HospitalInspections.org

PMC - Physicians Medical Center
Based on observation and interview, the facility failed to ensure patient room doors 2B20, 2E20, 2D31 on the 2nd floor, and smoke barrier doors 1B06 on the 1st floor, were capable of latching to resist the passage of smoke. Not maintaining these doors to latch in their frames would allow the spread of fire and/or smoke to or from other areas of the facility, which presents the risk of potential harm by fire/smoke to all patients of the facility. The findings are:

A. On 04/02/15 at 9:40 am, during observation in the 2nd floor corridor, resident room doors 2B20, 2E20, 2D31 did not latch closed when tested.

B. On 04/02/15 at 9:55 am, during observation in the 1st floor corridor, smoke doors 1B06, did not latch closed when tested.

C. On 04/02/15 during interview, the Safety Officer stated she was unaware the doors were not latching and confirmed the findings.

Based on observation and interview, the facility failed to ensure the ceiling was intact in room 3505B in the labor/delivery area. This failed practice may result in the passage of fire/smoke from the labor/delivery area in the event of a fire, which may lead to injury from fire/smoke to all patients. The findings are:

A. On 04/01/15 at 10:50 am during observation, the difuser, light fixture and 3 (feet) X 4 (feet) area of the ceiling in room 3505B was missing.

B. On 04/01/15 at 10:53 am during interview, the Facilities Director stated he was not aware of the missing items and open ceiling, confirming the deficiency.


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Reference NFPA 101, 2000 Edition
19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose.



Based on observation, the facility failed to ensure the smoke barrier walls located on the 2nd floor, above ceiling, adjacent to Operating Rooms 2(two), 3 (three), and Main Mechanical Room in the Physicians Medical Center was sealed to resist the passage of smoke. Incomplete construction, unprotected penetrations, openings and gaps in smoke barriers walls would permit the movement of smoke from one smoke compartment to another, which presents the risk of potential harm by fire/smoke to all patients in the facility. The findings are:


A. On 02/04/15, between 8:00 am and 9:00 am during observation, the 2nd floor smoke barrier walls (above ceiling), adjacent to Operating Rooms 2 (two) and 3 (three), revealed numerous 1 in. (inch) - 4 in. (inch) diameter unsealed penetrations in the drywall.

B. On 02/04/15, at 9:55 am, during observation, Main Mechanical Room revealed a large penetration on the east wall, 1 ft. (foot) x 6 in.(inch)

C. On 04/02/15 during interview, Director of Facilities Services and Safety Officer confirmed these findings.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


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

A. On 03/31/15, record review of fire drill log indicated all 3 (three) shifts lacked 1 (one) drill / quarter.
Shift 1 (6 am - 2 pm), February, March, April, May, 2014.
Shift 2 (2 pm - 10 pm), January, February, March, April, 2014.
Shift 3 (10 pm - 6 am), July, August, September, October, November, 2014.

B. On 04/02/15 at interview, Safety Officer and Director of Facilities Services confirmed fire drills were not conducted on the dates noted above.

Based on observation and interview, the facility failed to provide smoke detectors connected to the Fire Alarm System in three (3) locations. This failed practice may lead to a delay in notification in the event of a fire, which may lead to potential harm by smoke/fire to all patients. The findings are:

A. On 04/01/15 at 1:15 pm, during observation, the Vertical Area A, (near the Emergency Room) open to the exit corridor was not protected by a smoke detector.

B. On 04/01/15 at 1:17 pm, during interview the Facilities Director stated he was unaware that a smoke detector was required in that area.

C. On 04/02/15 at 8:00 am, during observation, the clean linen room on first floor was not properly protected by a smoke detector.

D. On 04/02/15 at 10:30 am, during observation, the Bio-Hazard room in the wound care clinic was not protected by a smoke detector.

E. On 04/02/15 at 2:00 pm, during observation, the Medical Records room was not protected by a smoke detector.

F. On 04/01/15 at 1:15 pm, during observation, Vertical Area A - (Main Hospital), open to the corridor with no smoke detection installed.

G. On 04/02/15 at 8:00 am, during observation, Clean Linen Storage room, 1st floor, (Physicians Medical Center), no smoke detection installed.

H. On 04/02/15 at 10:30 am, during observation, Bio Hazard Room located in Wound Care (Main Hospital), no smoke detection installed.

I. On 04/02/15 at 2:00 pm, during observation, Medical Records located at (Cancer Center), no smoke detection installed.

J. On 04/02/15 at 2:02 pm, the Facilities Director stated he was unaware that smoke detectors were required in those areas and will have the problem corrected.

NFPA 72, 1999 Edition.
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Based on record review, the facility failed to ensure smoke detectors had been sensitivity tested on a two (2) year cycle, which may result in the failure of Fire Alarm System to detect smoke in the event of a fire. This failed practice presents a potential risk of injury by fire/smoke to all patients of the facility. The findings are:

A. On 03/31/15, during record review of Fire Alarm system, no documentation was provided to ensure sensitivity testing of smoke detection devices had been conducted for the previous two (2) years.

B. On 04/02/15, at interview, Director of Facilities Services confirmed the findings.

9.7.2 Supervision

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.


Based on observation and interview, the facility failed to ensure that 6 (six) newly installed tamper switches on sprinkler system were properly connected to FACP (fire alarm control panel), which may result in the water supply to Sprinkler System, accidentally/intentionally being shut off. This failed practice presents a potential risk of injury by fire/smoke to all patients of the facility. The findings are:

A. On 04/01/15 at 10:40 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in mechanical room B0104 was not connected to FACP.

B. On 04/01/15 at 11:00 am, during observation, exposed electrical wires on sprinkler control valve tamper switch, located in room 2213 were not connected to FACP.

C. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 1(one) 2nd floor were not connected to FACP.

D. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 3 (three) 2nd floor were not connected to FACP.

E. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 5 (five) 2nd floor were not connected to FACP.

F. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 6 (six) 2nd floor were not connected to FACP.

G. On 04/02/15 at interview, Director of Facilities Services confirmed these findings.

NFPA 13 9-7 Fire Department Connections

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:

(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.

9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacture's instructions. Any obstructions that are present shall be removed.




Based on observation, the facility failed to ensure proper raised signage was posted indicating the location of FDC (fire department connection) and fire lanes located adjacent to Emergency Room entrance. This failed practice may delay the Fire Department from providing supplemental water to the Automatic Sprinkler System in the event of a fire, which may lead to harm by fire/smoke to all patients of the facility. The findings are:

A. On 04/02/15 at 10:05 am, during observation, there was no raised signage near the FDC indicating its location.

B. On 04/02/15 at 10:05 am, during observation, there was no signage indicating Fire Lane/No Parking, adjacent to FDC.

C. On 04/02/15 during interview, Director of Facilities Services and Safety Officer stated they were not aware signage had not been posted and confirmed the findings.

Reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.

3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Based on record review and interview, the facility failed to ensure fire/smoke dampers were maintained by qualified personnel at least every four (4) years as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from area to area via the heating and ventilation air duct system, which presents a risk of potential harm by fire/smoke to all patients in the facility. The findings are:


A. Record review of the facility's maintenance records 03/31/15, indicated thirteen (13) deficiencies found by the contractor during the inspection of Fire/Smoke Dampers in November, 2012 have not been corrected as of this date.

B. 1. Installation of (12) 6in. (inch) x 6in. (inch) Ruskin Duct Access Doors.
2. Installation of (23) 8in. x 8in. Ruskin Duct Access Doors.
3. Installation of (03) 10in. x 10in. Ruskin Duct Access Doors.
4. Installation of (01) 12in. x 12in. Ruskin Duct Access Door.
5. Installation of (02) 10in. Round Ruskin Access Doors.
6. Installation of (02) 12in. Round Ruskin Access Doors.
7. Installation of (01) 14in. Round Ruskin Access Door.
8. Installation of (02) 24in. Round Ruskin Access Doors.
9. Installation of (02) 12in. x 12in. Hard Ceiling Ruskin Access Doors.
10. Installation of (07) 14in. x 14in. Hard Ceiling Ruskin Access Doors.
11. Installation of (04) Custom Designed Duct Access Doors.
12. Installation of (13) Honeywell ML4115B1008 (H2000B) Electric Smoke Damper Actuators.
13. Installation of (01) Belimo FSNF120 70lb. Torque Electric Smoke Damper Actuator.

C. On 04/14/15 during interview, the Director of Facilities Director confirmed the findings.

Reference NFPA 99, 1999 Edition

3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.


Based on observation, record review and interview, the facility failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Not testing specific gravity could result in generator batteries not being capable to start the emergency generator in the event of power failure, which presents the risk of potential harm to all patients of the facility. The findings are:


A. Record review of the generator's maintenance log book revealed no evidence specific gravity tests were conducted for the following months. 01/2013, 03/2014, 04/2014, 07/2014, 08/2014, 11/2014, 12/2014, 01/2015.

B. On 04/02/15 during interview, the Director of Facilities Services and Maintenance Supervisor confirmed the findings.

NFPA 70,
Section 408.4 Identification Required

(A) Circuit Directory or Circuit Ientification
Every circuit and circuit modification shall be legibly identified as to its clear, evident and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to label circuit breakers in two (2) electrical panels. This failed practice may prevent staff from disconnected the power to an area where an electrical failure occurred. This may lead to fire/smoke, whick may lead to harm from fire/smoke, to all patients. The findings are:

A. On 04/01/15 at 10:45 am, during observation, the circuit breakers were not identified in electrical panel ECP3 on the third floor.

B. On 04/01/15 at 1:50 pm, during observation, the circuit breakers were not identified in electrical panel BL2A in the radiology unit.

C. On 04/01/14 at 2:00 pm, during interview, the Facilities Director stated he was not aware the breakers were not labeled.




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NFPA 70 National Electric Code

210.8 Ground Fault Circuit Interrupter Protection for Personnel
210.8 (B) Other than dwelling units. All 125 volt, single phase, 15 and 20 ampere receptacles installed in the locations specified in 210.8 (B)(1) through (8) shall have ground fault circuit interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors

Exception 1: to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow melting, de-icing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22 as applicable.

Exception 2: to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2)shall be permitted for only those receptacles outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.

(5) Sinks - where receptacles are installed within 6 ft. of the outside edge of the sink.

Exception 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.

Exception 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under 210.8(B)(1), GFCI protection shall not be required.

(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.

314.25: Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminary canopy, except where the installation complies with 410.24(B)

406.5(F): Receptacles shall be enclosed so that live wiring terminals are not exposed to contact.


Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupter (GFCI) outlets were installed in Pediatrics 3307 (bathrooms) and X Ray Core-2700B. Not providing GFCI's at indoor wet locations may result in electrical shock in the event water comes into contact with electricity, which presents the risk of potential harm by electric shock and burn injuries to six (6) patients, as identified by the patient census list provided by the Nursing staff on 03/31/15. The findings are:

A. On 04/01/15 at 10:30 am, during observation, there were no GFCI receptacles located in Pediatrics 3307, (bathrooms), rooms 7,8 and 9.

B. On 04/01/15 at 2:05 pm, during observation, there were no GFCI receptacle located in X Ray Core, 2700B.

C. On 04/02/15 during interview, the Director of Facilities Services confirmed the findings.

Based on observation and interview, the facility failed to ensure that two (2) electrical outlets were functioning properly in the nourishment area of the main treatment area of the cancer center. This failed practice may result in electrical shock to the patients utilizing the ice and juice machines. The findings are:

A. On 04/02/15 at 1:20 pm, during observation of electrical outlets (2PN269 and 2PN271) were malfunctioning (did not trip), when tested.

B. On 04/02/15 at 1:23 pm, during interview, the Facilities Director stated he was unaware the outlets were malfunctioning and confirmed the findings.

Based on observation, the facility failed to ensure exterior elevator located at parking lot areas, testing of communications from within the elevator was not reporting to Security Station. This failed practice may result in entrapment in the elevator to patients upon loss of power, or other type of emergency, which presents a potential risk of physical injury to all in the facility. The findings are:

A. On 04/02/15 at 10:00 am, during observation, there was no communication to Security station from the exterior Elevator, (main parking lot areas).

B. On 04/02/15 during interview, Safety Officer & Director of Facilities Services confirmed the finding.

PMC - Physicians Medical Center
Based on observation and interview, the facility failed to ensure patient room doors 2B20, 2E20, 2D31 on the 2nd floor, and smoke barrier doors 1B06 on the 1st floor, were capable of latching to resist the passage of smoke. Not maintaining these doors to latch in their frames would allow the spread of fire and/or smoke to or from other areas of the facility, which presents the risk of potential harm by fire/smoke to all patients of the facility. The findings are:

A. On 04/02/15 at 9:40 am, during observation in the 2nd floor corridor, resident room doors 2B20, 2E20, 2D31 did not latch closed when tested.

B. On 04/02/15 at 9:55 am, during observation in the 1st floor corridor, smoke doors 1B06, did not latch closed when tested.

C. On 04/02/15 during interview, the Safety Officer stated she was unaware the doors were not latching and confirmed the findings.

Based on observation and interview, the facility failed to ensure the ceiling was intact in room 3505B in the labor/delivery area. This failed practice may result in the passage of fire/smoke from the labor/delivery area in the event of a fire, which may lead to injury from fire/smoke to all patients. The findings are:

A. On 04/01/15 at 10:50 am during observation, the difuser, light fixture and 3 (feet) X 4 (feet) area of the ceiling in room 3505B was missing.

B. On 04/01/15 at 10:53 am during interview, the Facilities Director stated he was not aware of the missing items and open ceiling, confirming the deficiency.


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Reference NFPA 101, 2000 Edition
19.3.7.3. Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose.



Based on observation, the facility failed to ensure the smoke barrier walls located on the 2nd floor, above ceiling, adjacent to Operating Rooms 2(two), 3 (three), and Main Mechanical Room in the Physicians Medical Center was sealed to resist the passage of smoke. Incomplete construction, unprotected penetrations, openings and gaps in smoke barriers walls would permit the movement of smoke from one smoke compartment to another, which presents the risk of potential harm by fire/smoke to all patients in the facility. The findings are:


A. On 02/04/15, between 8:00 am and 9:00 am during observation, the 2nd floor smoke barrier walls (above ceiling), adjacent to Operating Rooms 2 (two) and 3 (three), revealed numerous 1 in. (inch) - 4 in. (inch) diameter unsealed penetrations in the drywall.

B. On 02/04/15, at 9:55 am, during observation, Main Mechanical Room revealed a large penetration on the east wall, 1 ft. (foot) x 6 in.(inch)

C. On 04/02/15 during interview, Director of Facilities Services and Safety Officer confirmed these findings.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


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

A. On 03/31/15, record review of fire drill log indicated all 3 (three) shifts lacked 1 (one) drill / quarter.
Shift 1 (6 am - 2 pm), February, March, April, May, 2014.
Shift 2 (2 pm - 10 pm), January, February, March, April, 2014.
Shift 3 (10 pm - 6 am), July, August, September, October, November, 2014.

B. On 04/02/15 at interview, Safety Officer and Director of Facilities Services confirmed fire drills were not conducted on the dates noted above.

Based on observation and interview, the facility failed to provide smoke detectors connected to the Fire Alarm System in three (3) locations. This failed practice may lead to a delay in notification in the event of a fire, which may lead to potential harm by smoke/fire to all patients. The findings are:

A. On 04/01/15 at 1:15 pm, during observation, the Vertical Area A, (near the Emergency Room) open to the exit corridor was not protected by a smoke detector.

B. On 04/01/15 at 1:17 pm, during interview the Facilities Director stated he was unaware that a smoke detector was required in that area.

C. On 04/02/15 at 8:00 am, during observation, the clean linen room on first floor was not properly protected by a smoke detector.

D. On 04/02/15 at 10:30 am, during observation, the Bio-Hazard room in the wound care clinic was not protected by a smoke detector.

E. On 04/02/15 at 2:00 pm, during observation, the Medical Records room was not protected by a smoke detector.

F. On 04/01/15 at 1:15 pm, during observation, Vertical Area A - (Main Hospital), open to the corridor with no smoke detection installed.

G. On 04/02/15 at 8:00 am, during observation, Clean Linen Storage room, 1st floor, (Physicians Medical Center), no smoke detection installed.

H. On 04/02/15 at 10:30 am, during observation, Bio Hazard Room located in Wound Care (Main Hospital), no smoke detection installed.

I. On 04/02/15 at 2:00 pm, during observation, Medical Records located at (Cancer Center), no smoke detection installed.

J. On 04/02/15 at 2:02 pm, the Facilities Director stated he was unaware that smoke detectors were required in those areas and will have the problem corrected.

NFPA 72, 1999 Edition.
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Based on record review, the facility failed to ensure smoke detectors had been sensitivity tested on a two (2) year cycle, which may result in the failure of Fire Alarm System to detect smoke in the event of a fire. This failed practice presents a potential risk of injury by fire/smoke to all patients of the facility. The findings are:

A. On 03/31/15, during record review of Fire Alarm system, no documentation was provided to ensure sensitivity testing of smoke detection devices had been conducted for the previous two (2) years.

B. On 04/02/15, at interview, Director of Facilities Services confirmed the findings.

9.7.2 Supervision

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.


Based on observation and interview, the facility failed to ensure that 6 (six) newly installed tamper switches on sprinkler system were properly connected to FACP (fire alarm control panel), which may result in the water supply to Sprinkler System, accidentally/intentionally being shut off. This failed practice presents a potential risk of injury by fire/smoke to all patients of the facility. The findings are:

A. On 04/01/15 at 10:40 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in mechanical room B0104 was not connected to FACP.

B. On 04/01/15 at 11:00 am, during observation, exposed electrical wires on sprinkler control valve tamper switch, located in room 2213 were not connected to FACP.

C. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 1(one) 2nd floor were not connected to FACP.

D. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 3 (three) 2nd floor were not connected to FACP.

E. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 5 (five) 2nd floor were not connected to FACP.

F. On 04/01/15 at 11:05 am, during observation, exposed electrical wires on sprinkler control valve tamper switch located in stairwell 6 (six) 2nd floor were not connected to FACP.

G. On 04/02/15 at interview, Director of Facilities Services confirmed these findings.

NFPA 13 9-7 Fire Department Connections

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:

(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.

9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacture's instructions. Any obstructions that are present shall be removed.




Based on observation, the facility failed to ensure proper raised signage was posted indicating the location of FDC (fire department connection) and fire lanes located adjacent to Emergency Room entrance. This failed practice may delay the Fire Department from providing supplemental water to the Automatic Sprinkler System in the event of a fire, which may lead to harm by fire/smoke to all patients of the facility. The findings are:

A. On 04/02/15 at 10:05 am, during observation, there was no raised signage near the FDC indicating its location.

B. On 04/02/15 at 10:05 am, during observation, there was no signage indicating Fire Lane/No Parking, adjacent to FDC.

C. On 04/02/15 during interview, Director of Facilities Services and Safety Officer stated they were not aware signage had not been posted and confirmed the findings.

Reference NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.

3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Based on record review and interview, the facility failed to ensure fire/smoke dampers were maintained by qualified personnel at least every four (4) years as required by NFPA 90A (Standard for Installation of Air Conditioning and Ventilating Systems). Without this preventative maintenance and in the event of fire, the distribution of smoke, hot gases and fire could travel from area to area via the heating and ventilation air duct system, which presents a risk of potential harm by fire/smoke to all patients in the facility. The findings are:


A. Record review of the facility's maintenance records 03/31/15, indicated thirteen (13) deficiencies found by the contractor during the inspection of Fire/Smoke Dampers in November, 2012 have not been corrected as of this date.

B. 1. Installation of (12) 6in. (inch) x 6in. (inch) Ruskin Duct Access Doors.
2. Installation of (23) 8in. x 8in. Ruskin Duct Access Doors.
3. Installation of (03) 10in. x 10in. Ruskin Duct Access Doors.
4. Installation of (01) 12in. x 12in. Ruskin Duct Access Door.
5. Installation of (02) 10in. Round Ruskin Access Doors.
6. Installation of (02) 12in. Round Ruskin Access Doors.
7. Installation of (01) 14in. Round Ruskin Access Door.
8. Installation of (02) 24in. Round Ruskin Access Doors.
9. Installation of (02) 12in. x 12in. Hard Ceiling Ruskin Access Doors.
10. Installation of (07) 14in. x 14in. Hard Ceiling Ruskin Access Doors.
11. Installation of (04) Custom Designed Duct Access Doors.
12. Installation of (13) Honeywell ML4115B1008 (H2000B) Electric Smoke Damper Actuators.
13. Installation of (01) Belimo FSNF120 70lb. Torque Electric Smoke Damper Actuator.

C. On 04/14/15 during interview, the Director of Facilities Director confirmed the findings.

Reference NFPA 99, 1999 Edition

3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.


Based on observation, record review and interview, the facility failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Not testing specific gravity could result in generator batteries not being capable to start the emergency generator in the event of power failure, which presents the risk of potential harm to all patients of the facility. The findings are:


A. Record review of the generator's maintenance log book revealed no evidence specific gravity tests were conducted for the following months. 01/2013, 03/2014, 04/2014, 07/2014, 08/2014, 11/2014, 12/2014, 01/2015.

B. On 04/02/15 during interview, the Director of Facilities Services and Maintenance Supervisor confirmed the findings.

NFPA 70,
Section 408.4 Identification Required

(A) Circuit Directory or Circuit Ientification
Every circuit and circuit modification shall be legibly identified as to its clear, evident and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to label circuit breakers in two (2) electrical panels. This failed practice may prevent staff from disconnected the power to an area where an electrical failure occurred. This may lead to fire/smoke, whick may lead to harm from fire/smoke, to all patients. The findings are:

A. On 04/01/15 at 10:45 am, during observation, the circuit breakers were not identified in electrical panel ECP3 on the third floor.

B. On 04/01/15 at 1:50 pm, during observation, the circuit breakers were not identified in electrical panel BL2A in the radiology unit.

C. On 04/01/14 at 2:00 pm, during interview, the Facilities Director stated he was not aware the breakers were not labeled.




34719


NFPA 70 National Electric Code

210.8 Ground Fault Circuit Interrupter Protection for Personnel
210.8 (B) Other than dwelling units. All 125 volt, single phase, 15 and 20 ampere receptacles installed in the locations specified in 210.8 (B)(1) through (8) shall have ground fault circuit interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors

Exception 1: to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow melting, de-icing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22 as applicable.

Exception 2: to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2)shall be permitted for only those receptacles outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.

(5) Sinks - where receptacles are installed within 6 ft. of the outside edge of the sink.

Exception 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.

Exception 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under 210.8(B)(1), GFCI protection shall not be required.

(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.

314.25: Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminary canopy, except where the installation complies with 410.24(B)

406.5(F): Receptacles shall be enclosed so that live wiring terminals are not exposed to contact.


Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupter (GFCI) outlets were installed in Pediatrics 3307 (bathrooms) and X Ray Core-2700B. Not providing GFCI's at indoor wet locations may result in electrical shock in the event water comes into contact with electricity, which presents the risk of potential harm by electric shock and burn injuries to six (6) patients, as identified by the patient census list provided by the Nursing staff on 03/31/15. The findings are:

A. On 04/01/15 at 10:30 am, during observation, there were no GFCI receptacles located in Pediatrics 3307, (bathrooms), rooms 7,8 and 9.

B. On 04/01/15 at 2:05 pm, during observation, there were no GFCI receptacle located in X Ray Core, 2700B.

C. On 04/02/15 during interview, the Director of Facilities Services confirmed the findings.

Based on observation and interview, the facility failed to ensure that two (2) electrical outlets were functioning properly in the nourishment area of the main treatment area of the cancer center. This failed practice may result in electrical shock to the patients utilizing the ice and juice machines. The findings are:

A. On 04/02/15 at 1:20 pm, during observation of electrical outlets (2PN269 and 2PN271) were malfunctioning (did not trip), when tested.

B. On 04/02/15 at 1:23 pm, during interview, the Facilities Director stated he was unaware the outlets were malfunctioning and confirmed the findings.

Based on observation, the facility failed to ensure exterior elevator located at parking lot areas, testing of communications from within the elevator was not reporting to Security Station. This failed practice may result in entrapment in the elevator to patients upon loss of power, or other type of emergency, which presents a potential risk of physical injury to all in the facility. The findings are:

A. On 04/02/15 at 10:00 am, during observation, there was no communication to Security station from the exterior Elevator, (main parking lot areas).

B. On 04/02/15 during interview, Safety Officer & Director of Facilities Services confirmed the finding.