HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 1 of 6 buildings, which could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 on September 10 through September 13, 2012, the building construction was observed.

Main Hospital
September 11, 2012

At 9:21 a.m. there was an approximately 3/4 inch unsealed penetration in the north wall of the Storage Room/Ortho Miscellaneous Room.

At 10:06 a.m., there was an approximately 1/2 inch unsealed penetration around a 3/4 pipe in the ceiling of the Lab Blood Banking Room.

At 1:04 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the East wall of the Lab Draw Room.

At 1:08 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the wall near Station 1 of the Lab Draw Center.

At 1:34 p.m., there was an approximately 2 inch by 2 inch unsealed penetration in the ceiling of the First floor EVS closet (North).

Main Hospital
Date: September 12, 2012

At 1:11 p.m. the was an approximately 2 inch by 3 inch unsealed penetration in the west wall adjacent to the Operating Room in OB.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to fully latch, and by doors that were impeded from closing. This affected 2 of 6 buildings, which could result in the spread of smoke.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable
with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During the facility tour with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the corridor doors were observed.

Main Hospital
Date: September 11, 2012

At 8:24 a.m., the corridor door to Room 1422 was impeded from closing with a bed and table that was in front of the door path.

At 8:25 a.m., Staff V1 attempted to close the door, and stated during an interview that the door was not going to close with the bed and table in the way.

At 8:58 a.m., the corridor to Room 1227 was impeded from closing with a trash can that was in the door path between the door and door frame.

Main Hospital
Date: September 12, 2012

At 10:22 a.m., the self closing corridor door to the Surgery Break Room was not latching when tested.

At 10:23 a.m., Staff V1 stated during an interview that they checked the door yesterday, and it latched.

General Hospital
Date: September 12, 2012

At 2:50 p.m., there was a self closing door to the Endoscopy Dirty Workroom that failed to close and latch when tested.



30514

Main Hospital
September 11, 2012

At 9:07 a.m., the door to the Linen Room near Nursing Station Med Surge 3 was unable to latch when tested. The strike plate in the door frame was bent, and prevented the door from latching.

Based on observation, the facility failed to display exit signs and/or directional signs on or by doors designated as emergency exit routes. This was evidenced by no signs displayed to indicate exits. This could delay egress in 2 of 6 buildings, and could cause potential harm to patients and staff in the event of a fire emergency.

NFPA 101 Life Safety Code (2000 Edition) 7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the egress paths and exit signs were observed.

Main Hospital
September 11, 2012

At 10:20 a.m., there was no "NO EXIT" sign displayed in the egress path from the first floor Radiology Suite, in the new construction area. The path could be considered as an exit.

Main Hospital
September 12, 2012

At 10:36 a.m., in the Operating Room (OR) corridor near OR 1 and OR 2, there was no exit sign displayed in the north and south direction. The facility's evacuation plan indicated this as an egress path.


30514

Main Hospital
September 12, 2012

At 12:53 p.m., there was an exit door in the Administration area that did not have an exit sign. The facility's evacuation plan indicated that the egress route was through that door, and the exit was not marked with an exit sign.

Outpatient Surgery Center
September 12, 2012

At 3:05 p.m., in the Pre-Operative area, there was no directional exit sign pointing north or south to indicate the egress path. The facility's evacuation plan indicated this was an egress path.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with NFPA 101. This was evidenced by unsealed penetrations in smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury to the patients due to smoke and fire. This affected 1 of 6 buildings.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Staff V and Staff V1 on September 1, 2012, the smoke barrier walls were observed.

Main Hospital
September 11, 2012

At 9:11 a.m., there was a 6 inch pipe in the smoke barrier wall near building 97, on the second floor, and in the Lobby waiting area with a 1 3/4 inch unsealed penetration around the pipe.

At 9:15 a.m., there was a round 2 inch unsealed penetration in the smoke barrier wall near Room 1273.

At 10:07 a.m., there was a 1/2 inch unsealed penetration above a 1/2 inch pipe in the smoke barrier wall near Surgery West near Pathology, and the north side.

At 11:07 a.m., there was an approximately 4 inch by 8 inch unsealed penetration in the smoke barrier wall near the Intensive Care Unit main entry on the second floor.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smokes barrier doors that failed to self-close and latch. This had the potential to smoke barrier doors to fail to contain smoke during a fire causing potential harm to the patients. This affected 2 of 6 buildings.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During fire alarm testing with Staff V, Staff V1 and Staff V2 on September 11, 2012 through September 12, 2012, the smoke barrier doors were observed.

Main Hospital
September 11, 2012

At 9:27 a.m., the south smoke barrier door near Room 1327 on the third floor was not latching when tested.

At 9:46 a.m., the west smoke barrier door near Room 1264 on the second floor was not latching when tested.

At 10:02 a.m., the west smoke barrier door to surgery and near Pathology was not latching when tested.

At 12:58 p.m., the north smoke barrier door near Room 1101 at the main entry to OB was not latching when tested.

General Hospital
September 12, 2012

At 2:55 p.m., the smoke barrier doors to Endoscopy were not latching when tested. The top portion of the latching hardware on the door frame was missing.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and were not equipped with a self-closing mechanism on the door, and by missing a door. This deficient practice affected 1 of 6 buildings, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 on September 11, 2012, through September 12, 2012, the hazardous area enclosures were observed.

Main Hospital
September 11, 2012

At 3:06 p.m., the door to the room identified as EVS Storage was missing a self closure device. The room was over 100 square feet in size, and contained over 100 large cardboard boxes of combustible material.

Main Hospital
September 12, 2012

At 8:50 a.m., the Stat Lab Storage was missing a door and self closure device. There were screw holes where the door and self-closing device had been installed. The room was over 50 square feet in size, and contained over 50 cardboard boxes of combustible material.

Based on interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by one staff member that could not locate a fire alarm activation device, and a fire extinguisher. This affected 1 of 6 buildings, and could result in facility staff not being prepared to respond to a fire emergency.

NFPA 101, Life Safety Code 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2, on September 11, 2012, the facility staff were interviewed.

Main Hospital
September 11, 2012

At 9:32 a.m., Staff W was interviewed in the Gift shop, and asked to locate a fire alarm activation device and a fire extinguisher. Staff W was unable to locate either a fire alarm activation device or a fire extinguisher. The fire alarm activation device was approximately 50 feet away, and the fire extinguisher was approximately 25 feet away.

Based on document observation, and interview, the facility failed to maintain the integrity of their fire alarm system. This was evidenced by audible devices that failed to sound an audible alarm. This could result in a delay to notify the occupants of the building of a fire or other emergency in the facility, and affected 2 of 6 buildings.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 101 Life Safety Code 2000 Edition
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with Staff V, Staff V1, and Staff V2 on September 11, 2012, through September 12, 2012, the fire alarm was tested, and a staff person was interviewed.

Main Hospital
September 11, 2012

At 1:42 p.m., there was a bell in the Main Storeroom in the Basement that was not sounding an alarm when tested.

At 1:43 p.m., Staff V stated during an interview that the device worked last month when it was tested.

General Hospital
September 12, 2012

At 2:10 p.m., there was a strobe light in the Microbiology Lab in the back room, and there was no audible alarm sounding in the lab while the fire alarm was activated and sounding.

At 2:11 p.m., Staff V stated during an interview that they could not hear the fire alarm sounding in the lab.

Main Hospital
September 11, 2102

At 1:30 p.m., the sprinkler in the hallway of the basement and near the whirlpool Room was missing an escutcheon ring.

Outpatient Surgery Center
September 12, 2012

At 4:34 p.m., there was 1 of 4 sprinklers that was missing an escutcheon ring in Operating Room 4.







30514

Based on observation, the facility failed to maintain their fire sprinkler system, as evidenced by the presence of paint on a sprinkler head, by missing escutcheon rings, and by a missing Inspector's Test Valve (ITV) sign. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly, and a missing escutcheon ring could allow heat and smoke to affect other areas in the building, which could cause harm to patients and staff could potentially be unable to identify the correct ITV valve. This affected 3 of 6 buildings.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 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.

NFPA 13 Installation of Sprinkler Systems, 1999 Edition
3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the automatic sprinkler system was observed.

Main Hospital
September 11, 2012

At 9:36 a.m., in the Material Management Room on the lower level, an escutcheon ring was missing from a sprinkler, and exposed a 1/2 inch unsealed penetration around the sprinkler.

At 9:54 a.m., there was a sprinkler in the Medical Records Coding Room with paint on the deflector plate.

General Hospital
September 12, 2012

At 2:41 p.m., there was an ITV in the Basement that was missing sign to identify the valve. The words "Inspector's Test Valve" was written on the wall near the ITV. There was another valve with an ITV inspection tag on it, and it was not an ITV valve.

Based on observation, and interview, the facility failed to maintain there electrical system as evidenced by circuit panels with unidentified circuit breakers, an appliance plugged into a multi-plugged power strip, and a missing faceplate. This failure would delay turning off a circuit breakers in the event of a electrical fire, and cause potential harm to the patients and staff. This deficient practice could lead to an increased risk for an electrical fire and shock, and affected 2 of 6 buildings.

NFPA 70, National Electrical Code (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

NFPA 70, National Electrical Code, 1999 Edition
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.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1) and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the facility electrical system was observed, and a staff person was interviewed.

Main Hospital
September 11, 2012

At 8:54 a.m., in the Electrical panel 2A on the second floor near the Nursing Station there were 11 of 16 circuits in the "on" position, and were unidentified. Circuits 1, 4, 7, 8, 9, 10, 12, 13, 14, 15, and 16 were not labeled to their purpose.

At 8:55 a.m., Staff V1 stated during an interview that they did not know what those circuit breakers were connected to.

At 9:55 a.m., in the Electrical Panel L1C on the first floor and near Room 116, there were 5 of 39 circuits that were in the "on" position, and were unidentified. Circuits 14, 15, 23, 25, and 27 were not labeled to their purpose.



30514

Main Hospital, 3rd Floor
September 11, 2012

At 8:48 a.m., there was a microwave that was plugged into a power strip and not directly into an electrical outlet in the Doctor's Sleep Room on the Third Floor.

General Hospital
September 12, 2012

At 2:24 p.m., there was a faceplate cover that was missing from a telephone port, with exposed wiring in the Doctor's Break Room in the Endoscopy Suite.

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 1 of 6 buildings, which could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 on September 10 through September 13, 2012, the building construction was observed.

Main Hospital
September 11, 2012

At 9:21 a.m. there was an approximately 3/4 inch unsealed penetration in the north wall of the Storage Room/Ortho Miscellaneous Room.

At 10:06 a.m., there was an approximately 1/2 inch unsealed penetration around a 3/4 pipe in the ceiling of the Lab Blood Banking Room.

At 1:04 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the East wall of the Lab Draw Room.

At 1:08 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the wall near Station 1 of the Lab Draw Center.

At 1:34 p.m., there was an approximately 2 inch by 2 inch unsealed penetration in the ceiling of the First floor EVS closet (North).

Main Hospital
Date: September 12, 2012

At 1:11 p.m. the was an approximately 2 inch by 3 inch unsealed penetration in the west wall adjacent to the Operating Room in OB.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to fully latch, and by doors that were impeded from closing. This affected 2 of 6 buildings, which could result in the spread of smoke.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable
with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During the facility tour with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the corridor doors were observed.

Main Hospital
Date: September 11, 2012

At 8:24 a.m., the corridor door to Room 1422 was impeded from closing with a bed and table that was in front of the door path.

At 8:25 a.m., Staff V1 attempted to close the door, and stated during an interview that the door was not going to close with the bed and table in the way.

At 8:58 a.m., the corridor to Room 1227 was impeded from closing with a trash can that was in the door path between the door and door frame.

Main Hospital
Date: September 12, 2012

At 10:22 a.m., the self closing corridor door to the Surgery Break Room was not latching when tested.

At 10:23 a.m., Staff V1 stated during an interview that they checked the door yesterday, and it latched.

General Hospital
Date: September 12, 2012

At 2:50 p.m., there was a self closing door to the Endoscopy Dirty Workroom that failed to close and latch when tested.



30514

Main Hospital
September 11, 2012

At 9:07 a.m., the door to the Linen Room near Nursing Station Med Surge 3 was unable to latch when tested. The strike plate in the door frame was bent, and prevented the door from latching.

Based on observation, the facility failed to display exit signs and/or directional signs on or by doors designated as emergency exit routes. This was evidenced by no signs displayed to indicate exits. This could delay egress in 2 of 6 buildings, and could cause potential harm to patients and staff in the event of a fire emergency.

NFPA 101 Life Safety Code (2000 Edition) 7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the egress paths and exit signs were observed.

Main Hospital
September 11, 2012

At 10:20 a.m., there was no "NO EXIT" sign displayed in the egress path from the first floor Radiology Suite, in the new construction area. The path could be considered as an exit.

Main Hospital
September 12, 2012

At 10:36 a.m., in the Operating Room (OR) corridor near OR 1 and OR 2, there was no exit sign displayed in the north and south direction. The facility's evacuation plan indicated this as an egress path.


30514

Main Hospital
September 12, 2012

At 12:53 p.m., there was an exit door in the Administration area that did not have an exit sign. The facility's evacuation plan indicated that the egress route was through that door, and the exit was not marked with an exit sign.

Outpatient Surgery Center
September 12, 2012

At 3:05 p.m., in the Pre-Operative area, there was no directional exit sign pointing north or south to indicate the egress path. The facility's evacuation plan indicated this was an egress path.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with NFPA 101. This was evidenced by unsealed penetrations in smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury to the patients due to smoke and fire. This affected 1 of 6 buildings.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Staff V and Staff V1 on September 1, 2012, the smoke barrier walls were observed.

Main Hospital
September 11, 2012

At 9:11 a.m., there was a 6 inch pipe in the smoke barrier wall near building 97, on the second floor, and in the Lobby waiting area with a 1 3/4 inch unsealed penetration around the pipe.

At 9:15 a.m., there was a round 2 inch unsealed penetration in the smoke barrier wall near Room 1273.

At 10:07 a.m., there was a 1/2 inch unsealed penetration above a 1/2 inch pipe in the smoke barrier wall near Surgery West near Pathology, and the north side.

At 11:07 a.m., there was an approximately 4 inch by 8 inch unsealed penetration in the smoke barrier wall near the Intensive Care Unit main entry on the second floor.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smokes barrier doors that failed to self-close and latch. This had the potential to smoke barrier doors to fail to contain smoke during a fire causing potential harm to the patients. This affected 2 of 6 buildings.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During fire alarm testing with Staff V, Staff V1 and Staff V2 on September 11, 2012 through September 12, 2012, the smoke barrier doors were observed.

Main Hospital
September 11, 2012

At 9:27 a.m., the south smoke barrier door near Room 1327 on the third floor was not latching when tested.

At 9:46 a.m., the west smoke barrier door near Room 1264 on the second floor was not latching when tested.

At 10:02 a.m., the west smoke barrier door to surgery and near Pathology was not latching when tested.

At 12:58 p.m., the north smoke barrier door near Room 1101 at the main entry to OB was not latching when tested.

General Hospital
September 12, 2012

At 2:55 p.m., the smoke barrier doors to Endoscopy were not latching when tested. The top portion of the latching hardware on the door frame was missing.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and were not equipped with a self-closing mechanism on the door, and by missing a door. This deficient practice affected 1 of 6 buildings, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 on September 11, 2012, through September 12, 2012, the hazardous area enclosures were observed.

Main Hospital
September 11, 2012

At 3:06 p.m., the door to the room identified as EVS Storage was missing a self closure device. The room was over 100 square feet in size, and contained over 100 large cardboard boxes of combustible material.

Main Hospital
September 12, 2012

At 8:50 a.m., the Stat Lab Storage was missing a door and self closure device. There were screw holes where the door and self-closing device had been installed. The room was over 50 square feet in size, and contained over 50 cardboard boxes of combustible material.

Based on interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by one staff member that could not locate a fire alarm activation device, and a fire extinguisher. This affected 1 of 6 buildings, and could result in facility staff not being prepared to respond to a fire emergency.

NFPA 101, Life Safety Code 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2, on September 11, 2012, the facility staff were interviewed.

Main Hospital
September 11, 2012

At 9:32 a.m., Staff W was interviewed in the Gift shop, and asked to locate a fire alarm activation device and a fire extinguisher. Staff W was unable to locate either a fire alarm activation device or a fire extinguisher. The fire alarm activation device was approximately 50 feet away, and the fire extinguisher was approximately 25 feet away.

Based on document observation, and interview, the facility failed to maintain the integrity of their fire alarm system. This was evidenced by audible devices that failed to sound an audible alarm. This could result in a delay to notify the occupants of the building of a fire or other emergency in the facility, and affected 2 of 6 buildings.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 101 Life Safety Code 2000 Edition
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with Staff V, Staff V1, and Staff V2 on September 11, 2012, through September 12, 2012, the fire alarm was tested, and a staff person was interviewed.

Main Hospital
September 11, 2012

At 1:42 p.m., there was a bell in the Main Storeroom in the Basement that was not sounding an alarm when tested.

At 1:43 p.m., Staff V stated during an interview that the device worked last month when it was tested.

General Hospital
September 12, 2012

At 2:10 p.m., there was a strobe light in the Microbiology Lab in the back room, and there was no audible alarm sounding in the lab while the fire alarm was activated and sounding.

At 2:11 p.m., Staff V stated during an interview that they could not hear the fire alarm sounding in the lab.

Main Hospital
September 11, 2102

At 1:30 p.m., the sprinkler in the hallway of the basement and near the whirlpool Room was missing an escutcheon ring.

Outpatient Surgery Center
September 12, 2012

At 4:34 p.m., there was 1 of 4 sprinklers that was missing an escutcheon ring in Operating Room 4.







30514

Based on observation, the facility failed to maintain their fire sprinkler system, as evidenced by the presence of paint on a sprinkler head, by missing escutcheon rings, and by a missing Inspector's Test Valve (ITV) sign. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly, and a missing escutcheon ring could allow heat and smoke to affect other areas in the building, which could cause harm to patients and staff could potentially be unable to identify the correct ITV valve. This affected 3 of 6 buildings.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 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.

NFPA 13 Installation of Sprinkler Systems, 1999 Edition
3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1), and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the automatic sprinkler system was observed.

Main Hospital
September 11, 2012

At 9:36 a.m., in the Material Management Room on the lower level, an escutcheon ring was missing from a sprinkler, and exposed a 1/2 inch unsealed penetration around the sprinkler.

At 9:54 a.m., there was a sprinkler in the Medical Records Coding Room with paint on the deflector plate.

General Hospital
September 12, 2012

At 2:41 p.m., there was an ITV in the Basement that was missing sign to identify the valve. The words "Inspector's Test Valve" was written on the wall near the ITV. There was another valve with an ITV inspection tag on it, and it was not an ITV valve.

Based on observation, and interview, the facility failed to maintain there electrical system as evidenced by circuit panels with unidentified circuit breakers, an appliance plugged into a multi-plugged power strip, and a missing faceplate. This failure would delay turning off a circuit breakers in the event of a electrical fire, and cause potential harm to the patients and staff. This deficient practice could lead to an increased risk for an electrical fire and shock, and affected 2 of 6 buildings.

NFPA 70, National Electrical Code (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

NFPA 70, National Electrical Code, 1999 Edition
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.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with Staff V, Staff V1, and Staff V2 (Team 1) and Staff X, Staff X1, and Staff X2 (Team 2) on September 11, 2012, through September 12, 2012, the facility electrical system was observed, and a staff person was interviewed.

Main Hospital
September 11, 2012

At 8:54 a.m., in the Electrical panel 2A on the second floor near the Nursing Station there were 11 of 16 circuits in the "on" position, and were unidentified. Circuits 1, 4, 7, 8, 9, 10, 12, 13, 14, 15, and 16 were not labeled to their purpose.

At 8:55 a.m., Staff V1 stated during an interview that they did not know what those circuit breakers were connected to.

At 9:55 a.m., in the Electrical Panel L1C on the first floor and near Room 116, there were 5 of 39 circuits that were in the "on" position, and were unidentified. Circuits 14, 15, 23, 25, and 27 were not labeled to their purpose.



30514

Main Hospital, 3rd Floor
September 11, 2012

At 8:48 a.m., there was a microwave that was plugged into a power strip and not directly into an electrical outlet in the Doctor's Sleep Room on the Third Floor.

General Hospital
September 12, 2012

At 2:24 p.m., there was a faceplate cover that was missing from a telephone port, with exposed wiring in the Doctor's Break Room in the Endoscopy Suite.