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Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls and ceilings. This affected 3 of 5 smoke compartments, in one of two buildings. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a tour of the facility on April 17, 2012 through April 19, 2012, the walls and ceilings were observed.

April 17, 2012 - Building 2 (Existing)
1. At 2:00 p.m., there was an approximately 2 inch penetration along the left side of the sprinkler escutcheon plate, in the kitchen near the coffee grinder machine.
2. At 2:11 p.m., there were 3 approximately 1/4 to 1/2 inch penetrations, on the back wall, in the old fire alarm panel room.
3. At 2:31 p.m., there was an approximately 2 inch penetration on the right side of the sprinkler escutcheon plate, in the Quarterly Review Office.
4. At 2:32 p.m., there was an approximately 1 inch penetration along the left side of the sprinkler escutcheon plate, in the Oxygen Storage room.
5. At 2:44 p.m., there was an approximately 4 foot by 4 foot cut out on the left wall, in the mechanical room, next to the pharmacy.
6. At 2:57 p.m., there was an approximately 1/2 inch penetration on the right wall in the janitorial closet. There were 7 approximately 1/8 inch to 1 inch penetrations on the left wall.

Based on observation the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that were obstructed from closing. This may cause the passage of smoke and flames in the event of a fire, and affected 1 of 6 smoke compartments in the new building.

Findings:

On a tour of the facility on April 18, 2012, the corridor doors were observed.

1. At 3:17 p.m., the door to Room E 186, had a kick down door stop. When the door stop was activated the door was obstructed from closing.
2. At 3:21 p.m., the door to Room E 183, had a kick down door stop. When the door stop was activated the door was obstructed from closing.

Based on observation, the facility failed to maintain the doors protecting corridor openings in two of two buildings. This was evidenced by doors that failed to close and latch. This may cause the passage of smoke and flames in the event of a fire, and affected 1 of 5 smoke compartments in the existing building.

Findings:

On a tour of the facility on April 17, 2012 through April 19, 2012, the corridor doors were observed.
April 17, 2012 - Building 2 (old)
1. At 2:22 p.m., the women's staff restroom door, by the cafeteria, was equipped with a self-closing device. The door failed to close and latch.
2. At 2:24 p.m., the means' staff restroom door by the cafeteria, was equipped with a self-closing device. The door failed to close and latch.
3. At 2:26 p.m., the MAK Retreat/ Med Surg (medical/surgical) break room door was equipped with a self-closing device. The door failed to close and latch.
4. At 2:32 p.m., the Oxygen storage room door, in med/surg, failed to close and latch on self closure.

Based on observation, document review and interview, the facility failed to maintain 5 of 5 drop down windows/doors. This was evidenced by no documentation of annual testing in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. This affected 1 of 5 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition

15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a tour of the facility with Facility Staff 1, on April 18, 2012, the drop down windows and door were observed.

1. At 1:50 p.m., there were drop down windows or doors at the Emergency Room Check In, at Admitting, at the patient billing area (2 windows) and at the vending machine alcove.

During an interview at 1:50 p.m., Facility Staff 1 was asked for documentation for testing the fire windows and door. Facility Staff 1 stated that there was no documentation and that he was unsure if the doors had been tested. The windows and door were activated by a smoke detector on each side that released the drop downs to close in the event of a fire.

2. At 1:53 p.m., there were 2 computer screens and other equipment sitting on the counter at the admitting window. If the window dropped the equipment would obstruct the window from closing completely.

3. On April 19, 2012, at 9 a.m., the Fire Alarm Inspection Report dated January 18, 2012, was reviewed. There was no indication on the report, that the drop down windows or door were tested annually as required.

Based on observation, the facility failed to protect a hazardous area, as evidenced by a hazardous area door that was equipped with a kick down door stop. This obstructed the self closing door from closing. This affected 1 of 6 compartments, and could result in the passage of smoke and flames.

NFPA 101, Life Safety Code , 2000 edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system , if provided, and the fire alarm system and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

On April 18, 2012, during a tour of the facility with Facility Staff 1, the hazardous area doors were observed.

At 3:19 p.m., the door E 183, Clean Processing in the OR suite, was held in the open position with a kick down door stop. The door was equipped with a self closing device.

Based on observation and interview, the facility failed to maintain the battery operated emergency lights. This was evidenced by the failure of emergency lights in 3 of 5 smoke compartments in one of two buildings. This could result in a delay of evacuation from the building in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
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 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers 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:

On a tour of Building 1 on April 17, 2012, with Facility Staff 1, the emergency lights were observed.
1. At 2:09 p.m., the battery operated emergency light, in the electrical room, failed when tested with the push button. During an interview, Facility Staff 1 was asked for records for monthly and annual testing of the emergency lights. He stated the lights had not been tested.

2. At 2:48 p.m., the emergency light, on the left wall in the teaching class room, failed when tested.

3. At 2:49 p.m., the emergency light in Bio-Med failed when tested.

Based on document review and interview, the facility failed to provide records for 1 of 2 disaster drills, in accordance with NFPA 99. This could result in a delay in staff response in the event of an emergency. This affected residents and staff in 2 of 2 buildings.

NFPA 99, Health Care Facilities, 1999 Edition
Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

On April 19, 2012, during document review, disaster drill records were requested. The facility failed to provide written documentation for 1 of 2 disaster drills.

During an interview on April 19, 2012, Facility Staff 1 stated that there was another disaster drill conducted. No documentation was provided for the second disaster drill.

Based on document review and interview, the facility failed to conduct fire drills in accordance with NFPA 101. This was evidenced by no documentation for fire drills during 3 of 4 quarters on the day shift, no drills held during the overnight shift during 4 of 4 quarters, and no fire drills for the Women's Center. This had the potential to delay staff response in the event of a fire. This affected all patients in 1 of 2 buildings and 1 of 1 smoke compartment in the Women's Center.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on April 18, 2012 and April 19, 2012, the facility fire drills were reviewed.

1. On April 18, 2012, at 12 p.m., the "Summary of Fire Drills" was reviewed. The grid (log) notes that fire drills were held on August 5, 2011 at 9:00 a.m., on the medical surgical unit, on August 5, 2011 at 6:00 p.m., in the emergency room, on October 11, 2011, at 3:30 p.m., in the pharmacy, and on February 18, 2012, at 1:30 p.m.

The only fire drill report provided was for the February 18, 2012 drill. There were no records for three of four drills held during the day shift.

2. The nursing staff work from 7:00 a.m. to 7:00 p.m., and 7:00 p.m., to 7:00 a.m.. There were no fire drill records for drills conducted after 6:00 p.m., or before 9:00 a.m., during 4 of 4 quarters.

During an interview, Facility Staff 1 confirmed that no drills were conducted on the 7:00 p.m. to 7:00 a.m., shift.

3. On April 19, 2012, at 9;15 a.m., during a tour of the the Women's Clinic, documentation for fire drills was requested. Facility staff 1 stated they have not conducted fire drills in the Women's Center.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system devices in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by three devices that failed to activate the fire alarm system and by one device that was displaced. This affected 3 of 5 smoke compartments in 1 of 2 buildings. This could result in the potential delay in notification in the event the fire alarm system was activated.

Findings:

During fire alarm system testing, with Facility Staff 1 and the mechanical engineer, on April 18, 2012, the fire alarm devices were tested.

1. At 4:04 p.m., the pull station by information systems, failed to activate the fire alarm system during 3 attempts by staff.
2. At 4:06 p.m., the strobe in the old lobby, failed to activate when the fire alarm system was tested.
3. At 4:08 p.m., the pull station by Room 101, failed to activate the fire alarm system during 2 attempts by staff.

During document review on April 18, 2012, the Fire & Safety Inspection Report, dated April 3, 2012, was reviewed. The report noted a chime/strobe in the mechanical room that was broken.

On April 18, 2012, at 3:45 p.m., the chime strobe in mechanical room was observed to be hanging loose from the wall.

Based on document review and interview the facility failed to maintain the smoke detectors in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by the failure to perform smoke sensitivity testing for the smoke detectors. This affected 2 of 2 buildings, and may result in the failure of a smoke detector in the event of a fire.

NFPA 72, National Fire Alarm Code, 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 the 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: The 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 an device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review from April 17, 2012 through April 19, 2012, no documentation of smoke detector sensitivity testing was provided.
On April 19, 2012, at 9:10 a.m., during an interview, Facility Staff 1 stated smoke sensitivity testing was not done.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. This was evidenced by sprinklers with missing escutcheon plates and by one sprinkler contaminated with paint. This affected 5 of 5 smoke compartments in 1 of 2 buildings, and could result in the failure of a sprinkler or the spread of smoke and fire.
Escutcheon plates are used to cover penetrations around sprinkler pipes and sprinkler heads.

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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

On April 17. 2012, during a tour of the facility with Facility Staff 1, the sprinklers were observed.

1. At 2:17 p.m., the sprinkler escutcheon plate was missing in medical records.
2. At 2:22 p.m., the sprinkler head had paint on it, in the oxygen storage closet.
3. At 2:24 p.m., the sprinkler escutcheon plate was missing in the medical/surgical supply room.
4. At 3:01 p.m., 2 escutcheon plates were missing in the IT (Information Technology) room back office.

Based on document review and interview, the facility failed to provide documentation for testing and maintenance of the HVAC system. This was evidenced by no documentation of damper testing. This affected 2 of 2 buildings, and could result in the passage of smoke and flames in the event of fire, if the dampers failed to close.

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.

Findings:

From April 17, 2012, through April 19, 2012, facility maintenance and testing documentation was requested.

On April 19, 2012, at 9:12 a.m., no records for damper testing were provided by the facility.
At 9:12 a.m., during an interview, Facility Staff 1 stated no damper testing had been done.

Based on observation and interview, the facility failed to prevent the use of portable heating devices in patient care areas. This was evidenced by a portable heater, in use, in one area. This affected 1 of 6 smoke compartments in 1 of 2 buildings, and could increase the risk of fire.

Findings:

On April 18, 2012, during a tour of the facility with Facility Staff 1, the Labor and Delivery Department was toured. In the Labor and Deliver employee lounge there was a portable space heater in use. The heater was on and had a small oil leak.

During an interview, Facility Staff 1 stated it was not one of the floor heaters that belonged to the facility. He reported there was no information on how hot the heating elements get and if it automatically shuts off if tipped over.

Based on observation, and interview the facility failed to maintain the humidity levels in 2 of 2 operating rooms (OR)s and 1 procedure room. This was evidenced by no documentation of humidity levels. This affected 1 of 6 smoke compartments, and had the potential to increase the risk of fire.

Findings:

During record review on April 17, 2012, the records for the humidity levels were requested.

During an interview at 1:55 p.m., Facility Staff 1 stated that the facility does not log humidity levels. When asked who is responsible for monitoring the humidity levels he stated that operating room staff monitor it.

At 3:53 p.m., during an interview, OR Staff 1 was asked about logging the humidity levels. She stated her staff does not check the humidity levels.

On April 18, 2012, during a tour of the operating room suites, the humidity levels were observed in 2 of 3 rooms and 1 procedure room.
At 3:06 p.m., the humidity level in OR 3 was 16 percent. This room was used for storage of equipment.
At 3:08 p.m., in OR 2 the humidity level was 41 percent.

At 3:26 p.m., procedure room staff reported the humidity levels are not monitored in the procedure room.

On April 19, 2012, at 8:30 a.m., Facility Staff 1 stated the facility does not have a written policy and procedure for monitoring the humidity levels on anesthetizing locations.

Based on document review and interview, the facility failed to ensure generators were maintained and tested in accordance with NFPA 110, for 2 of 2 buildings. This was evidenced by no records for testing the generator under a load of not less than 30% of the nameplate rating, by no evidence of annual load bank testing, and by no records for testing a temporary generator during December 2011. This could result in a generator failure, in the event of a power outage. This affected 5 of 5 smoke compartments in the existing building.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
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 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.

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with available
EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

1. During an interview with the maintenance technician, on April 18, 2012, staff was asked about testing the generator under load each month. At 9:45 a.m., Maintenance Staff 1 stated the generators are tested monthly for 30 minutes. He did not know if they were tested at 30 percent of the nameplate rating, or if they maintained the minimum exhaust gas temperatures as recommended by the manufacturer.

On April 19, 2012, at 11:00 a.m., the chief engineer 1 reported that they do not conduct an annual load bank test on the generator for the existing (hospital) building.


On April 18, 2012, at 10:38 a.m., during record review, the maintenance tech stated that the generator had an injector leak in December 2011 and confirmed that the facility brought in a temporary generator. The facility had no testing logs for the temporary generator. During an interview the maintenance tech reported they did not inspect the temporary generator weekly or test it during the month it was in use.

3. During record review on April 19, 2012, the Generator Log Book was reviewed. At 10:02 a.m., there was no documentation of a monthly load test for March 2012, provided in the records.

Based on document review and interview, the facility failed to provide records for generator testing, under load, for 30 minutes monthly, and for exercising transfer switches. This could result in the potential failure of 2 of 2 generators, in the event of power outage. This affected 6 of 6 smoke compartments.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
6-3.5* Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and when repaired.
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 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.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

On April 18, 2012, at 9:45 a.m., during an interview, Maintenance Technician 1 was asked about testing the generator under load monthly. He stated the generators are tested monthly and run for 30 minutes. He was asked if the generators are running at 30 percent of name plate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Maintenance Tech 1 stated they do not run the generators under load or monitor the minimum exhaust gas temperatures.

At 10:00 a.m., Maintenance Tech 1 stated he would provide documentation for a load bank for the Caterpillar generator that supplies power to the Labor and Delivery area, Operating Suites, Emergency Room, and some parts of the lab.

On April 19, 2012, at 10:30 a.m., the chief engineer was interviewed. He reported that they do not run the Perkins generator (for the lab) under load monthly because the transfer switch is manual. Documentation was provided for an annual load bank on July 20, 2011. The Perkins generator supplies power for emergency lighting, approximately 8 outlets and lab equipment.

At 11:00 a.m., no documentation was provided for the Caterpillar generator. The chief engineer stated they do not do a load bank on the caterpillar generator.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. This was evidenced by the use of surge protectors and extension cords in lieu of permanent wiring and by failing to maintain the clearance around electrical panels. This affected 3 of 5 smoke compartments, in 1 of 2 buildings, and could result in an increased risk of an electrical fire.

NEC 70, National Electrical Code, 1999 Edition
110.32 Work Space About Equipment
Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall no be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 feet (914 m) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34 (a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On April 17, 2012, during a tour of the facility with Facility Staff 1, the electrical wiring and equipment were observed.

1. At 2:08 p.m., there was no 3 foot clearance around Electrical panel E in the Main Building electrical room. Cardboard boxes were stacked against the front of the panel.

2. At 2:20 p.m., a refrigerator was plugged into a surge protector in the Interpreter Services office.

3. At 2:26 p.m., there was a microwave oven plugged into a surge protector in the MAK Retreat (med/surg) breakroom.

4. At 2:31 p.m., a table was placed against the front of Electrical panel E1 in the Quality Review office. The required 3 foot clearance was not maintained.

5. At 2:54 p.m., there was an extension cord in use, and a microwave plugged into a surge protector, in the women's changing room, now used by the LIS Coordinator.

6. At 2:59 p.m., there were cardboard boxes stacked against the panels in the IT office. Electrical Panels E3 and C, did not have 3 foot clearance.

Based on document review and interview the facility failed to provide documentation of a written fire watch or evacuation procedure, in the event the automatic sprinkler system is out of service for 4 hours or more in a 24 hour period. This affected 2 of 2 buildings and could result in a delay in extinguishing a fire.

Findings:

On April 18, 2012, during document review, there was no written documentation of a fire watch or evacuation procedure, in the event the automatic sprinkler system was out of service.

At 4:20 p.m., during an interview, Facility Staff 1 stated the facility has no written fire watch procedure.

Based on document review and interview, the facility failed to provide documentation of a written fire watch or evacuation procedure, in the event the fire alarm system is out of service for 4 hours or more in a 24 hour period. This affected 2 of 2 buildings and could result in a delay in notification in the event of a fire.

Findings:

On April 18, 2012, during document review, there was no written documentation of a fire watch or evacuation procedure, in the event the fire alarm system was out of service.

At 4:20 p.m., during an interview, Facility Staff 1 stated the facility has no written fire watch procedure.

Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls and ceilings. This affected 3 of 5 smoke compartments, in one of two buildings. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a tour of the facility on April 17, 2012 through April 19, 2012, the walls and ceilings were observed.

April 17, 2012 - Building 2 (Existing)
1. At 2:00 p.m., there was an approximately 2 inch penetration along the left side of the sprinkler escutcheon plate, in the kitchen near the coffee grinder machine.
2. At 2:11 p.m., there were 3 approximately 1/4 to 1/2 inch penetrations, on the back wall, in the old fire alarm panel room.
3. At 2:31 p.m., there was an approximately 2 inch penetration on the right side of the sprinkler escutcheon plate, in the Quarterly Review Office.
4. At 2:32 p.m., there was an approximately 1 inch penetration along the left side of the sprinkler escutcheon plate, in the Oxygen Storage room.
5. At 2:44 p.m., there was an approximately 4 foot by 4 foot cut out on the left wall, in the mechanical room, next to the pharmacy.
6. At 2:57 p.m., there was an approximately 1/2 inch penetration on the right wall in the janitorial closet. There were 7 approximately 1/8 inch to 1 inch penetrations on the left wall.

Based on observation the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that were obstructed from closing. This may cause the passage of smoke and flames in the event of a fire, and affected 1 of 6 smoke compartments in the new building.

Findings:

On a tour of the facility on April 18, 2012, the corridor doors were observed.

1. At 3:17 p.m., the door to Room E 186, had a kick down door stop. When the door stop was activated the door was obstructed from closing.
2. At 3:21 p.m., the door to Room E 183, had a kick down door stop. When the door stop was activated the door was obstructed from closing.

Based on observation, the facility failed to maintain the doors protecting corridor openings in two of two buildings. This was evidenced by doors that failed to close and latch. This may cause the passage of smoke and flames in the event of a fire, and affected 1 of 5 smoke compartments in the existing building.

Findings:

On a tour of the facility on April 17, 2012 through April 19, 2012, the corridor doors were observed.
April 17, 2012 - Building 2 (old)
1. At 2:22 p.m., the women's staff restroom door, by the cafeteria, was equipped with a self-closing device. The door failed to close and latch.
2. At 2:24 p.m., the means' staff restroom door by the cafeteria, was equipped with a self-closing device. The door failed to close and latch.
3. At 2:26 p.m., the MAK Retreat/ Med Surg (medical/surgical) break room door was equipped with a self-closing device. The door failed to close and latch.
4. At 2:32 p.m., the Oxygen storage room door, in med/surg, failed to close and latch on self closure.

Based on observation, document review and interview, the facility failed to maintain 5 of 5 drop down windows/doors. This was evidenced by no documentation of annual testing in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. This affected 1 of 5 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition

15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a tour of the facility with Facility Staff 1, on April 18, 2012, the drop down windows and door were observed.

1. At 1:50 p.m., there were drop down windows or doors at the Emergency Room Check In, at Admitting, at the patient billing area (2 windows) and at the vending machine alcove.

During an interview at 1:50 p.m., Facility Staff 1 was asked for documentation for testing the fire windows and door. Facility Staff 1 stated that there was no documentation and that he was unsure if the doors had been tested. The windows and door were activated by a smoke detector on each side that released the drop downs to close in the event of a fire.

2. At 1:53 p.m., there were 2 computer screens and other equipment sitting on the counter at the admitting window. If the window dropped the equipment would obstruct the window from closing completely.

3. On April 19, 2012, at 9 a.m., the Fire Alarm Inspection Report dated January 18, 2012, was reviewed. There was no indication on the report, that the drop down windows or door were tested annually as required.

Based on observation, the facility failed to protect a hazardous area, as evidenced by a hazardous area door that was equipped with a kick down door stop. This obstructed the self closing door from closing. This affected 1 of 6 compartments, and could result in the passage of smoke and flames.

NFPA 101, Life Safety Code , 2000 edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system , if provided, and the fire alarm system and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

On April 18, 2012, during a tour of the facility with Facility Staff 1, the hazardous area doors were observed.

At 3:19 p.m., the door E 183, Clean Processing in the OR suite, was held in the open position with a kick down door stop. The door was equipped with a self closing device.

Based on observation and interview, the facility failed to maintain the battery operated emergency lights. This was evidenced by the failure of emergency lights in 3 of 5 smoke compartments in one of two buildings. This could result in a delay of evacuation from the building in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
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 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers 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:

On a tour of Building 1 on April 17, 2012, with Facility Staff 1, the emergency lights were observed.
1. At 2:09 p.m., the battery operated emergency light, in the electrical room, failed when tested with the push button. During an interview, Facility Staff 1 was asked for records for monthly and annual testing of the emergency lights. He stated the lights had not been tested.

2. At 2:48 p.m., the emergency light, on the left wall in the teaching class room, failed when tested.

3. At 2:49 p.m., the emergency light in Bio-Med failed when tested.

Based on document review and interview, the facility failed to provide records for 1 of 2 disaster drills, in accordance with NFPA 99. This could result in a delay in staff response in the event of an emergency. This affected residents and staff in 2 of 2 buildings.

NFPA 99, Health Care Facilities, 1999 Edition
Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

On April 19, 2012, during document review, disaster drill records were requested. The facility failed to provide written documentation for 1 of 2 disaster drills.

During an interview on April 19, 2012, Facility Staff 1 stated that there was another disaster drill conducted. No documentation was provided for the second disaster drill.

Based on document review and interview, the facility failed to conduct fire drills in accordance with NFPA 101. This was evidenced by no documentation for fire drills during 3 of 4 quarters on the day shift, no drills held during the overnight shift during 4 of 4 quarters, and no fire drills for the Women's Center. This had the potential to delay staff response in the event of a fire. This affected all patients in 1 of 2 buildings and 1 of 1 smoke compartment in the Women's Center.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on April 18, 2012 and April 19, 2012, the facility fire drills were reviewed.

1. On April 18, 2012, at 12 p.m., the "Summary of Fire Drills" was reviewed. The grid (log) notes that fire drills were held on August 5, 2011 at 9:00 a.m., on the medical surgical unit, on August 5, 2011 at 6:00 p.m., in the emergency room, on October 11, 2011, at 3:30 p.m., in the pharmacy, and on February 18, 2012, at 1:30 p.m.

The only fire drill report provided was for the February 18, 2012 drill. There were no records for three of four drills held during the day shift.

2. The nursing staff work from 7:00 a.m. to 7:00 p.m., and 7:00 p.m., to 7:00 a.m.. There were no fire drill records for drills conducted after 6:00 p.m., or before 9:00 a.m., during 4 of 4 quarters.

During an interview, Facility Staff 1 confirmed that no drills were conducted on the 7:00 p.m. to 7:00 a.m., shift.

3. On April 19, 2012, at 9;15 a.m., during a tour of the the Women's Clinic, documentation for fire drills was requested. Facility staff 1 stated they have not conducted fire drills in the Women's Center.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system devices in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by three devices that failed to activate the fire alarm system and by one device that was displaced. This affected 3 of 5 smoke compartments in 1 of 2 buildings. This could result in the potential delay in notification in the event the fire alarm system was activated.

Findings:

During fire alarm system testing, with Facility Staff 1 and the mechanical engineer, on April 18, 2012, the fire alarm devices were tested.

1. At 4:04 p.m., the pull station by information systems, failed to activate the fire alarm system during 3 attempts by staff.
2. At 4:06 p.m., the strobe in the old lobby, failed to activate when the fire alarm system was tested.
3. At 4:08 p.m., the pull station by Room 101, failed to activate the fire alarm system during 2 attempts by staff.

During document review on April 18, 2012, the Fire & Safety Inspection Report, dated April 3, 2012, was reviewed. The report noted a chime/strobe in the mechanical room that was broken.

On April 18, 2012, at 3:45 p.m., the chime strobe in mechanical room was observed to be hanging loose from the wall.

Based on document review and interview the facility failed to maintain the smoke detectors in accordance with NFPA 72, National Fire Alarm Code. This was evidenced by the failure to perform smoke sensitivity testing for the smoke detectors. This affected 2 of 2 buildings, and may result in the failure of a smoke detector in the event of a fire.

NFPA 72, National Fire Alarm Code, 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 the 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: The 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 an device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review from April 17, 2012 through April 19, 2012, no documentation of smoke detector sensitivity testing was provided.
On April 19, 2012, at 9:10 a.m., during an interview, Facility Staff 1 stated smoke sensitivity testing was not done.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. This was evidenced by sprinklers with missing escutcheon plates and by one sprinkler contaminated with paint. This affected 5 of 5 smoke compartments in 1 of 2 buildings, and could result in the failure of a sprinkler or the spread of smoke and fire.
Escutcheon plates are used to cover penetrations around sprinkler pipes and sprinkler heads.

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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

On April 17. 2012, during a tour of the facility with Facility Staff 1, the sprinklers were observed.

1. At 2:17 p.m., the sprinkler escutcheon plate was missing in medical records.
2. At 2:22 p.m., the sprinkler head had paint on it, in the oxygen storage closet.
3. At 2:24 p.m., the sprinkler escutcheon plate was missing in the medical/surgical supply room.
4. At 3:01 p.m., 2 escutcheon plates were missing in the IT (Information Technology) room back office.

Based on document review and interview, the facility failed to provide documentation for testing and maintenance of the HVAC system. This was evidenced by no documentation of damper testing. This affected 2 of 2 buildings, and could result in the passage of smoke and flames in the event of fire, if the dampers failed to close.

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.

Findings:

From April 17, 2012, through April 19, 2012, facility maintenance and testing documentation was requested.

On April 19, 2012, at 9:12 a.m., no records for damper testing were provided by the facility.
At 9:12 a.m., during an interview, Facility Staff 1 stated no damper testing had been done.

Based on observation and interview, the facility failed to prevent the use of portable heating devices in patient care areas. This was evidenced by a portable heater, in use, in one area. This affected 1 of 6 smoke compartments in 1 of 2 buildings, and could increase the risk of fire.

Findings:

On April 18, 2012, during a tour of the facility with Facility Staff 1, the Labor and Delivery Department was toured. In the Labor and Deliver employee lounge there was a portable space heater in use. The heater was on and had a small oil leak.

During an interview, Facility Staff 1 stated it was not one of the floor heaters that belonged to the facility. He reported there was no information on how hot the heating elements get and if it automatically shuts off if tipped over.

Based on observation, and interview the facility failed to maintain the humidity levels in 2 of 2 operating rooms (OR)s and 1 procedure room. This was evidenced by no documentation of humidity levels. This affected 1 of 6 smoke compartments, and had the potential to increase the risk of fire.

Findings:

During record review on April 17, 2012, the records for the humidity levels were requested.

During an interview at 1:55 p.m., Facility Staff 1 stated that the facility does not log humidity levels. When asked who is responsible for monitoring the humidity levels he stated that operating room staff monitor it.

At 3:53 p.m., during an interview, OR Staff 1 was asked about logging the humidity levels. She stated her staff does not check the humidity levels.

On April 18, 2012, during a tour of the operating room suites, the humidity levels were observed in 2 of 3 rooms and 1 procedure room.
At 3:06 p.m., the humidity level in OR 3 was 16 percent. This room was used for storage of equipment.
At 3:08 p.m., in OR 2 the humidity level was 41 percent.

At 3:26 p.m., procedure room staff reported the humidity levels are not monitored in the procedure room.

On April 19, 2012, at 8:30 a.m., Facility Staff 1 stated the facility does not have a written policy and procedure for monitoring the humidity levels on anesthetizing locations.

Based on document review and interview, the facility failed to ensure generators were maintained and tested in accordance with NFPA 110, for 2 of 2 buildings. This was evidenced by no records for testing the generator under a load of not less than 30% of the nameplate rating, by no evidence of annual load bank testing, and by no records for testing a temporary generator during December 2011. This could result in a generator failure, in the event of a power outage. This affected 5 of 5 smoke compartments in the existing building.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
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 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.

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with available
EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

1. During an interview with the maintenance technician, on April 18, 2012, staff was asked about testing the generator under load each month. At 9:45 a.m., Maintenance Staff 1 stated the generators are tested monthly for 30 minutes. He did not know if they were tested at 30 percent of the nameplate rating, or if they maintained the minimum exhaust gas temperatures as recommended by the manufacturer.

On April 19, 2012, at 11:00 a.m., the chief engineer 1 reported that they do not conduct an annual load bank test on the generator for the existing (hospital) building.


On April 18, 2012, at 10:38 a.m., during record review, the maintenance tech stated that the generator had an injector leak in December 2011 and confirmed that the facility brought in a temporary generator. The facility had no testing logs for the temporary generator. During an interview the maintenance tech reported they did not inspect the temporary generator weekly or test it during the month it was in use.

3. During record review on April 19, 2012, the Generator Log Book was reviewed. At 10:02 a.m., there was no documentation of a monthly load test for March 2012, provided in the records.

Based on document review and interview, the facility failed to provide records for generator testing, under load, for 30 minutes monthly, and for exercising transfer switches. This could result in the potential failure of 2 of 2 generators, in the event of power outage. This affected 6 of 6 smoke compartments.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
6-3.5* Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and when repaired.
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 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.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position
6-4.7 The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Findings:

On April 18, 2012, at 9:45 a.m., during an interview, Maintenance Technician 1 was asked about testing the generator under load monthly. He stated the generators are tested monthly and run for 30 minutes. He was asked if the generators are running at 30 percent of name plate rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Maintenance Tech 1 stated they do not run the generators under load or monitor the minimum exhaust gas temperatures.

At 10:00 a.m., Maintenance Tech 1 stated he would provide documentation for a load bank for the Caterpillar generator that supplies power to the Labor and Delivery area, Operating Suites, Emergency Room, and some parts of the lab.

On April 19, 2012, at 10:30 a.m., the chief engineer was interviewed. He reported that they do not run the Perkins generator (for the lab) under load monthly because the transfer switch is manual. Documentation was provided for an annual load bank on July 20, 2011. The Perkins generator supplies power for emergency lighting, approximately 8 outlets and lab equipment.

At 11:00 a.m., no documentation was provided for the Caterpillar generator. The chief engineer stated they do not do a load bank on the caterpillar generator.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. This was evidenced by the use of surge protectors and extension cords in lieu of permanent wiring and by failing to maintain the clearance around electrical panels. This affected 3 of 5 smoke compartments, in 1 of 2 buildings, and could result in an increased risk of an electrical fire.

NEC 70, National Electrical Code, 1999 Edition
110.32 Work Space About Equipment
Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall no be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 feet (914 m) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34 (a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On April 17, 2012, during a tour of the facility with Facility Staff 1, the electrical wiring and equipment were observed.

1. At 2:08 p.m., there was no 3 foot clearance around Electrical panel E in the Main Building electrical room. Cardboard boxes were stacked against the front of the panel.

2. At 2:20 p.m., a refrigerator was plugged into a surge protector in the Interpreter Services office.

3. At 2:26 p.m., there was a microwave oven plugged into a surge protector in the MAK Retreat (med/surg) breakroom.

4. At 2:31 p.m., a table was placed against the front of Electrical panel E1 in the Quality Review office. The required 3 foot clearance was not maintained.

5. At 2:54 p.m., there was an extension cord in use, and a microwave plugged into a surge protector, in the women's changing room, now used by the LIS Coordinator.

6. At 2:59 p.m., there were cardboard boxes stacked against the panels in the IT office. Electrical Panels E3 and C, did not have 3 foot clearance.

Based on document review and interview the facility failed to provide documentation of a written fire watch or evacuation procedure, in the event the automatic sprinkler system is out of service for 4 hours or more in a 24 hour period. This affected 2 of 2 buildings and could result in a delay in extinguishing a fire.

Findings:

On April 18, 2012, during document review, there was no written documentation of a fire watch or evacuation procedure, in the event the automatic sprinkler system was out of service.

At 4:20 p.m., during an interview, Facility Staff 1 stated the facility has no written fire watch procedure.

Based on document review and interview, the facility failed to provide documentation of a written fire watch or evacuation procedure, in the event the fire alarm system is out of service for 4 hours or more in a 24 hour period. This affected 2 of 2 buildings and could result in a delay in notification in the event of a fire.

Findings:

On April 18, 2012, during document review, there was no written documentation of a fire watch or evacuation procedure, in the event the fire alarm system was out of service.

At 4:20 p.m., during an interview, Facility Staff 1 stated the facility has no written fire watch procedure.