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Based on observation the hospital failed to properly install and maintain the automatic sprinkler system.

Failure to maintain fire sprinklers in the hospital by replacing standard sprinkler heads with quick-response sprinklers when converting a compartment space increases the risk that the fire suppression system will not operate properly. This places the patients, staff and visitors of the facility at risk of injury from the effects of smoke and fire.

References: NFPA 13 5-3.1.5.2 states: "When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in a compartment space shall be changed to quick-response sprinklers

Findings include:

1. On 12/13/2011, Surveyor #5 noted that the sprinklers located in the 2 Alder electrical room were obstructed by a cable bundle installed below the sprinkler heads.

2. On 12/13/2011, Surveyor #5 noted that the sprinklers located in the 1 Alder electrical room were obstructed by a cable bundle, a large junction box, a light fixture and various hangers.

3. On 12/13/11, at 1:20 PM during a tour of the hospital endoscopy unit with the manager Surveyor #4 observed a missing sprinkler head escutcheon in room #3. Missing escutcheons were also noted by surveyor #5 in the pharmacy closet and the 2 Alder janitor closet.

4. On 12/13/2011, Surveyor #5 noted that Operating Rooms 1-4 lacked sprinkler coverage.

5. On 12/14/2011, Surveyor #5 noted that the sprinklers in the area of the kitchen scullery were of a quick response (QR) type. It was also noted by the surveyor that the rest of the kitchen was served by standard response sprinklers. A violation exists because the scullery and the main kitchen area have dissimilar sprinkler head types in the same compartment without the benefit of barrier or lintel of at least 8 inches.

Based on observation the facility failed to protect its cooking facilities in accordance with NFPA 101 Chapter 9.2.3. More specifically the facility failed to maintain kitchen hoods free of grease build up.

Failure on the part of the facility to maintain its kitchen hoods as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

References:

NFPA 101, 2000 Edition; Chapter 9.2.3 Commercial Cooking Equipment states: "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction"; and

NFPA 96, 1998 Edition: Chapter 8-3 Cleaning, sub-chapter 8-3.1 states: "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1".

Findings include:

1. On 12/14/2011, Surveyor #5 noted in the Main Campus Kitchen that the kitchen hoods and associated filters over the grill were heavily laden with grease whereas grease droplets had formed on their surfaces.

Based on observation the facility failed to maintain the means of egress and its access free of obstructions and impediments.

Failure on the part of the facility to maintain the means of egress and its access free of obstructions and or impediments puts staff at risk of death in the event of fire.

References:

NFPA 101, 2000 Edition; Chapter 7.1.10.1 states: "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".

Findings include:

1. On 12/13/2011, Surveyor #5 noted in the medical records archives room that the aisles between shelving units (access to egress pathways) were blocked by various surplus items and equipment.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99; and failed to properly post the storage room.

Failure on the part of the facility to properly secure compressed gas cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death. Not properly posting oxidizing gas storage rooms puts patients, staff and visitors at risk of serious injury and death from fire.

Findings include:

1. On 12/13/2011, Surveyor #5 noted that K cylinders of both oxygen and medical blended gas in the 2 Cedar oxygen storage room were not properly secured in a manner to prevent their toppling over and potentially becoming projectiles.

2. On 12/13/2011, Surveyor #5 noted that the 2 Cedar oxygen storage room was provided with a sign that indicated "Oxygen Storage...Med Gas Storage". NFPA 99 Chapter 8-3.1.11.3 requires the following wording on the precautionary sign "Caution....Oxidizing Gas(es) Stored Within....No Smoking".

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.

References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

Findings include:

1. On 12/15/2011 Surveyor #5 noted that the compartment containing the emergency generator (Birch) was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 12/13/2011, Surveyor #5 noted that in the 2 Cedar gift shop storage room a multi-plug power strip was daisy chained with a second power strip.

2. On 12/13/2011, Surveyor #5 noted that In the Information Technology lead's office (1B13A) a multi-plug power strip was daisy chained with a second power strip.

Based on observation the hospital failed to properly install and maintain the automatic sprinkler system.

Failure to maintain fire sprinklers in the hospital by replacing standard sprinkler heads with quick-response sprinklers when converting a compartment space increases the risk that the fire suppression system will not operate properly. This places the patients, staff and visitors of the facility at risk of injury from the effects of smoke and fire.

References: NFPA 13 5-3.1.5.2 states: "When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in a compartment space shall be changed to quick-response sprinklers

Findings include:

1. On 12/13/2011, Surveyor #5 noted that the sprinklers located in the 2 Alder electrical room were obstructed by a cable bundle installed below the sprinkler heads.

2. On 12/13/2011, Surveyor #5 noted that the sprinklers located in the 1 Alder electrical room were obstructed by a cable bundle, a large junction box, a light fixture and various hangers.

3. On 12/13/11, at 1:20 PM during a tour of the hospital endoscopy unit with the manager Surveyor #4 observed a missing sprinkler head escutcheon in room #3. Missing escutcheons were also noted by surveyor #5 in the pharmacy closet and the 2 Alder janitor closet.

4. On 12/13/2011, Surveyor #5 noted that Operating Rooms 1-4 lacked sprinkler coverage.

5. On 12/14/2011, Surveyor #5 noted that the sprinklers in the area of the kitchen scullery were of a quick response (QR) type. It was also noted by the surveyor that the rest of the kitchen was served by standard response sprinklers. A violation exists because the scullery and the main kitchen area have dissimilar sprinkler head types in the same compartment without the benefit of barrier or lintel of at least 8 inches.

Based on observation the facility failed to protect its cooking facilities in accordance with NFPA 101 Chapter 9.2.3. More specifically the facility failed to maintain kitchen hoods free of grease build up.

Failure on the part of the facility to maintain its kitchen hoods as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

References:

NFPA 101, 2000 Edition; Chapter 9.2.3 Commercial Cooking Equipment states: "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction"; and

NFPA 96, 1998 Edition: Chapter 8-3 Cleaning, sub-chapter 8-3.1 states: "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1".

Findings include:

1. On 12/14/2011, Surveyor #5 noted in the Main Campus Kitchen that the kitchen hoods and associated filters over the grill were heavily laden with grease whereas grease droplets had formed on their surfaces.

Based on observation the facility failed to maintain the means of egress and its access free of obstructions and impediments.

Failure on the part of the facility to maintain the means of egress and its access free of obstructions and or impediments puts staff at risk of death in the event of fire.

References:

NFPA 101, 2000 Edition; Chapter 7.1.10.1 states: "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".

Findings include:

1. On 12/13/2011, Surveyor #5 noted in the medical records archives room that the aisles between shelving units (access to egress pathways) were blocked by various surplus items and equipment.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99; and failed to properly post the storage room.

Failure on the part of the facility to properly secure compressed gas cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death. Not properly posting oxidizing gas storage rooms puts patients, staff and visitors at risk of serious injury and death from fire.

Findings include:

1. On 12/13/2011, Surveyor #5 noted that K cylinders of both oxygen and medical blended gas in the 2 Cedar oxygen storage room were not properly secured in a manner to prevent their toppling over and potentially becoming projectiles.

2. On 12/13/2011, Surveyor #5 noted that the 2 Cedar oxygen storage room was provided with a sign that indicated "Oxygen Storage...Med Gas Storage". NFPA 99 Chapter 8-3.1.11.3 requires the following wording on the precautionary sign "Caution....Oxidizing Gas(es) Stored Within....No Smoking".

Based on observation the facility failed to maintain its emergency electrical system in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition and NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. More specifically, the facility failed to provide emergency lighting in the space containing the emergency generator.

Failure on the part of the facility to maintain its emergency power system as is required puts patients, staff and visitors of the facility at risk should the emergency power system fail and repairs are required.

References: NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, Chapter 5-3.1 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

Findings include:

1. On 12/15/2011 Surveyor #5 noted that the compartment containing the emergency generator (Birch) was not provided with a battery-powered emergency lighting system as is required.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 12/13/2011, Surveyor #5 noted that in the 2 Cedar gift shop storage room a multi-plug power strip was daisy chained with a second power strip.

2. On 12/13/2011, Surveyor #5 noted that In the Information Technology lead's office (1B13A) a multi-plug power strip was daisy chained with a second power strip.