Based on observation and interview, the facility failed to ensure the circuit breaker, which serves and is solely dedicated to the fire alarm control panel, was mechanically protected (mechanism preventing circuit breaker from being switched off) and identified with a red marking in accordance with NFPA 72 (National Fire Alarm Code). This deficient practice presents a risk that the fire alarm system may not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner. An unlocked alarm panel breaker could potentially be accidentally switched to the "off" position during electrical maintenance work and not switched back "on". This deficient practice presents a risk of potential harm by fire to all patients, visitors and staff. The findings are:

A. On 06/01/17 at 2:30 pm, during observation and interview, circuit control or electrical breakers #14 and #18 on the S1 floor dedicated to the fire alarm system was not mechanically protected.

B. On 06/01/17 at 2:35 pm, during interview, the Director of Facilities Engineering acknowledged the findings.

Building 3:

NFPA 101 Life Safety Code (2012 Edition)

19.3.4.2.1 Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems, unless otherwise permitted by 19.3.4.2.2 through 19.3.4.2.4.

NFPA 101 Life Safety Code (2012 Edition)

9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation the complete fire alarm system shall be initiated by, but shall not be limited to, any or all of the following means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.2.2 Manual fire alarm boxes shall be used only for fire protective signaling purposes. Combination fire alarm and guard's tour stations shall be acceptable.
9.6.2.3 A manual fire alarm box shall be provided as follows, unless modified by another section of this Code:
(1) For new alarm system installations, the manual fire alarm
(2) For existing alarm system installations, the manual fire alarm doorways.
9.6.2.4 Manual fire alarm boxes shall be mounted on both sides of grouped openings over 40 ft (12.2 m) in width, and within 60 in. (1525 mm) of each side of the opening.
9.6.2.5* Additional manual fire alarm boxes shall be located so that, on any given floor in any part of the building, no horizontal distance on that floor exceeding 200 ft (61 m) shall need to be traversed to reach a manual fire alarm box.


Based on observation and interview, facility failed to ensure that manual fire alarm pull boxes were installed in all penthouse buildings located on the penthouse level (Level 6). Not having manual fire alarm pull boxes installed at all required exits, could result in the inability to activate the fire alarm by manual means in the event of fire. This failed practice presents a likelihood of injury by fire to all patients, staff and occupants of the Hospital. The findings are:

A. On 05/31/17 at 10:40 am, observation of no manual fire alarm boxes located in the Penthouse (HVAC Rooms), located on the penthouse level (Level 6), in Tower 1. A total of four (4), HVAC buildings located on the 6th level.

B. On 05/31/17 at 10:50 am, Security Personnel stated he was unaware the manual fire alarm boxes had not been installed in these locations, acknowledging the finding.

Building 4:

Reference NFPA 13, 2010 Edition

8.3 Use of Sprinklers.
8.3.1 General.

8.3.1.1* Sprinklers shall be installed in accordance with their
listing.

Upright Sprinkler. A sprinkler designed to be installed in such a way that the water spray is directed upwards against the deflector.

Pendant Sprinkler. A sprinkler designed to be installed in such a way that the water stream is directed downward against the deflector.


Based on observation and interview, the facility failed to ensure fire sprinkler heads were installed in accordance with their listing as required by NFPA 13 (Standard for the Installation of Sprinkler System). This failied practice resulted in a upright head installed in the pendant position. It is important that sprinklers are installed in accordance with their listing to ensure proper sprinkler coverage in the event of fire. Without the proper sprinkler coverage, fire is likely to spread to and from areas of the facility, which presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:

A. On 06/01/17 at 7:30 am, during observation, a upright sprinkler head was installed in the pendant position within the corridor near the cleaning storage and house keeping rooms located in the sleep center.

B. On 06/01/17 at 7:35 am, during interview, the Engineering Manager stated they never noticed the sprinkler was installed incorrectly. He stated the sprinkler head may have been there since the building was constructed.

Based on observation and interview, the facility failed to ensure the automatic fire sprinkler system was installed in all areas of the facility as required by NFPA 13, (Standard for the Installation of Sprinkler Systems). Not providing sprinklers in all required areas of the smoke compartment is likely to allow the development and spread of fire from these unprotected areas into other areas of the building, which presents a likelihood of harm to patients, staff, and visitors of the facility. The findings are:

A. On 05/31/17 at 6:00 am, during observation, the laminar flow room was not protected by the fire sprinkler system. The entire smoke compartment was protected by the fire sprinkler system with exception to this space. This space measured 2 1/2 feet wide by 20 feet long.

B. On 05/31/17 at 6:05 am, during interview, the Director of Facilities Engineering stated the space was modified to house some laminar flow equipment. He stated they never realized the space was not sprinklered.

Building 3:

Reference NFPA 25, 2011 Edition

5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions
if necessary.

5.3.4.1* Solutions shall be in accordance with Table 5.3.4.1(a) and Table 5.3.4.1(b).

5.3.4.1.1* Listed CPVC sprinkler pipe and fittings shall be protected from freezing with glycerin only. The use of diethylene, ethylene, or propylene glycols shall be specifically prohibited.

5.3.4.1.2 The concentration of antifreeze solution shall be limited to the minimum necessary for the anticipated minimum temperature.

5.3.4.2 The use of antifreeze solutions shall be in accordance with any state or local health regulations.

5.3.4.3 The antifreeze solution shall be tested at its most remote portion and where it interfaces with the wet pipe system.

5.3.4.3.1 When antifreeze systems have a capacity larger than 150 gal (568 L), tests at one additional point for every 100 gal (379 L) shall be made.

5.3.4.3.2 If the test results indicate an incorrect freeze point at any point in the system, the system shall be drained, the solution adjusted, and the systems refilled. 5.3.4.3.3 For premixed solutions, the manufacturer ' s instructions shall be permitted to be used with regard to the number of test points and refill procedure.


Based on record review and interview, the facility failed to ensure the specific gravity and the concentration of the antifreeze solution used in the piping to protect the automatic sprinkler system from freezing was being tested at least every 12 months as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA Tentative Interim Amendment (TIA) 11-1. This failed practice is likely to result in the fire sprinkler system located at the loading dock to freeze during times of freezing conditions, which could result in this area of the facility not being properly protected in the event of a fire. Also, some varieties of antifreeze solutions are flammable in character when not properly mixed. High concentration of antifreeze solution used in the sprinkler system piping is combustible in character and accelerates fire. In the event of fire, this failed practice presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:


A. Review of the Annual Fire Sprinkler Inspection dated 02/23/17 failed to indicate any record of the specific gravity (freezing point) of the antifreeze solution and the concentration of the antifreeze solution used in the facility's antifreeze system located at the loading dock.

B. Review of the Fire Sprinkler Quarterly Inspections dated 08/16/16 and 11/28/16 both noted that the last time the specific gravity of the antifreeze was tested was on 03/10/14. There was no record noting the last date the antifreeze solution was tested annually since 03/10/14.

C. On 05/24/17 at 11:00 am, during interview, the Fire Safety Officer stated he was unaware the professional company was not testing the antifreeze solution freezing point and concentration at least annually. He stated they [professional company] know to test that system annually, but they must be forgetting.

Building 3:

Reference NFPA 10, 2010 Edition

6.1.3.10 Cabinets.

6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.

6.1.3.10.2 The location of fire extinguishers as described in 6.1.3.3.2 shall be marked conspicuously.


(Appendix included for guidance only)
A.6.1.3.3.2 Acceptable means of identifying the fire extinguisher locations include arrows, lights, signs, or coding of the wall or column.

Based on observation and interview, the facility failed to ensure fire extinguisher cabinets were marked conspicuously to indicate the extinguisher location as required by NFPA 10 (Standard for Portable Fire Extinguishers). The locations of these fire extinguishers housed in unmarked cabinets may not be apparent and are likely to result in delay in extinguishing a developing fire. This failed practice presents a likelihood of harm to patients, staff, and visitors located on 3rd floor and lower level of Tower II. The findings are:

A. On 05/31/17 at 10:00 am, during observation, the fire extinguisher cabinet located on the 3rd floor of Tower II, near patient room #3221, was not marked conspicuously (readily visible or observable) with signage.

B. On 05/31/17 at 10:20 am, during observation, the fire extinguisher cabinet located on the 3rd floor of Tower II, near patient room #3209, was not marked conspicuously with signage.

C. On 05/31/17 at 12:00 pm, during observation, the fire extinguisher cabinets located throughout the lower level of Tower II were not marked conspicuously with signage.

D. On 05/31/17 at 12:10 pm, during interview, the Safety Officer stated they never noticed that many of the fire extinguisher cabinets were not labeled. He stated that all the fire extinguisher cabinets need to be more visible, which may be better addressed by including signage at the top of each cabinet visible from several directions.

Building 1:

Reference NFPA 101, 2012 Edition

19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure that the smoke barrier on the L1 floor and S2 floor were maintained and properly protected from openings in accordance with NFPA 101 (Life Safety Code) section 8.5. These unprotected openings would permit the passage of smoke from one smoke compartment to another, which presents a likelihood of harm to all patients, staff and visitors. The findings are:


A. On 05/30/17 at 10:00 am, during observation, the smoke barrier on the L1 floor at the north/south corridor separating smoke compartments 1 and 2 had several conduit and cable unsealed wall penetrations

B. On 05/30/17 at 10:35 am, during observation, the smoke barrier on the L1 floor at the north/south corridor separating smoke compartments 1 and 2 had an unsealed structural member (building support component).

C. On 05/30/17 at 10:45 am, during observation, the smoke barrier on the L1 floor at the east end of the east/west corridor in Smoke Compartment 4 had an unsealed duct.

D. On 05/30/17 at 2:15 pm, during observation, the smoke barrier on the S1 floor at the east/west corridor separating Smoke Compartments 3 and 2 had an unsealed cable penetration.

E. On 05/30/17 at 2:20 pm, during interview, the Director of Facilities Engineering acknowledged these findings.

Building 4:

Reference NFPA 101, 2012 Edition

19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.5.6 Penetrations.

8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Based on observation and interview, the facility failed to ensure that the smoke barriers were maintained and properly protected from openings in accordance with NFPA 101, section 8.5. These unprotected openings would permit the passage of smoke from one smoke compartment to another, which presents a likelihood of harm to patients, staff and visitors. The findings are:


A. On 06/01/17 at 5:40 am, during observation, the smoke barrier at the entrance to the In-patient S10 area had an unsealed conduit.

B. On 06/01/17 at 5:50 am, during observation, the smoke barrier at the south end of the north/south corridor, south of the Triage room in the Pain and Spine area of building had two openings in the wall approximately 12 inches by 18 inches in size.

C. On 06/01/17 at 6:35 am, during observation, the smoke barrier the north end of the north/south corridor west of the courtyard had two unsealed conduits.

D. On 06/01/17 at 6:55 am, during observation, the smoke barrier at the north end of equipment storage corridor west of suite 1 had an opening approximately 2 inches by 2 inches in size.

E. On 06/01/17 at 7:10 am, during observation, the smoke barrier west of the main entrance to the building had several wall openings.

F. On 06/01/17 at 7:15 am, during interview, the Engineering Manager acknowledged the findings of these penetrations.

Building 3:

Based on observation and interview, the facility failed to ensure elevator communications from within the elevator were reporting the exact location of elevator to Security Station. This failed practice may result in the delay to patients during an evacuation, loss of power, or other type of emergency, which presents a likelihood of physical injury to all in the facility. The findings are:

A. On 05/30/17 at 11:00 am, during observation, there was no communication to the Security station from Elevator B-2, (located in Tower 1).

B. On 05/30/15 at 11:15 am, during interview, Security Officer and Maintenance Personnel confirmed the finding.

Building 3:

Reference NFPA 82, 2009 Edition

Definition:
3.3.1.3 Limited Access Chute. Chute not capable of being accessed by the general public with a restriction on use to authorized personnel.


5.2* Gravity Waste or Linen Chutes.

5.2.1.1 Linen gravity chutes shall only be limited access chutes.

5.2.1.2 A limited access chute shall be secured either by locking the intake door or the entry door into the service room so that it can be used only by authorized personnel.


Based on observation and interview, the facility failed to ensure limited access linen and waste chute entry doors were kept locked so that they can be used only by authorized personnel as required by NFPA 82 (Standard on Incinerators and Waste and Linen Handling Systems and Equipment). Not locking these entry doors is likely to result in unauthorized personnel tampering with the chute or falling down the chute to the lower level. This failed practice presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:

A. On 05/31/17 at 10:45 am, observation of the double doors, located in a corridor wall, that serve as entry doors to access the linen and waste chutes were able to be pulled open even when the latch was locked. One door leaf was supplied with a manual flush bolt that was not locked in place, which allowed the doors to be pulled open.

B. On 05/31/17 at 10:50 am, during interview, the Safety Officer stated the doors are required to be locked and was unsure why they were able to be opened.

C. On 05/31/17 at 10:52 am, during interview, the Maintenance Engineer stated the doors require an automatic flush bolt instead of a manual flush bolt in order for the doors to lock properly, otherwise staff will lock one side, but will forget to lock the manual side and both doors would open as they just did now.

Building 1:

82-12 INCINERATORS AND WASTE AND LINEN HANDLING SYSTEMS AND EQUIPMENT
2009 Edition

5.2* Gravity Waste or Linen Chutes.

5.2.6 Automatic Sprinklers.

5.2.6.1 Gravity Chute.

5.2.6.1.1 Gravity chutes shall be protected internally by automatic
sprinklers.

5.2.6.1.2 This protection requires that a sprinkler be installed
at or above the top service opening of the chute.

5.2.6.1.3 This protection requires automatic sprinklers installed
in gravity chute service openings shall be recessed out
of the chute area through which the material travels.

5.2.6.1.4 In addition, a sprinkler shall be installed within the
chute at alternate floor levels in buildings over two stories in
height, with a mandatory sprinkler located at the lowest service
level.


Based on observation and interview, the facility failed to ensure that sprinklers are installed in the waste and linen chutes in accordance with NFPA 82, (Standard on Incinerators and Waste and Linen Handling Systems and Equipment). This failed practice is likely to result in a developing fire to travel up the chute(s), which presents a likelihood of harm to patients, staff and visitors. The findings are:

A. On 06/01/17 at 9:10 am, during observation, the waste and linen chutes on the L3 floor were not protected with a sprinkler.

B. On 06/01/17 at 2:25 pm, during observation, the waste and linen chutes on the S2 floor were not protected with a sprinkler.

C. On 06/01/17 at 2:30 pm, during interview, the Director of Facilities Engineering acknowledged these findings.

Building 1:

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all three nursing shifts to ensure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:

A. Record review of the fire drill log indicated the facility had three (3) nursing shifts:

First Shift (7:00 am - 3:00 pm)
Second Shift (3:00 pm - 11:00 pm)
Third Shift (11:00 pm - 7:00 am)

B. Record review of the fire drill log revealed that only one fire drill has been conducted on the 3rd shift for 2017. This fire drill was conducted on 05/08/17.

C. On 05/24/17 at 11:45 am, the Fire Safety Officer went through the fire drill log and confirmed that the drill conducted on 05/08/17 was the only drill conducted on the 3rd shift for the year 2017.

D. On 05/24/17 at 1:10 pm, the Safety and Ergonomics Manager stated their intent was to conduct a change of shift drills with the operating rooms in January, but it didn't work out as planned. He stated the spacing must have gotten off track after that.

Building 3:

Based on observation and interview, the facility's practice failed to ensure electrical outlets within 6 feet of a water supply were equipped with Ground Fault Circuit Interrupters (GFCI) as required by NFPA 70 (National Electrical Code), which resulted in a hydrocollator (a device that consists of a thermostatically controlled water bath for placing bentonite-filled cloth heating pads) plugged into a standard regular electrical outlet within the Rehab Services room #1515. In the event moisture from the hydrocollator comes into contact with a standard electrical outlet, this outlet is not designed to cut off the electrical supply to the hydrocollator, which presents a likelihood of harm to patients and staff in the physical therapy room. The findings are:


A. On 05/31/17 at 2:00 pm, based on observation, the hydrocollator located in the rehabilitation services room was plugged into a standard electrical outlet instead of the required GFCI outlet.The distance between the hydrocollator and the standard electrical outlet was approximately 12 inches.

B. On 05/31/17 at 2:05 pm, during interview, the Engineering Manager acknowledged the finding.

Building 4:

Reference NFPA 110, 2010 Edition

5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.


(Appendix included for guidance only, not regulatory)
A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.


Based on observation and interview, the facility failed to ensure a remote manual stop station, which shuts down the generator manually in the event of emergency such as fire, was provided external to the emergency generators weatherproof enclosure as required by NFPA 110 (Standard for Emergency and Standby Power Systems). Not having a remote emergency stop external to the generator's weather proof enclosure may result in harm to persons, fire, mechanical damage, and inadvertent or unintentional operation of the emergency generator. In the event the emergency generator can't be shut down quickly due to the above circumstances, may result in harm to service personnel as well as mechanical failure. Mechanical failure is likely to result in an unreliable source of secondary power in the event of primary power failure, which presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:

A. On 06/01/17 at 8:40 am, observation of the new emergency generator revealed two manual emergency stop buttons, one was located internal to the weatherproof enclosure and the remote manual emergency stop button was located external to the enclosure. Upon observation, the wires supplying the external emergency stop were not connected which means the remote emergency stop would not have shut the emergency generator down in the event of emergency such as fire.

B. On 06/01/17 at 8:50 am, during interview, the Engineering Manager stated the generator and the underground fuel tank were recently installed. He stated the facility now has two generators to supply power to the facility. He stated the remote emergency stop (external to the enclosure) was not secured from the public right of way so the facility was worried that the public could shut down the generator in the event it was running. He stated they are in the process of figuring out how to protect the emergency stop from being inadvertently shut off after they have wired it in.

Building 4:

Reference NFPA 99, 2012 Edition

11.3.3.3 When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders.


Based on observation and interview, the facility failed to ensure gas cylinders were properly chained or supported in a proper cylinder stand, cart or rack as required by NFPA 99 (Standard for Health Care Facilities). Cylinders are highly pressurized vessels, and improper handling is likely to result in accidental discharge, which presents a likelihood of harm to patients, staff and visitors of the facility. The findings are:

A. On 06/01/17 at 6:15 am, during observation of the linear accelerator service room, there were two size D sulfur exiflouride compressed gas cylinders, freestanding on the floor.

B. On 06/01/17 at 6:12 am, during interview, the Engineering Manager stated the cylinders should be secured to the wall in a rack or stand.