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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected two of ten smoke compartments on the first floor and could result in the spread of fire and smoke causing potential harm to patients and staff, in the event of a fire.

Findings:

During the tour of the facility with staff the walls and ceilings were observed.
1. On 04/27/10, at 10:45 a.m., there was a penetration along the back wall in the Cashier Office. The penetration was sealed with a 3 X 2 cut out of sheet rock. There was an approximately 1 inch penetration around the sheet rock that was not sealed.
2. At 1:16 p.m., in the Operator Services Office, there was a broken cover plate around a television cable wire.
3. At 2:25 p.m., in the OR Janitor Closet #1161, the escutcheon ring had shifted to one side and exposed an approximately one inch penetration in the ceiling.

Based on observation and staff interview, the facility failed to maintain the gift shop fire doors, as evidenced by one door that did not close upon activation of the smoke detector on the doors. This affected one of ten smoke compartments on the first floor and could result in the potential spread of smoke in the event of a fire.

Findings:

During fire alarm testing with facility staff members on 04/27/10, at 11:33 a.m., the doors to the gift shop were observed. The doors were equipped with Sentronic local smoke detectors. When the smoke detectors were tested, the doors failed to release and close. The doors remained fully open.
During an interview at 11:34 a.m., Staff confirmed that the doors did not close during testing.

Based on document review and staff interview, the facility failed to conduct fire drills once per shift per quarter, for all staff. This was evidenced by missing records for NOC shift fire drills for three of four quarters and by day shift fire drills that did not have the majority of employees participating. This affected all patients with the potential lack of staff knowledge and delay in response, in the event of a fire.

Findings:

During document review, on 04/28/10, the fire drill records were reviewed.
1. Records indicated four of five units participated in one NOC shift drill in the past twelve months. NOC shift drills were conducted for one unit at a time instead of all units participating in all four quarterly NOC shift drills.
2. Records for Day Shift Drills, in the past twelve months, indicated 122 employees participated in the 1st quarter, 37 employees in the 3rd quarter and 17 employees participated in the 4th quarter fire drill.

During an interview, Staff stated that there are approximately 300 employees on any given day.

Based on record review, the facility failed to ensure the maintenance, inspection and testing of smoke detectors was completed in accordance with NFPA 72. This was evidenced by no documentation provided for the bi-annual smoke detector sensitivity testing. This affected five of five floors and could result in the potential for smoke detector malfunction, resulting in a delay in notification and the spread of fire and smoke.

NFPA 72, 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.

Findings:

During record review on 04/27/10, no documents were provided to show that the facility had conducted the bi-annual sensitivity testing of the smoke detectors. There was no report for smoke sensitivity testing, including a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. There was no documentation indicating that the smoke detectors were tested as required.

Based on observation, the facility failed to maintain the sprinkler system in accordance with NFPA 25. This was evidenced by incomplete records for quarterly sprinkler testing for three of four quarters. This affected five of five floors and could result in a failure of the sprinkler system and a delay in extinguishing a fire.

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

NFPA 25, table 2-1:
Summary of Sprinkler System Inspection, Testing, and Maintenance.
Item Activity Frequency Reference
Control Valves Inspection Weekly/Monthly 2-2.4.2
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Findings:

During document review on 04/27/10, no documents were provided for the quarterly water flow and alarm tests of the automatic sprinkler system for all four quarters. Further document review disclosed that the facility is conducting the quarterly flow tests semi-annually. In the past twelve months one of four flow quarterly inspections had been conducted. There were no test record for the second quarter and third quarter of 2009 and no test record for the first quarter of 2010.

Based on observation, the facility failed to maintain portable fire extinguishers, as evidenced by one fire extinguisher that was blocked and by one fire extinguisher that was inspected one of seven months in the past year. This affected two of ten smoke compartments on the first floor with the potential delay of access to the portable fire extinguishers in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6* Fire extinguishers shall not be obstructed or obscured
from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.

4-3 Inspection.
4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
4-3.4 Inspection Record keeping.
4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

During a tour of the facility with a staff member on 04/27/10, the fire extinguishers were observed.
1. At 10:57 a.m., in the Lab, the fire extinguisher near the rear entrance, had one signature on the annual tag. The tag indicated the extinguisher was inspected in April 2010. No other signatures were on the tag for any other monthly inspections. The annual certification for the fire extinguisher was conducted on 8/4/09.
2. At 1:33 p.m., in the engineering Department, the fire extinguisher was blocked by a ladder and 5 standing fans.

Based on observation and staff interview, the facility failed to maintain the facility free of flammable furnishing or decorations, as evidenced by two folding walls in the conference rooms that did not have fire ratings. This affected one of two smoke compartments on the second floor and could result in the potential combustion of of the folding walls near the kitchen.

Findings:

During a tour of the facility with a staff member on 04/27/10, the second floor conference rooms were observed. There were two folding walls installed that opened fully to create two conference rooms.

During an interview, Staff 1 was asked for the fire rating of the walls. Staff 1 stated that they would have to look up the information. No information was provided during the survey.

Based on observation, the facility failed to maintain the storage of medical gas cylinders, as evidenced by one oxygen storage area where full and empty cylinders were stored together without signs. This could result in delay to access a full cylinder in the event of an emergency.

NFPA 99 1999 edition
4-3 Storage Requirements
4-3.5.2.2(b)2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a tour of the facility with a staff member on 04/27/10, at 3:05 p.m., the outside storage area for oxygen cylinders was observed. Full and empty cylinders were stored together with no signs posted to distinguish the full cylinders from the empty cylinders.

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities, as evidenced by the use of surge protectors for medical equipment and motorized items. This condition affected five of ten smoke compartments and could result in the potential to ignite an electrical fire.

NFPA 70 National Electrical Code
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:

During a tour of the facility with a staff member on 04/27/10, the electrical wiring and connections were observed.
1. At 10:50 a.m., in the Admittance Office, a microwave and small refrigerator were plugged into a power strip instead of directly into the wall outlet.
2. At 1:30 p.m., in the EVS Office, a microwave and a small refrigerator were plugged into a power strip instead of directly into the wall outlet.
3. At 1:47 p.m., in the Pathology Lab, a centrifuge was plugged into a power strip that was plugged into another power strip instead of directly into the wall outlet.
4. At 2:05 p.m., in the Radiology Break Room, two microwaves were plugged into a power strip instead of directly into the wall outlet.
5. At 2:30 p.m., in the Operating Cysto Room, a Litho Machine was plugged into a power strip instead of directly into the wall outlet. An Xray machine, video machine, and two printers were plugged into a power strip instead of directly into the wall outlet.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected two of ten smoke compartments on the first floor and could result in the spread of fire and smoke causing potential harm to patients and staff, in the event of a fire.

Findings:

During the tour of the facility with staff the walls and ceilings were observed.
1. On 04/27/10, at 10:45 a.m., there was a penetration along the back wall in the Cashier Office. The penetration was sealed with a 3 X 2 cut out of sheet rock. There was an approximately 1 inch penetration around the sheet rock that was not sealed.
2. At 1:16 p.m., in the Operator Services Office, there was a broken cover plate around a television cable wire.
3. At 2:25 p.m., in the OR Janitor Closet #1161, the escutcheon ring had shifted to one side and exposed an approximately one inch penetration in the ceiling.

Based on observation and staff interview, the facility failed to maintain the gift shop fire doors, as evidenced by one door that did not close upon activation of the smoke detector on the doors. This affected one of ten smoke compartments on the first floor and could result in the potential spread of smoke in the event of a fire.

Findings:

During fire alarm testing with facility staff members on 04/27/10, at 11:33 a.m., the doors to the gift shop were observed. The doors were equipped with Sentronic local smoke detectors. When the smoke detectors were tested, the doors failed to release and close. The doors remained fully open.
During an interview at 11:34 a.m., Staff confirmed that the doors did not close during testing.

Based on document review and staff interview, the facility failed to conduct fire drills once per shift per quarter, for all staff. This was evidenced by missing records for NOC shift fire drills for three of four quarters and by day shift fire drills that did not have the majority of employees participating. This affected all patients with the potential lack of staff knowledge and delay in response, in the event of a fire.

Findings:

During document review, on 04/28/10, the fire drill records were reviewed.
1. Records indicated four of five units participated in one NOC shift drill in the past twelve months. NOC shift drills were conducted for one unit at a time instead of all units participating in all four quarterly NOC shift drills.
2. Records for Day Shift Drills, in the past twelve months, indicated 122 employees participated in the 1st quarter, 37 employees in the 3rd quarter and 17 employees participated in the 4th quarter fire drill.

During an interview, Staff stated that there are approximately 300 employees on any given day.

Based on record review, the facility failed to ensure the maintenance, inspection and testing of smoke detectors was completed in accordance with NFPA 72. This was evidenced by no documentation provided for the bi-annual smoke detector sensitivity testing. This affected five of five floors and could result in the potential for smoke detector malfunction, resulting in a delay in notification and the spread of fire and smoke.

NFPA 72, 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.

Findings:

During record review on 04/27/10, no documents were provided to show that the facility had conducted the bi-annual sensitivity testing of the smoke detectors. There was no report for smoke sensitivity testing, including a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. There was no documentation indicating that the smoke detectors were tested as required.

Based on observation, the facility failed to maintain the sprinkler system in accordance with NFPA 25. This was evidenced by incomplete records for quarterly sprinkler testing for three of four quarters. This affected five of five floors and could result in a failure of the sprinkler system and a delay in extinguishing a fire.

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

NFPA 25, table 2-1:
Summary of Sprinkler System Inspection, Testing, and Maintenance.
Item Activity Frequency Reference
Control Valves Inspection Weekly/Monthly 2-2.4.2
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Findings:

During document review on 04/27/10, no documents were provided for the quarterly water flow and alarm tests of the automatic sprinkler system for all four quarters. Further document review disclosed that the facility is conducting the quarterly flow tests semi-annually. In the past twelve months one of four flow quarterly inspections had been conducted. There were no test record for the second quarter and third quarter of 2009 and no test record for the first quarter of 2010.

Based on observation, the facility failed to maintain portable fire extinguishers, as evidenced by one fire extinguisher that was blocked and by one fire extinguisher that was inspected one of seven months in the past year. This affected two of ten smoke compartments on the first floor with the potential delay of access to the portable fire extinguishers in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6* Fire extinguishers shall not be obstructed or obscured
from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.

4-3 Inspection.
4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
4-3.4 Inspection Record keeping.
4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

During a tour of the facility with a staff member on 04/27/10, the fire extinguishers were observed.
1. At 10:57 a.m., in the Lab, the fire extinguisher near the rear entrance, had one signature on the annual tag. The tag indicated the extinguisher was inspected in April 2010. No other signatures were on the tag for any other monthly inspections. The annual certification for the fire extinguisher was conducted on 8/4/09.
2. At 1:33 p.m., in the engineering Department, the fire extinguisher was blocked by a ladder and 5 standing fans.

Based on observation and staff interview, the facility failed to maintain the facility free of flammable furnishing or decorations, as evidenced by two folding walls in the conference rooms that did not have fire ratings. This affected one of two smoke compartments on the second floor and could result in the potential combustion of of the folding walls near the kitchen.

Findings:

During a tour of the facility with a staff member on 04/27/10, the second floor conference rooms were observed. There were two folding walls installed that opened fully to create two conference rooms.

During an interview, Staff 1 was asked for the fire rating of the walls. Staff 1 stated that they would have to look up the information. No information was provided during the survey.

Based on observation, the facility failed to maintain the storage of medical gas cylinders, as evidenced by one oxygen storage area where full and empty cylinders were stored together without signs. This could result in delay to access a full cylinder in the event of an emergency.

NFPA 99 1999 edition
4-3 Storage Requirements
4-3.5.2.2(b)2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a tour of the facility with a staff member on 04/27/10, at 3:05 p.m., the outside storage area for oxygen cylinders was observed. Full and empty cylinders were stored together with no signs posted to distinguish the full cylinders from the empty cylinders.

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities, as evidenced by the use of surge protectors for medical equipment and motorized items. This condition affected five of ten smoke compartments and could result in the potential to ignite an electrical fire.

NFPA 70 National Electrical Code
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:

During a tour of the facility with a staff member on 04/27/10, the electrical wiring and connections were observed.
1. At 10:50 a.m., in the Admittance Office, a microwave and small refrigerator were plugged into a power strip instead of directly into the wall outlet.
2. At 1:30 p.m., in the EVS Office, a microwave and a small refrigerator were plugged into a power strip instead of directly into the wall outlet.
3. At 1:47 p.m., in the Pathology Lab, a centrifuge was plugged into a power strip that was plugged into another power strip instead of directly into the wall outlet.
4. At 2:05 p.m., in the Radiology Break Room, two microwaves were plugged into a power strip instead of directly into the wall outlet.
5. At 2:30 p.m., in the Operating Cysto Room, a Litho Machine was plugged into a power strip instead of directly into the wall outlet. An Xray machine, video machine, and two printers were plugged into a power strip instead of directly into the wall outlet.