HospitalInspections.org

Based on observation and interview, the facility failed to maintain a 2-hour rated occupancy separation wall. This was evidenced by fire doors located at a 2-hour fire barrier wall separation with unknown fire rating. This had the potential to not have the correct fire protection that could cause injury to the patients. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating

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

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the facility's occupancy separation barriers were observed.

Basement Level, HOSPITAL-A:
On 4/29/2014, at 9:00 a.m., the occupancy separation fire doors located on the Basement level of HOSPITAL-A were not labeled to identify their fire rating. The door was an entrance into the passageway tunnel to the CLASSIC BUILDING and MOB 1 & 2. The fire doors are required to be rated at a minimum fire protection rating of 90-minutes (1.5 hours) at 2-hour fire rated wall separations. During an interview with the Chief Engineer of Facilities Services on 5/6/2014, at 8:30 a.m., he stated that the rating of the door could not be identified.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke and fire. This was evidenced by a corridor door that failed to latch and by corridor doors that were obstructed from closing. This had the potential to allow the spread of smoke and fire, resulting in injury patients. This affected one of eight levels at HOSPITAL-A and one of five levels at the CLASSIC BUILDING.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the corridor doors were observed.

First Floor, HOSPITAL-B:
1. On 4/29/2014, at 10:20 a.m., the corridor door to Triage 4 (door #1304), located in the Emergency Department, failed to positive latch to stay closed. The door lead into the waiting room.

First Floor, CLASSIC BUILDING:
2. On 5/6/2014, at 11:11 a.m., the corridor door labeled Endoscopy 1 (door #1329), located in the GI Lab, was obstructed from closing by a rubber wedge placed at the base of the door.

3. On 5/6/2014, at 11:12 a.m., the corridor door labeled Sigmoid 2 (door #1328), located in the GI Lab, was obstructed from closing by a rubber wedge placed at the base of the door.

4. On 5/6/2014, at 11:13 a.m., the corridor door labeled Holding Area (door #1321), located in the GI Lab, was obstructed from closing by a rubber wedge placed at the base of the door.

5. On 5/6/2014, at 11:13 a.m., the corridor door labeled Pulmonary Lab (door #1336), located in the GI Lab, was obstructed from closing by a rubber wedge placed at the base of the door.

6. On 5/6/2014, at 11:14 a.m., the corridor door (door #1338), located in the GI Lab, was obstructed from closing by a scale placed in front of the door.

7. On 5/6/2014, at 11:15 a.m., the corridor door (door #1313), located in the GI Lab, was obstructed from closing by a trash can placed in front of the door.

Based on observation and record review, the facility failed to maintain their vertical openings. This was evidenced by unsealed vertical openings penetrating floors. This could result in the spread of smoke and fire from one floor to the other, in the event of a fire. This affected one of eight levels at HOSPITAL-A.

NFPA 101 Life Safety Code 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 on of the following condition:
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 the designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following condition:
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 the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the vertical openings were observed.

First Floor, HOSPITAL-A:
On 4/29/2014, at 11:25 a.m., there were four unsealed pipes penetrating the ceiling and one pipe penetrating the floor in Room 1613. The pipes measured approximately 4-inches each in diameter and the plans did not list the room and areas affected as a shaft.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke or fire. This was evidenced by cross corridor fire doors that failed to close upon activation of the fire alarm system. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected three of eight levels at HOSPITAL-A and one of six levels at HOSPITAL-B.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the cross corridor fire doors were observed while testing the fire alarm.

Sixth Floor, HOSPITAL-A:
1. On 4/30/2014, at 10:32 a.m., 1 of 2 cross corridor fire doors (door #60C08), located on the 6th Floor South, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

2. On 4/30/2014, at 10:42 a.m., 1 of 2 cross corridor fire doors (door #61C04), located on the 6th Floor by Room 631, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

Third Floor, HOSPITAL-A:
3. On 4/30/2014, at 11:42 a.m., 2 of 2 cross corridor fire doors (door #31C01), located on the 3rd Floor by an Electric Room, failed to close upon activation of a smoke detector by the doors. The doors remained open to their full extent for more than 30 seconds after the fire alarm device was activated.

4. On 4/30/2014, at 1:26 p.m., 1 of 2 cross corridor fire doors (door #34C04), located on the 3rd Floor by the Nurses Station, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

Second Floor, HOSPITAL-A:
5. On 4/30/2014, at 1:56 p.m., 1 of 2 cross corridor fire doors (door #22C04), located on the 2nd Floor by Stairwell 3, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

6. On 4/30/2014, at 2:05 p.m., 1 of 2 cross corridor fire doors (door #20C06), located on the 2nd Floor South portion of the "spine" corridor, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

7. On 4/30/2014, at 2:06 p.m., 1 of 2 cross corridor fire doors (door #20C04), located on the 2nd Floor North portion of the "spine" corridor, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

8. On 4/30/2014, at 2:18 p.m., 1 of 2 cross corridor fire doors (door #23C04), located on the 2nd Floor Operating Room corridor, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

9. On 4/30/2014, at 2:19 p.m., 1 of 2 cross corridor fire doors (door #23C06), located on the 2nd Floor Operating Room corridor, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

First Floor, HOSPITAL-B:
10. On 5/2/2014, at 1:35 p.m., 1 of 2 cross corridor fire doors (door #1405C), located on the 1st Floor by the Emergency Department, failed to close upon activation of a smoke detector by the doors. The door remained open to its full extent for more than 30 seconds after the fire alarm device was activated.

Based on observation, the facility failed to ensure that doors to stairwell were maintained to provide a smoke tight separation. This was evidenced by stairway door that had missing hardware. This had the potential to allow the passage of smoke and fire through the doorways resulting in injury to patients, visitors, and staff. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the stairwells were observed.

First Floor, HOSPITAL-A:
On 4/29/2014, at 11:43 a.m., the door (door # 1612L) in stairwell #1 on the 1st Floor had missing screws to the fire exit hardware.

Based on observation, the facility failed to ensure that exits were readily accessible at all times. This was evidenced by exit doors that were obstructed from opening. This had the potential to delay evacuation and cause injury to patients, visitors, and staff. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the exits and exit discharges were observed.

First Floor, HOSPITAL-A:
On 4/29/2014, at 2:53 p.m., the two exit doors located by the vending machines in the cafeteria were obstructed by a trash can placed in front of them. The trash can prevented both doors from opening from the egress side.

Based on observation and interview, the facility failed to ensure that doors be maintained to allow ready access. This was evidenced by a door to a patient room, which was difficult to open from the inside. This had the potential to delay evacuation from the room during an emergency, resulting in injury to patients and staff. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the patient room doors were observed.

Third Floor, HOSPITAL-A:
On 4/30/2014, at 1:38 p.m., the door to the NICU Room 11 (door #3516) was observed to require greater than fifteen pounds of force to open the door from inside the room. The Nurse Staff stated that doors were left open since a Doctor had previously been stuck in the room from not being able to open the door.

Based on observation, the facility failed to maintain their battery powered emergency lights. This was evidenced by battery powered emergency lights that failed to illuminate when tested. This could result in injury during a power outage. This affected 1 of 3 smoke compartments at the AMBULATORY SURGICAL CENTER and 4 of 4 generators at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the battery powered emergency lights were observed and tested.

AMBULATORY SURGICAL CENTER
1. On 5/6/2014, at 6:54 a.m., one battery powered emergency lighting unit in the Health Information Management Office (door #A1001) failed to illuminate when pushing down on the test button.

GENERATORS FOR HOSPITAL-A.
2. On 5/6/2014, at 9:29 a.m., one of one battery powered emergency lighting unit in Generator Room 1 failed to illuminate when pushing down on the test button.

3. On 5/6/2014, at 9:38 a.m., one of four battery powered emergency lighting unit in Generator Room 2 failed to illuminate when pushing down on the test button.

4. On 5/6/2014, at 9:39 a.m., one of four battery powered emergency lighting unit in Generator Room 3 failed to illuminate when pushing down on the test button.

5. On 5/6/2014, at 9:40 a.m., two of four battery powered emergency lighting units in Generator Room 2 failed to illuminate when pushing down on the test button.

Based on observation, the facility failed to install exit signs at all required exit doors. This was evidenced by two doors exiting into a corridor that did not contain approved exit signs. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction of exit access.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the exit signs were observed.

First Floor, HOSPITAL-A:
On 4/29/2014, at 11:15 a.m., there was no exit signs installed inside a room (greater than 2,250 square feet), to direct people to the path of egress, at two doors (door # 16501) exiting into a corridor. The room contained cubicle partition panels that were arranged throughout the room. The room housed Risk Management, Infection Control, and Quality Assurance.

Based on staff interviews, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by staff who were not familiar with all written plans for the protection and evacuation of patients in the event of a fire. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors. This affected HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, facility staffs were interviewed to determine their knowledge of their fire emergency procedures and the usage of life safety equipments.

HOSPITAL-A:
1. On 4/30/2014, at 10:39 a.m., the Infection Control Staff that was on the 6th Floor was interviewed and asked how she would respond to a fire in a patient's room. The staff failed to mentioned how to contain the fire and could not recall the acronym R.A.C.E. or its meaning.


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HOSPITAL-A:
During a tour of the facility with Operations Staff 1 on 4/30/14, staff were interviewed on procedures during a fire emergency.

2. At 10:20 a.m., the Social Services Staff 1 was asked what to do if smoke were coming out of a patient room in the area where she was working. Social Services Staff 1 was unable to clearly articulate RACE or PASS, which were both in the policy and procedure book as appropriate responses to fire in the hospital.

3. At 10:45 a.m., the Unit Secretary on the 6th floor was asked what to do if smoke were coming out of a patient room in the area where she was working. The Unit Secretary was unable to clearly articulate RACE or PASS, which were both in the policy and procedure book as appropriate responses to fire in the hospital.

Based on observation, the facility failed to ensure that their fire alarm system was properly maintained. This was evidenced by the fire alarm strobe lights not functioning. This had the potential for patients and staff to not be notified of a fire in the building, increasing the risk for injury. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
18.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)
9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the fire alarm system was tested and observed.

First Floor, HOSPITAL-A:
On 4/30/2014, at 2:50 p.m., the fire alarm system was activated and all strobe lights failed to activate in the laboratory and in the south end portion of the corridor by the laboratory. The following strobe lights did not function when the fire alarm was tested: VN 10.001, VN 10.002, VN 10.003, VN 10.008, VN 10.009, VN 10.110, VN 10.006, and VN 10.004.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, 1998 edition. This was evidenced by a Post Indicator Valve (PIV) tamper switch that failed to send a signal and report to the Fire Control Panel (FCP). This had the potential to have a delayed response to the tampering of the sprinkler system, increasing the risk of injury to patients, visitors and staff. This affected HOSPITAL-A.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the fire sprinkler system was tested and observed.

HOSPITAL-A:
On 5/1/2014, at 11:53 a.m., there was a Post Indicator Valve (PIV) in front of the building by the Main Lobby that failed to send a signal to the Fire Control Panel (FCP) when the tamper switch was tested by turning the valve handle more than two complete turns. The PIV was tested a second time by closing the valve fully at 11:58 a.m. and again no signals were received at the FCP [See K-tag 62 (2)].

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinklers with debris, failing to install identification signs at Post Indicator Valves to indicate areas controlled, and sprinklers with missing escutcheon rings that created openings in the ceilings. Sprinkler heads and scutcheon rings are listed to respond to a calculated ceiling temperature and a missing or detached escutcheon ring could allow heat and smoke to affect other areas in the building and cause failure of the sprinkler system in the event of a fire. This affected one of five levels at the CLASSIC BUILDING and the entire facility at HOSPITAL-A and HOSPITAL-B.

NFPA 101, 2000 Edition. Life Safety Code.
18.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, 1999 Edition. Standard for the Installation of Sprinkler Systems.
3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.
3-2.7.2* Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-14.1.1.12 Identification signs shall be provided at each valve to indicate its function and what it controls.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
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.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the sprinkler system was observed.

First Floor, CLASSIC BUILDING:
1. On 5/1/2014, at 8:53 a.m., 1 of 3 sprinkler heads located in Recovery Rooms 104 & 105 (door #KE193) had accumulation of debri on its fusible link and deflector.

HOSPITAL-A:
2. On 5/1/2014, at 11:53 a.m., there was a Post Indicator Valve (PIV) in front of the building by the Main Lobby that had no identification that marked the area/s of the building it controlled. During an interview with Engineering III, he stated that he did not know the areas it controlled [See K-tag 61].

3. On 5/1/2014, at 12:07 p.m., there was a PIV outside the building by Imaging that had no identification that marked the area/s of the building it controlled. The PIV reported to the panel a tamper alarm "N025_L01_MM006."

4. On 5/1/2014, at 12:12 p.m., there was a PIV outside the building that had no identification that marked the area/s of the building it controlled. The PIV reported to the panel a tamper alarm "N03_L07_MM101."

HOSPITAL-B:
5. On 5/2/2014, at 2:59 p.m., there were two PIVs outside the building on the corner of Healthcare Circle N. and Via Kaiser Permanente that had identification that were marked as "Sectional" and not the area/s of the building they controlled. There was no key available to test the tampers.

6. On 5/1/2014, at 3:08 p.m., there was a PIV outside the building by the generators that had identification that was marked as "Sectional" and not the area/s of the building it controlled. The PIV reported to the panel a tamper alarm "M1.152."


29751


HOSPITAL-A:
During a tour of the facility with Operations Staff 1 on 4/30/14, the sprinklers were observed.

7. At 10:10 a.m., there was an approximately three diameter hole in the ceiling were a escutcheon ring was missing outside Patient Room 718.

Based on observation, the facility failed to maintain their Water-Based Fire Protection Systems. This was evidenced by water leaking from fire pump assemblies in two separate locations. This could result in the failure of the fire protection system in the event of a fire. This affected eight of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
5-2 Inspection.
5-2.1 The purpose of inspection is to verify that the pump assembly appears to be in operating condition and is free from physical damage.
5-2.2.2 Pump System Conditions.
(b) Piping is free of leaks.

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the locations containing fire pumps were observed.

HOSPITAL-A:
1. On 4/29/2014, at 2:10 p.m., the Fire Control Panel in PBX had an active supervisory signal. The signal was indicated to be a fire pump supervisory Z026 "Jockey Pump Suction 1623 MOB6." The fire pump room on the 1st Floor had water throughout the floor. Water was observed to be leaking from the fire pump assembly. Engineering III stated that parts had been ordered to make repairs.

2. On 4/30/2014, at 3:30 p.m., the fire pump room on the Basement Level had water throughout the floor. A high volume of water was observed to be leaking from the fire pump assembly while the system was running.

Based on observation, the facility failed to maintain portable fire extinguishers readily accessible. This was evidenced by a fire extinguishers that was blocked from access. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors, and staff. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 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.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the fire extinguisher locations were observed.

First Floor, HOSPITAL-A:
On 4/29/2014, at 2:01 p.m., there was a portable fire extinguisher in PBX that was obstructed by a wheeled cart placed directly in front of the fire extinguisher.

Based on observation, the facility failed to maintain fire safety from flammable gases. This was evidenced by failing to post a precautionary signs for "NO SMOKING" in an area containing flammable gases. This had the potential for causing fire and result in injury to patients, visitors and staff. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) Smoking by patients classified as not responsible shall be prohibited.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the areas that shall prohibit smoking were observed.

Basement Level, HOSPITAL-A:
On 4/29/2014, at 10:07 a.m., there was no precautionary signs for "NO SMOKING" that was posted on the door entrance into Room 5003F or posted near the exterior portion of the door. The door was labeled as "Flammable Storage Room" and was located near the loading dock.

Based on observation, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by obstructions in a corridor leading to an exit door. This had the potential to delay evacuation and cause injury to patients, visitors, and staff. This affected one of five levels at the CLASSIC BUILDING.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the exit access was observed.

First Floor, CLASSIC BUILDING:
On 5/6/2014, at 11:05 a.m., the pathway leading to the exit door (door #1018A) from the PACU was obstructed by wheeled carts and a scale, restricting the pathway to approximately 2.5-feet. The corridor measured 8-feet.

Based on observation, the facility failed to ensure fire safety in their medical gas cylinder storage room. This was evidenced by a light switch installed less than 5-feet (60-inches) from the floor in a medical gas cylinder storage area and by combustible material in the bulk oxygen storage area. This could cause harm to patients, visitors, and staff in the event that the cylinder damaged the light switch or the combustible material ignited. This affected one of eight levels at HOSPITAL-A.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by
1. A minimum distance of 20 ft (6.1 m)

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the medical gas cylinders and their storage areas were observed.

Basement Level, HOSPITAL-A:
1. On 4/29/2014, at 9:49 a.m., the area used for storing medical gas cylinders that contained greater than 3,000 cubic feet of oxygen was observed to have a light switch installed at 48-inches from the floor. The room was observed to have E-sized (measuring approximately 24 cubic feet each) and H-sized (measuring approximately 240 cubic feet) oxygen cylinders.

Outside by the CLASSIC BUILDING:
2. On 5/6/2014, at 9:05 a.m., the bulk oxygen storage area located between the classic building the central plant had an accumulation of debri in a corner. The debri contained cigarette butts, dried up leaves, paper, and other combustible material.

Based on observation and interview, the facility failed to maintain humidity level monitors accessible and visible during surgical procedures. This was evidenced by temperature and humidity level monitors in Operating Rooms that were obstructed by carts. This failure could increase the risk of harm to patients if staff are unable to determine if the relative humidity levels are within required range. This affected the Operating Rooms at the CLASSIC BUILDING.

NFPA 99, Health Care Facilities, 1999 Edition
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, the humidity monitors in the Operating Rooms were observed.

CLASSIC BUILDING:
1. On 5/1/2014, at 9:15 a.m., Operating Room 3 had its humidity monitor on the wall that were obstructed from view by an Airway Cart and an IV cart.

2. On 5/1/2014, at 9:18 a.m., Operating Room 4 had its humidity monitor on the wall that were obstructed from view by an Airway Cart and an IV cart.

3. On 5/1/2014, at 9:20 a.m., a staff working in the OR was interviewed and stated that the carts are always place in the locations, including during surgical procedures.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by an unsealed penetrations in a smoke barrier wall. This could result in the spread of smoke and fire to other compartments. This affected 1 of 4 smoke compartments in Labor and Delivery at HOSPITAL-B.

NFPA 101 Life Safety Code, 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 tour of the facility with Operations Staff 2 on 5/2/14, the smoke barrier walls were observed.

Third Floor, HOSPITAL-B:
At 10:20 a.m., there were two, 1/4 inch, round holes in the smoke barrier wall at doors 3402-C in Labor and Delivery.

Based on observation, the facility failed to ensure that flammable liquids were properly stored. This was evidenced by flammable liquids containers that were not stored within an approved storage cabinet. This could result in the rapid spread of fire and potentially cause injury to patients and staff in the event of a fire. This affected one of five levels at the CLASSIC BUILDING.

NFPA 99, Health Care Facilities, 1999 Edition
6-2.2.1 Flammable Agents. Facility administrative authorities, in consultation with the medical staff and others with training and expertise, shall determine the adequacy of storage space for disinfecting agents and medicaments (see NFPA 30, Flammable and Combustible Liquids Code and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, for storage cabinet requirements) and shall provide and enforce regulations
for the storage and handling of containers of such agents. Said regulations also shall provide for the periodic inspection and maintenance of said storage locations.
10-7.2.2 Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory.
Exception: Very small laboratory work areas acceptable to the authorities

NFPA 30, Flammable and Combustible Liquids Code, 2000 Edition
4.3.3 Storage cabinets that meet at least one of the following sets of requirements shall be acceptable for storage of liquids:
(a) Storage cabinets that are designed and constructed to limit the internal temperature at the center of the cabinet and 1 in. (25 mm) from the top of the cabinet to not more than 325°F (162.8°C), when subjected to a 10-minute fire test that simulates the fire exposure of the standard time-temperature curve specified in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, shall be acceptable. All joints and seams shall remain tight and the door shall remain securely closed during the test.
(b) Metal storage cabinets that are constructed in the following manner shall be acceptable. The bottom, top, door, and sides of the cabinet shall be at least No. 18 gauge sheet steel and shall be double-walled, with 11/2 in. (38 mm) air space. Joints shall be riveted, welded, or made tight by some equally effective means. The door shall be provided with a three-point latch arrangement, and the door sill shall be raised at least 2 in. (50 mm) above the bottom of the cabinet to retain spilled liquid within the cabinet.
(c) Wooden cabinets constructed in the following manner shall be acceptable. The bottom, sides, and top shall be constructed of exterior grade plywood that is at least 1 in. (25 mm) thick and of a type that will not break down or delaminate under fire conditions. All joints shall be rabbetted and shall be fastened in two directions with wood screws. Where more than one door is used, there shall be a rabbetted overlap of not less than 1 in. (25 mm). Doors shall be equipped with a means of latching and hinges shall be constructed and mounted in such a manner as to not lose their holding capacity when subjected to fire exposure. A raised sill or pan capable of containing a 2 in. (50 mm) depth of liquid shall be provided at the bottom of the cabinet to retain spilled liquid within the cabinet.
(d) Listed storage cabinets that have been constructed and tested in accordance with 4.3.3(a) shall be acceptable.
4.3.5 Storage cabinets shall be marked in conspicuous lettering: FLAMMABLE - KEEP FIRE AWAY.

Findings:

During the facility tour with the Chief Engineer of Facilities Services from 4/28/2014 through 5/7/2014, flammable liquids were observed.

First Floor, CLASSIC BUILDING:
On 5/1/2014, at 9:22 a.m., the storage closet in the Operating Room corridor had containers with flammable liquids that accumulated to approximately 4.5 Gallons. The six glass bottles (three measured 3.8 liters and three measured 1.92 liters) contained clear liquids and were marked with the NFPA flammability rating of 1. This portion of the building, including the closet, was not sprinklered.

Based on document review and interview, the facility failed to perform weekly generator inspections. This was evidenced by missing documentation for 44 of 52 weeks of visual inspection. This had the potential to harm patients and staff in the event of a power failure. This affected the entire facility at HOSPITAL-B.

NFPA 99 Standard for Health Care Facilities 1999 Edition.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 110, 1999 Edition. Standard for Emergency And Standby Power Systems.
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant
components, shall be inspected weekly and shall be exercised
under load at least monthly.
Exception: If the generator set is used for standby power or for peak
load shaving, such use shall be recorded and shall be permitted to be
substituted for scheduled operations and testing of the generator set,
provided the appropriate data are recorded..

Findings:

During document review and interview with Operations Staff 2 on 5/1/14, the records for weekly generator inspections were requested.

HOSPITAL-B:
At 4:00 p.m., Operations Staff 2 stated the facility had started to perform weekly generator inspections 3/20/2014. Operations Staff 2 stated the facility was not familiar with the requirement but had been performing a daily inspection without documentation.