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NFPA 101, 2000 Edition

7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.


Based on observation and staff interview, the facility failed to ensure exit signs were provided at the main exit (first floor) and at open area near the top of the escalator (second floor) to provide clear direction of travel to the nearest exit. This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to all eighty-nine (89) patients located in building 1 as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:

A. On 04/14/15 at 1:00 pm, during observation, the main entrance doors (two sets) located on the first floor were not identified with exit signs.

B. On 04/14/15 at 1:15 pm, during observation, the area near the escalator on the second floor did not have exit signs indicating the direction of travel to reach the nearest exit.

C. On 04/14/15 at 1:20 pm, during interview, the Plant Operations Director stated he was uncertain why exit and directional signs were not installed in these areas at the time the building was constructed.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.


Based on observation and interview, the facility failed to ensure the enclosed foyer, located at the main entrance, and the Payroll and Human Resource areas located on the lower lever, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within the foyer could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire. Not providing smoke detection in common work spaces could result in undetected fire in areas where large numbers of staff could be affected and may render them not be able to respond to their duties as required by the facility's emergency preparedness plan. In the event of fire, this failed practice presents a risk of potential harm to all eighty-nine (89) patients located in building 1 as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:


A. On 04/15/15 at 8:20 pm, during observation, an automatic smoke detection device was not provided within the foyer located at the main entrance of the building.

B. On 04/15/15 at 8:30 am, during observation, the payroll area and human resources area were not provided with smoke detectors. Numerous office cubicles (work spaces) are located in these areas.

C. On 04/15/15 at 8:32 pm, during interview, the Plant Operations Director stated he never noticed the spaces were not protected by smoke detectors.

Reference NFPA 96, 1999 Edition

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

Reference NFPA 17A, 1998 Edition

3-6.3
Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzles during cooking operations.

Based on observation and interview, the facility failed to ensure the flat cooking skillet located underneath the rangehood fire extinguishing system was properly positioned in relation to the fire extinguishing discharge nozzles as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 17A (Standard for Wet Chemical Extinguishing Systems). In the event of fire underneath the range hood, the fire extinguishing system would not be effective in extinguishing fire, which presents a risk of potential harm to all eighty-nine patients as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:

A. On 04/14/15 at 4:24 pm, during observation, the range hood fire extinguishing system located in the cafe revealed the discharge nozzle protecting the flat cooking skillet was positioned to the far left of the skillet. This cooking appliance was not adequately protected by the range hoods fire extinguishing system.

B. On 04/14/15 at 4:25 pm, during interview, the Plant Operations Director stated he was unaware the nozzles were not properly positioned to protect the skillet. He stated the flat skillet must have been shifted to the right and was not placed back into proper position under the nozzles.

Reference NFPA 99, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.

Reference NFPA 50, 2001 Edition
Storage containers, piping, valves, regulating equipment, and other accessories shall be protected against physical damage and against tampering by the general public. A shutoff valve shall be located in liquid product withdrawal lines as close to the container as practical.


Based on observation and interview, the facility failed to ensure the bulk liquid oxygen storage container, which serves the piped in liquid oxygen system for the hospital, was protected against physical damage (ie: vehicular traffic) as required by NFPA 50, (Standard for Bulk Oxygen Systems at Consumer Sites). Without this protection from impact, the piped in liquid oxygen system can be subject to leaks or total breakage, which could render the system out of service, which present the risk of potential harm to all patients that require the use of piped in liquid oxygen in building 1. The findings are:

A. On 04/15/15 at 9:45 am, during observation, the bulk liquid oxygen container located in the medical gas storage area, was not adequately protected from vehicular damage from the street.

B. On 04/15/15 at 9:50 am, during interview, the Executive Director of Ancillary Services stated he was unaware additional protection against vehicular damage was not provided at this location.

NFPA 101, 2000 Edition

7.10.1.2 Exits:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

7.10.2 Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.


Based on observation and staff interview, the facility failed to ensure exit signs were provided at the main exit (first floor) and at open area near the top of the escalator (second floor) to provide clear direction of travel to the nearest exit. This failed practice could result in delay and unclear direction during emergency evacuation, which presents a risk of potential harm to all eighty-nine (89) patients located in building 1 as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:

A. On 04/14/15 at 1:00 pm, during observation, the main entrance doors (two sets) located on the first floor were not identified with exit signs.

B. On 04/14/15 at 1:15 pm, during observation, the area near the escalator on the second floor did not have exit signs indicating the direction of travel to reach the nearest exit.

C. On 04/14/15 at 1:20 pm, during interview, the Plant Operations Director stated he was uncertain why exit and directional signs were not installed in these areas at the time the building was constructed.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.


Based on observation and interview, the facility failed to ensure the enclosed foyer, located at the main entrance, and the Payroll and Human Resource areas located on the lower lever, were provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within the foyer could result in an undetected fire at this location, which would render this required exit as unavailable in the event of fire. Not providing smoke detection in common work spaces could result in undetected fire in areas where large numbers of staff could be affected and may render them not be able to respond to their duties as required by the facility's emergency preparedness plan. In the event of fire, this failed practice presents a risk of potential harm to all eighty-nine (89) patients located in building 1 as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:


A. On 04/15/15 at 8:20 pm, during observation, an automatic smoke detection device was not provided within the foyer located at the main entrance of the building.

B. On 04/15/15 at 8:30 am, during observation, the payroll area and human resources area were not provided with smoke detectors. Numerous office cubicles (work spaces) are located in these areas.

C. On 04/15/15 at 8:32 pm, during interview, the Plant Operations Director stated he never noticed the spaces were not protected by smoke detectors.

Reference NFPA 96, 1999 Edition

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

Reference NFPA 17A, 1998 Edition

3-6.3
Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzles during cooking operations.

Based on observation and interview, the facility failed to ensure the flat cooking skillet located underneath the rangehood fire extinguishing system was properly positioned in relation to the fire extinguishing discharge nozzles as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 17A (Standard for Wet Chemical Extinguishing Systems). In the event of fire underneath the range hood, the fire extinguishing system would not be effective in extinguishing fire, which presents a risk of potential harm to all eighty-nine patients as identified by the Nursing Bed Roster provided by the Director of Plant Operations on 04/13/15. The findings are:

A. On 04/14/15 at 4:24 pm, during observation, the range hood fire extinguishing system located in the cafe revealed the discharge nozzle protecting the flat cooking skillet was positioned to the far left of the skillet. This cooking appliance was not adequately protected by the range hoods fire extinguishing system.

B. On 04/14/15 at 4:25 pm, during interview, the Plant Operations Director stated he was unaware the nozzles were not properly positioned to protect the skillet. He stated the flat skillet must have been shifted to the right and was not placed back into proper position under the nozzles.

Reference NFPA 99, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.

Reference NFPA 50, 2001 Edition
Storage containers, piping, valves, regulating equipment, and other accessories shall be protected against physical damage and against tampering by the general public. A shutoff valve shall be located in liquid product withdrawal lines as close to the container as practical.


Based on observation and interview, the facility failed to ensure the bulk liquid oxygen storage container, which serves the piped in liquid oxygen system for the hospital, was protected against physical damage (ie: vehicular traffic) as required by NFPA 50, (Standard for Bulk Oxygen Systems at Consumer Sites). Without this protection from impact, the piped in liquid oxygen system can be subject to leaks or total breakage, which could render the system out of service, which present the risk of potential harm to all patients that require the use of piped in liquid oxygen in building 1. The findings are:

A. On 04/15/15 at 9:45 am, during observation, the bulk liquid oxygen container located in the medical gas storage area, was not adequately protected from vehicular damage from the street.

B. On 04/15/15 at 9:50 am, during interview, the Executive Director of Ancillary Services stated he was unaware additional protection against vehicular damage was not provided at this location.