HospitalInspections.org

1) The facility failed to ensure complete two-hour fire rated wall assemblies between the 1959 hospital building and the business occupancy located in the 1917 building.

Multiple missing plaster ceiling materials in multiple rooms reduce the construction type of the 1917 building to Type II (000). Because the 1917 building was not separated from the hospital building with a two-hour fire resistant separation on all floors, the entire healthcare occupancy (1959 and 1965 buildings) must be classified a Type II (000) construction type. This construction classification is not allowed for healthcare buildings over two stories in height.

2) The facility failed to ensure complete one-hour fire rated wall assemblies between the 1970 Same Day Surgery building and the business occupancy located in the 1917 building.

Observation determined the head-of-wall joint in the occupancy separation wall was not fire-caulked.

3) The facility failed to ensure complete two-hour fire rated wall assemblies between the 1917 building and the sky bridge to the 1980 building. The bottom rods on the 90-minute fire doors did not latch into the floor.

The facility failed to ensure complete two-hour fire rated wall assemblies between the Hospital and the Skywalk.

Manufacturers typically design 90-minute fire rated metal double doors to latch into the door frame and into the floor.

Observation determined the 90-minute fire rated double doors located between the Hospital and the Skywalk were not latching into the floor.

The facility failed to maintan the integrity of the floor/ceiling assemblies resulting in a noncompliant construction Type II (000).

Observation determined:

1) Unsealed spaces around three (3) conduits through the floor/ceiling assembly between the 4th and 5th floor in Room #4131.

2) Unsealed spaces around three (3) conduits adjacent to the fire alarm panel through the floor/ceiling assembly between the 3rd and 4th floor in the Equipment Room.

3) Unsealed spaces around two (2) drain pipes in the floor to the Kidney Dialysis Unit filled with mineral fiber but no fire sealant.

Health care occupancies of five stories must be Type I (443), Type I (332), or Type II (222). The facility failed to ensure building construction was maintained.

1) Observation determined steel members supporting the ceiling/floor assembly were not protected at the second floor mechanical space behind the telephone/drinking fountain casework.

2) The original construction for the building was altered from Type I (332) to Type II (000) when the South Addition was built. Five-story buildings of Type II (000) construction are not permitted.

Record review determined the facility has not ensured exposed interior surfaces in rooms have a flame spread rating of Class A or B. Flame spread documentation was not available for the following:

1) Wood paneling in the Dietary Manager's office.

2) Folding wall partition in the old Swing Bed Dining Room.

3) Carpet on the walls in the Wheelchair Storage Room.

4) Folding wall partition in the Gym Craft Room.

5) Folding wall partition in the 5th floor Dining Room.

The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class B rating.

Documentation review indicated the facility did not have interior finish documentation for the folding partitions in the Cafeteria Dining Area.

The facility failed to ensure corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating.
1) Observation determined the third floor Coding Library was separated from the corridor by a vinyl folding wall partition that was open to the corridor approximately one foot from the floor.
2) The facility failed to prevent the corridor being used as a portion of the return air system. The return air system for the central heating system was through the concealed space above the suspended ceiling of the egress corridors. Observation determined the facility failed to ensure corridors were separated from use areas by walls with at least ½ hour fire resistance rating due to unsealed spaces around through-wall penetrations. Where automatic sprinkler system protection is provided throughout, corridor walls may terminate at a suspended ceiling. The suspended ceiling was not constructed to limit the transfer of smoke due to open egg crate panels in the suspended ceiling grids.

The facility failed to ensure doors in corridor walls have automatic, positive latching devices that provide a means suitable for keeping the door closed.

Observation determined numerous corridor doors in multiple locations throughout the facility had no automatic positive latching device.

The facility failed to ensure vertical openings between floors were enclosed with at least one-hour construction.

Observation determined:

1) Unsealed spaces around a pipe penetration in the north wall of the dumbwaiter shaft in the 1959 building.

2) The door separating the Elevator Equipment Room in the 1959 building was open to the corridor and could not be closed. The door frame had rusted and was detached from the wall. The opening to the elevator shaft and Elevator Equipment Room was open to the corridor with no fire separation.

The facility failed to maintain the 2-hour fire resistive rating at the floor/ceiling assembly of the South Penthouse.

Observation determined the concrete floor had two eight inch diameter PVC pipe penetrations for roof drain down spouts. The openings were not sealed with fire rated material to assure the fire rating was maintained.

The facility failed to provide smoke barriers with at least one-half hour fire resistance rating at two (2) of two (2) locations.

Observation determined:

1) There was a lack of fire-rated caulking installed in accordance with the manufacturer's UL listing around two (2) electrical conduits in the 4th floor smoke barrier in the 1965 building.

2) There was a lack of fire-rated caulking installed in accordance with the manufacturer's UL listing around two (2) electrical conduits above the smoke barrier doors in the 1960 building smoke barrier.


Note: Verification that the smoke barrier walls extended beyond the plaster ceilings to the roof deck could not be completed due to the integrity of the roof/ceiling assemblies.

The facility failed to ensure hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors.

Observation determined:
1) The door to the first floor Elevator Equipment Room had a fusible link hold-open device installed.

2) A large quantity of combustible storage located on the first floor of the 1965 building was not separated from the corridor.

The facility failed to ensure exit access was readily accessible at all times.

Observation determined numerous doors throughout the facility had deadbolt locking hardware that impeded access to the corridors. Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces.

The facility failed to ensure exit access is readily accessible at all times.

Observation determined:
1) The doors to the Patient Rooms and the door to the East Common Area Suite are equipped with dead-bolt locking hardware that impedes access to the exit corridors on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors.
2) The south corridor door from the Gift Shop was equipped with dead bolt hardware and a roller latch.

Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10.1

The facility failed to keep corridors free of obstructions.

Observation determined an automated external defibrillator (AED) extended into the 2nd floor corridor near the 1959 building main entrance.

1) The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture would not leave the area in darkness. CMS allows a light fixture equipped with a long life bulb with a quick strike feature to illuminate exit discharge. Observation determined exit discharge light fixtures were single bulb fixtures that were equipped with high pressure sodium bulbs without quick strike capabilities.
2) Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1. The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2. Observation determined the facility failed to provide emergency illumination throughout the facility. The emergency lighting throughout the building corridor system on all floors and stairs was controlled by switches.

1) The facility failed to ensure the illumination of means of egress, including exit discharge, is arranged so that a failure of a single lighting fixture will not leave the area in darkness.

CMS allows a light fixture equipped with a long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined:
a) All exit discharge light fixtures were single bulb fixtures that were equipped with high pressure sodium bulbs without quick strike capabilities.
b) The emergency lighting at the east exit from the Boiler Room was a single lamp fluorescent fixture and was switched.

2) Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1
The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Observation determined the facility failed to provide emergency illumination throughout the facility. The emergency lighting throughout the building corridor system on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors was controlled by switches.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. Annual testing must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.
Review of records indicated the facility failed to document a 1 ½ hour annual test of the emergency lighting battery packs located throughout the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

Review of records indicated the facility failed to document a 1 ½ hour annual test of the emergency lighting battery packs located throughout the facility.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined:
1) The east corridor was not adequately marked by approved signage to clearly identify the path of exit. The cross corridor smoke doors on the east side of the corridor system on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors did not have exit signs on both sides of the doors.
2) The exit into the Medflight Staging Room from the North Penthouse Mechanical Room did not have an exit sign over the door.

The administration of health care facilities must develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees must be periodically instructed and kept informed with respect to their duties under the plan.
Review of policies/procedures indicated the facility failed to provide a written evacuation plan that clearly indicated safe areas of refuge in the event of a fire. The evacuation plan did not identify each smoke compartment.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Review of policies/procedures indicated the facility failed to provide a written evacuation plan that clearly indicates safe areas of refuge in the event of a fire. The evacuation plan does not identify each smoke compartment.

Review of the facility's fire drill records determined the facility failed to conduct quarterly drills on each shift at unexpected times under varying conditions. Fire drill records indicated all night shift drills were conducted between 6:00am and 6:30am during the past 12 months.

Review of the facility's fire drill records determined the facility failed to conduct quarterly drills on each shift at unexpected times under varying conditions. Fire drill records indicate night drills are conducted between 6:00am and 6:30am during the past 12 months.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72.
1) Records review indicated the audible alarms from the fire alarm system were not heard by staff during all of the fire drills.

2) Staff on the Chemical Dependency unit did not carry a key for the key-locked fire alarm manual pull stations. The key was located at the nurse's station.

3) Records review indicated not all components of the fire alarm system were tested. Records indicated sprinkler tamper switches, flow switches and strobes were not tested.

4) No rate-of-rise heat detector was located above the fire panel in the 1965 building.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72.

1) Record review indicated staff did not hear audible alarms during some of the fire drills.
2) Record review indicated the annual Fire Alarm Test & Sensitivity Report listed 493 detectors but only 446 detectors were tested.

Fire alarm systems and their components are to be inspected, tested and maintained in accordance with NFPA 72, National Fire Alarm Code.

The facility failed to maintain the fire alarm system in a reliable operating condition.

Observation determined the fire alarm control panel displayed a non-restorable trouble signal. According to staff, the non-restorable trouble signal was due to a defective smoke detector for which a replacement was ordered but had not been received.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system. When the construction type of a building is maintained in compliance, sprinklers are not required. However, the lack of ½ -hour fire-rated corridor walls (through-wall penetrations) in numerous locations required sprinklers or ½ -hour fire-rated wall separation throughout.
1) Observation determined the lack of sprinkler protection in multiple locations in the 1959 and 1965 buildings.Numerous sprinklers throughout the buildings would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing plaster and suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.
2) The facility failed to ensure the proper position/presence of ceilings in areas protected by the automatic fire sprinkler system. (Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.) 5.6.4.1.1 Observation determined the removal of plaster and suspended ceiling tiles/egg-crate panels in several locations that could affect the activation of the sprinkler system. Broken, water damaged and missing ceiling tiles were observed throughout the facility.

The facility failed to ensure the fire alarm system sounds a local trouble alarm in the event a sprinkler valve is closed.

Observation determined the facility has not ensured the required automatic sprinkler system has valves supervised so that at least a local alarm will sound when the valves are closed. The system reliability cannot be ensured since the shutoff valves located at all stair enclosures were chained & locked and not electronically monitored.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
1) Sprinkler records review determined the facility failed to conduct and document quarterly flow alarm tests and maintenance of the sprinkler system.
2) The facility has not ensured automatic sprinkler protection for building coverage. Ordinary temperature rated sprinklers must be used.

Observations identified the sprinklers in numerous areas that were not ordinary rated, but were intermediate temperature rated. The sprinklers are white color coded which is an indication of an intermediate temperature rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 150 deg Fahrenheit. The contents of these rooms did not warrant treatment as ordinary or extra hazard occupancy because no fuel-fired equipment was located in these areas.

3) A sprinkler was obstructed by a light in the Clean Linen Room #4015.

4) A corroded sprinkler was located in Shower Room #4027.

5) A corroded sprinkler was located in the Water Condenser Storage Room.

Health care kitchens must be equipped with a K-extinguisher and an operational sign for the portable fire extinguisher mounted by the K-extinguisher.

Observation determined the facility failed to post an operational sign at the location of the K-extinguisher.

Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the kitchen hood automatic fire-extinguishing system must activate the fire alarm signaling system. NFPA 96, 10-6.2.

The facility failed to provide a cooking equipment fire extinguishing system in compliance with NFPA 96. Records review of the kitchen hood suppression system test report indicated:
1) The kitchen hood extinguishing system was not connected to the fire alarm system.
2) The commercial kitchen hood fire-extinguishing system was not in compliance with the required UL 300 Standard.

The automatic fire-extinguishing system installed over the commercial cooking equipment must be in compliance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards. NFPA 96

The facility failed to provide a cooking equipment fire extinguishing system in compliance with NFPA 96.

Review of records indicated that the kitchen hood extinguishing system was not connected to the fire alarm system.

The facility failed to ensure chute loading doors had a self-closing, positive-latching frame and gasketed fire door assembly approved for Class B openings in accordance with 1999 edition, NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment.

Observation determined the self-closing fire door to the rubbish chute in Room #3070 was not positive-latching into the frame and was not a gasketed fire door assembly approved for a Class B opening.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined:
1) Wall mounted computer touch screen locations had chairs and blood pressure stands stored in the corridor on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors.
2) Built-in work stations and chairs were located in the exit corridor outside the Delivery Rooms on the third (3rd) floor.
3) Two Bio Hazard waste containers were stored at the first (1st) floor Laboratory suite south exit.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the west exterior exit was illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm system are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

c) The number of smoke detectors/duct detectors tested during the 2010 annual fire alarm test was 237 and the number of smoke detectors/duct detectors tested during the 2010 sensitivity test was 262. This indicates that 25 smoke detectors/duct detectors were not tested during the 2010 annual fire alarm test.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Sprinkler record review determined:

a) The facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) The sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly; obstructed by light fixtures, cubical curtains, radiology graphic equipment, and signage; and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

5) Any vertical opening must be enclosed or protected in accordance with 8.2.5. 39.3.1

Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; or shaftways used for light, ventilation, or building services must be enclosed with fire barrier walls. Such enclosures must be continuous from floor to floor or floor to roof. Opening must be protected as appropriate for the fire resistance rating of the barrier. 8.2.5.2

The facility failed to ensure that vertical shafts were of two-hour fire resistive rated construction.

Observation determined:

a) The space between the concrete block walls of the elevator shafts and the stair enclosures were not sealed with a fire-rated assembly.

b) The stair enclosure door into the Ambulatory Surgical Center on the 4th floor was not equipped with a fire-rated smoke gasket.

6) Mixed occupancies must comply with 6.1.14. 39.1.2

Where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. 6.1.14

The facility failed to ensure the two-hour fire separation between the hospital and the clinic was maintained.

Observation determined the 90-minute fire rated door in the two-hour separation in the tunnel that connects the clinic and the hospital would not self-close to the latched position.

7) Ambulatory health care occupancies (ASC) must be separated from other tenants and occupancies by fire barriers with at least a 1-hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 ¾ inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors must be of fixed fire window assemblies. 21.1.2

The facility failed to provide a one-hour fire resistance rated separation between the ASC and the clinic.

Observation determined the facility has not ensured the ambulatory health care occupancy is separated from the business occupancy and the skybridge to Trinity Hospital by an occupancy separation wall with at least a 1 hour fire resistance rating.

a) The occupancy separation walls were observed to have numerous unsealed spaces in multiple locations due to unsealed spaces around pipes, conduits and data cables.

b) The cross-corridor doors were equipped with vision panels that were tempered glass rather than fire rated glass.

c) The cross-corridor doors were not equipped with positive latching hardware and the gap between the door leaves would not resist the passage of smoke.

d) The 90-minute fire rated door installed in the access to the skybridge was a wood door in a steel frame. The typical installation requires a fire-rated smoke gasket and an intumescent gasket be installed on this assembly. Currently the door was equipped with a fire-rated smoke gasket but no intumescent gasket.

8) Draperies, curtains and other loosely hanging fabrics and films serving as furnishings, except curtains at shower, must be inherently fire resistant rated or treated with a product that meets NFPA 701, Standard Methods of
Fire Tests for Flame Propagation of Textiles and Films. 21.7.5

The facility failed to provide documentation for the fire resistance rating of the cubical curtains used throughout the ASC.

Review of documentation indicated a lack of information to verify the cubical curtains in the ASC were inherently fire resistant or treated with a product that would meet NFPA 701.

9) There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 21.7.1

The facility failed to ensure that staff were trained to evacuate the building as per the written evacuation plan.

Review of documentation and interview with the director of nursing indicated the current evacuation plan was not the method that was being used for emergency evacuation training.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits and east stair enclosure were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for the fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

a) Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) Observation determined the sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

c) Doors must be arranged to be opened readily from the egress side whenever the building is occupied. Locks must not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The west entrance door was equipped with a key lock and a lever latch.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location of and test results the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

a) Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) Observation determined the sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly visual inspections and maintenance of the emergency generator electrical transfer switch.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

The facility failed to provide documentation of a preventive maintenance program that included quarterly inspections for the emergency generator electrical transfer switch.

Patients and hospital personnel in the area of oxygen administration should be advised of respiratory therapy hazards and regulations.
Visitors should be cautioned of these hazards through the prominent posting of signs.
Precautionary signs, readable from a distance of 5-ft, must be conspicuously displayed wherever supplemental oxygen is in use. They must be attached to adjacent doorways or to building walls or be supported by other appropriate means. A suggested text for precautionary signs for oxygen is CAUTION - OXYGEN IN USE - KEEP FLAMES AWAY - NO SMOKING - NO ELECTRICAL APPLIANCES.

In health care facilities where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with NO SMOKING language are not required. The nonsmoking policies shall be strictly enforced.

The facility failed to provide precautionary signs adjacent to patient room doorways where oxygen was in use or in rooms where cylinders were stored.

Observation determined:
1) Oxygen was in use in Patient Rooms on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors but precautionary signs were not posted adjacent to the door.
2) Oxygen cylinders were stored in Supply Rooms on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors but precautionary signs were not posted adjacent to the door.

The facility failed to ensure the generator was inspected weekly, including battery electrolyte levels. 1999 edition, NFPA 110, 6-3.6.

Observation determined the batteries for the emergency generator were of the maintenance free design. Maintenance free batteries are specifically disallowed in NFPA 110, 1999 edition, chapter 3-5.4.5.

1) The facility failed to ensure complete two-hour fire rated wall assemblies between the 1959 hospital building and the business occupancy located in the 1917 building.

Multiple missing plaster ceiling materials in multiple rooms reduce the construction type of the 1917 building to Type II (000). Because the 1917 building was not separated from the hospital building with a two-hour fire resistant separation on all floors, the entire healthcare occupancy (1959 and 1965 buildings) must be classified a Type II (000) construction type. This construction classification is not allowed for healthcare buildings over two stories in height.

2) The facility failed to ensure complete one-hour fire rated wall assemblies between the 1970 Same Day Surgery building and the business occupancy located in the 1917 building.

Observation determined the head-of-wall joint in the occupancy separation wall was not fire-caulked.

3) The facility failed to ensure complete two-hour fire rated wall assemblies between the 1917 building and the sky bridge to the 1980 building. The bottom rods on the 90-minute fire doors did not latch into the floor.

The facility failed to ensure complete two-hour fire rated wall assemblies between the Hospital and the Skywalk.

Manufacturers typically design 90-minute fire rated metal double doors to latch into the door frame and into the floor.

Observation determined the 90-minute fire rated double doors located between the Hospital and the Skywalk were not latching into the floor.

The facility failed to maintan the integrity of the floor/ceiling assemblies resulting in a noncompliant construction Type II (000).

Observation determined:

1) Unsealed spaces around three (3) conduits through the floor/ceiling assembly between the 4th and 5th floor in Room #4131.

2) Unsealed spaces around three (3) conduits adjacent to the fire alarm panel through the floor/ceiling assembly between the 3rd and 4th floor in the Equipment Room.

3) Unsealed spaces around two (2) drain pipes in the floor to the Kidney Dialysis Unit filled with mineral fiber but no fire sealant.

Health care occupancies of five stories must be Type I (443), Type I (332), or Type II (222). The facility failed to ensure building construction was maintained.

1) Observation determined steel members supporting the ceiling/floor assembly were not protected at the second floor mechanical space behind the telephone/drinking fountain casework.

2) The original construction for the building was altered from Type I (332) to Type II (000) when the South Addition was built. Five-story buildings of Type II (000) construction are not permitted.

Record review determined the facility has not ensured exposed interior surfaces in rooms have a flame spread rating of Class A or B. Flame spread documentation was not available for the following:

1) Wood paneling in the Dietary Manager's office.

2) Folding wall partition in the old Swing Bed Dining Room.

3) Carpet on the walls in the Wheelchair Storage Room.

4) Folding wall partition in the Gym Craft Room.

5) Folding wall partition in the 5th floor Dining Room.

The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class B rating.

Documentation review indicated the facility did not have interior finish documentation for the folding partitions in the Cafeteria Dining Area.

The facility failed to ensure corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating.
1) Observation determined the third floor Coding Library was separated from the corridor by a vinyl folding wall partition that was open to the corridor approximately one foot from the floor.
2) The facility failed to prevent the corridor being used as a portion of the return air system. The return air system for the central heating system was through the concealed space above the suspended ceiling of the egress corridors. Observation determined the facility failed to ensure corridors were separated from use areas by walls with at least ½ hour fire resistance rating due to unsealed spaces around through-wall penetrations. Where automatic sprinkler system protection is provided throughout, corridor walls may terminate at a suspended ceiling. The suspended ceiling was not constructed to limit the transfer of smoke due to open egg crate panels in the suspended ceiling grids.

The facility failed to ensure doors in corridor walls have automatic, positive latching devices that provide a means suitable for keeping the door closed.

Observation determined numerous corridor doors in multiple locations throughout the facility had no automatic positive latching device.

The facility failed to ensure vertical openings between floors were enclosed with at least one-hour construction.

Observation determined:

1) Unsealed spaces around a pipe penetration in the north wall of the dumbwaiter shaft in the 1959 building.

2) The door separating the Elevator Equipment Room in the 1959 building was open to the corridor and could not be closed. The door frame had rusted and was detached from the wall. The opening to the elevator shaft and Elevator Equipment Room was open to the corridor with no fire separation.

The facility failed to maintain the 2-hour fire resistive rating at the floor/ceiling assembly of the South Penthouse.

Observation determined the concrete floor had two eight inch diameter PVC pipe penetrations for roof drain down spouts. The openings were not sealed with fire rated material to assure the fire rating was maintained.

The facility failed to provide smoke barriers with at least one-half hour fire resistance rating at two (2) of two (2) locations.

Observation determined:

1) There was a lack of fire-rated caulking installed in accordance with the manufacturer's UL listing around two (2) electrical conduits in the 4th floor smoke barrier in the 1965 building.

2) There was a lack of fire-rated caulking installed in accordance with the manufacturer's UL listing around two (2) electrical conduits above the smoke barrier doors in the 1960 building smoke barrier.


Note: Verification that the smoke barrier walls extended beyond the plaster ceilings to the roof deck could not be completed due to the integrity of the roof/ceiling assemblies.

The facility failed to ensure hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors.

Observation determined:
1) The door to the first floor Elevator Equipment Room had a fusible link hold-open device installed.

2) A large quantity of combustible storage located on the first floor of the 1965 building was not separated from the corridor.

The facility failed to ensure exit access was readily accessible at all times.

Observation determined numerous doors throughout the facility had deadbolt locking hardware that impeded access to the corridors. Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces.

The facility failed to ensure exit access is readily accessible at all times.

Observation determined:
1) The doors to the Patient Rooms and the door to the East Common Area Suite are equipped with dead-bolt locking hardware that impedes access to the exit corridors on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors.
2) The south corridor door from the Gift Shop was equipped with dead bolt hardware and a roller latch.

Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10.1

The facility failed to keep corridors free of obstructions.

Observation determined an automated external defibrillator (AED) extended into the 2nd floor corridor near the 1959 building main entrance.

1) The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture would not leave the area in darkness. CMS allows a light fixture equipped with a long life bulb with a quick strike feature to illuminate exit discharge. Observation determined exit discharge light fixtures were single bulb fixtures that were equipped with high pressure sodium bulbs without quick strike capabilities.
2) Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1. The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2. Observation determined the facility failed to provide emergency illumination throughout the facility. The emergency lighting throughout the building corridor system on all floors and stairs was controlled by switches.

1) The facility failed to ensure the illumination of means of egress, including exit discharge, is arranged so that a failure of a single lighting fixture will not leave the area in darkness.

CMS allows a light fixture equipped with a long life bulb with a quick strike feature to illuminate exit discharge.

Observation determined:
a) All exit discharge light fixtures were single bulb fixtures that were equipped with high pressure sodium bulbs without quick strike capabilities.
b) The emergency lighting at the east exit from the Boiler Room was a single lamp fluorescent fixture and was switched.

2) Emergency illumination must be provided for not less than 1-1/2 hours in the event of failure of normal lighting. Emergency lighting must be arranged to provide initial illumination that is not less than an average of 1 ft-candle measured along the path of egress of floor level. 7.9.2.1
The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Observation determined the facility failed to provide emergency illumination throughout the facility. The emergency lighting throughout the building corridor system on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors was controlled by switches.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. Annual testing must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.
Review of records indicated the facility failed to document a 1 ½ hour annual test of the emergency lighting battery packs located throughout the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

Review of records indicated the facility failed to document a 1 ½ hour annual test of the emergency lighting battery packs located throughout the facility.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined:
1) The east corridor was not adequately marked by approved signage to clearly identify the path of exit. The cross corridor smoke doors on the east side of the corridor system on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors did not have exit signs on both sides of the doors.
2) The exit into the Medflight Staging Room from the North Penthouse Mechanical Room did not have an exit sign over the door.

The administration of health care facilities must develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees must be periodically instructed and kept informed with respect to their duties under the plan.
Review of policies/procedures indicated the facility failed to provide a written evacuation plan that clearly indicated safe areas of refuge in the event of a fire. The evacuation plan did not identify each smoke compartment.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Review of policies/procedures indicated the facility failed to provide a written evacuation plan that clearly indicates safe areas of refuge in the event of a fire. The evacuation plan does not identify each smoke compartment.

Review of the facility's fire drill records determined the facility failed to conduct quarterly drills on each shift at unexpected times under varying conditions. Fire drill records indicated all night shift drills were conducted between 6:00am and 6:30am during the past 12 months.

Review of the facility's fire drill records determined the facility failed to conduct quarterly drills on each shift at unexpected times under varying conditions. Fire drill records indicate night drills are conducted between 6:00am and 6:30am during the past 12 months.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72.
1) Records review indicated the audible alarms from the fire alarm system were not heard by staff during all of the fire drills.

2) Staff on the Chemical Dependency unit did not carry a key for the key-locked fire alarm manual pull stations. The key was located at the nurse's station.

3) Records review indicated not all components of the fire alarm system were tested. Records indicated sprinkler tamper switches, flow switches and strobes were not tested.

4) No rate-of-rise heat detector was located above the fire panel in the 1965 building.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72.

1) Record review indicated staff did not hear audible alarms during some of the fire drills.
2) Record review indicated the annual Fire Alarm Test & Sensitivity Report listed 493 detectors but only 446 detectors were tested.

Fire alarm systems and their components are to be inspected, tested and maintained in accordance with NFPA 72, National Fire Alarm Code.

The facility failed to maintain the fire alarm system in a reliable operating condition.

Observation determined the fire alarm control panel displayed a non-restorable trouble signal. According to staff, the non-restorable trouble signal was due to a defective smoke detector for which a replacement was ordered but had not been received.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system. When the construction type of a building is maintained in compliance, sprinklers are not required. However, the lack of ½ -hour fire-rated corridor walls (through-wall penetrations) in numerous locations required sprinklers or ½ -hour fire-rated wall separation throughout.
1) Observation determined the lack of sprinkler protection in multiple locations in the 1959 and 1965 buildings.Numerous sprinklers throughout the buildings would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing plaster and suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.
2) The facility failed to ensure the proper position/presence of ceilings in areas protected by the automatic fire sprinkler system. (Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.) 5.6.4.1.1 Observation determined the removal of plaster and suspended ceiling tiles/egg-crate panels in several locations that could affect the activation of the sprinkler system. Broken, water damaged and missing ceiling tiles were observed throughout the facility.

The facility failed to ensure the fire alarm system sounds a local trouble alarm in the event a sprinkler valve is closed.

Observation determined the facility has not ensured the required automatic sprinkler system has valves supervised so that at least a local alarm will sound when the valves are closed. The system reliability cannot be ensured since the shutoff valves located at all stair enclosures were chained & locked and not electronically monitored.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
1) Sprinkler records review determined the facility failed to conduct and document quarterly flow alarm tests and maintenance of the sprinkler system.
2) The facility has not ensured automatic sprinkler protection for building coverage. Ordinary temperature rated sprinklers must be used.

Observations identified the sprinklers in numerous areas that were not ordinary rated, but were intermediate temperature rated. The sprinklers are white color coded which is an indication of an intermediate temperature rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 150 deg Fahrenheit. The contents of these rooms did not warrant treatment as ordinary or extra hazard occupancy because no fuel-fired equipment was located in these areas.

3) A sprinkler was obstructed by a light in the Clean Linen Room #4015.

4) A corroded sprinkler was located in Shower Room #4027.

5) A corroded sprinkler was located in the Water Condenser Storage Room.

Health care kitchens must be equipped with a K-extinguisher and an operational sign for the portable fire extinguisher mounted by the K-extinguisher.

Observation determined the facility failed to post an operational sign at the location of the K-extinguisher.

Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the kitchen hood automatic fire-extinguishing system must activate the fire alarm signaling system. NFPA 96, 10-6.2.

The facility failed to provide a cooking equipment fire extinguishing system in compliance with NFPA 96. Records review of the kitchen hood suppression system test report indicated:
1) The kitchen hood extinguishing system was not connected to the fire alarm system.
2) The commercial kitchen hood fire-extinguishing system was not in compliance with the required UL 300 Standard.

The automatic fire-extinguishing system installed over the commercial cooking equipment must be in compliance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards. NFPA 96

The facility failed to provide a cooking equipment fire extinguishing system in compliance with NFPA 96.

Review of records indicated that the kitchen hood extinguishing system was not connected to the fire alarm system.

The facility failed to ensure chute loading doors had a self-closing, positive-latching frame and gasketed fire door assembly approved for Class B openings in accordance with 1999 edition, NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment.

Observation determined the self-closing fire door to the rubbish chute in Room #3070 was not positive-latching into the frame and was not a gasketed fire door assembly approved for a Class B opening.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined:
1) Wall mounted computer touch screen locations had chairs and blood pressure stands stored in the corridor on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors.
2) Built-in work stations and chairs were located in the exit corridor outside the Delivery Rooms on the third (3rd) floor.
3) Two Bio Hazard waste containers were stored at the first (1st) floor Laboratory suite south exit.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the west exterior exit was illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm system are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

c) The number of smoke detectors/duct detectors tested during the 2010 annual fire alarm test was 237 and the number of smoke detectors/duct detectors tested during the 2010 sensitivity test was 262. This indicates that 25 smoke detectors/duct detectors were not tested during the 2010 annual fire alarm test.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Sprinkler record review determined:

a) The facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) The sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly; obstructed by light fixtures, cubical curtains, radiology graphic equipment, and signage; and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

5) Any vertical opening must be enclosed or protected in accordance with 8.2.5. 39.3.1

Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; or shaftways used for light, ventilation, or building services must be enclosed with fire barrier walls. Such enclosures must be continuous from floor to floor or floor to roof. Opening must be protected as appropriate for the fire resistance rating of the barrier. 8.2.5.2

The facility failed to ensure that vertical shafts were of two-hour fire resistive rated construction.

Observation determined:

a) The space between the concrete block walls of the elevator shafts and the stair enclosures were not sealed with a fire-rated assembly.

b) The stair enclosure door into the Ambulatory Surgical Center on the 4th floor was not equipped with a fire-rated smoke gasket.

6) Mixed occupancies must comply with 6.1.14. 39.1.2

Where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. 6.1.14

The facility failed to ensure the two-hour fire separation between the hospital and the clinic was maintained.

Observation determined the 90-minute fire rated door in the two-hour separation in the tunnel that connects the clinic and the hospital would not self-close to the latched position.

7) Ambulatory health care occupancies (ASC) must be separated from other tenants and occupancies by fire barriers with at least a 1-hour fire resistance rating. Doors in such barriers are solid bonded core wood of 1 ¾ inches or equivalent and are equipped with a positive latch and closing device. Vision panels, if provided in fire barriers or doors must be of fixed fire window assemblies. 21.1.2

The facility failed to provide a one-hour fire resistance rated separation between the ASC and the clinic.

Observation determined the facility has not ensured the ambulatory health care occupancy is separated from the business occupancy and the skybridge to Trinity Hospital by an occupancy separation wall with at least a 1 hour fire resistance rating.

a) The occupancy separation walls were observed to have numerous unsealed spaces in multiple locations due to unsealed spaces around pipes, conduits and data cables.

b) The cross-corridor doors were equipped with vision panels that were tempered glass rather than fire rated glass.

c) The cross-corridor doors were not equipped with positive latching hardware and the gap between the door leaves would not resist the passage of smoke.

d) The 90-minute fire rated door installed in the access to the skybridge was a wood door in a steel frame. The typical installation requires a fire-rated smoke gasket and an intumescent gasket be installed on this assembly. Currently the door was equipped with a fire-rated smoke gasket but no intumescent gasket.

8) Draperies, curtains and other loosely hanging fabrics and films serving as furnishings, except curtains at shower, must be inherently fire resistant rated or treated with a product that meets NFPA 701, Standard Methods of
Fire Tests for Flame Propagation of Textiles and Films. 21.7.5

The facility failed to provide documentation for the fire resistance rating of the cubical curtains used throughout the ASC.

Review of documentation indicated a lack of information to verify the cubical curtains in the ASC were inherently fire resistant or treated with a product that would meet NFPA 701.

9) There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 21.7.1

The facility failed to ensure that staff were trained to evacuate the building as per the written evacuation plan.

Review of documentation and interview with the director of nursing indicated the current evacuation plan was not the method that was being used for emergency evacuation training.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits and east stair enclosure were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for the fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location and test results of the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

a) Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) Observation determined the sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

1) All means of egress must be in accordance with Chapter 7. 39.2.1

a) Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

The facility failed to mark exit paths with readily visible signage.

Observation determined the exit system throughout the building was not adequately marked by approved signage to clearly identify the path of exit.

b) The illumination of means of egress, including exit discharge, is arranged so that the failure of any single lighting fixture, such as the burning out of a bulb, will not leave the area in darkness. 7-8.1.4 and 7-9.2.2

Emergency illumination of means of egress must be arranged so that a failure of a single lighting fixture (bulb) will not leave the area in darkness and be arranged to provide not less than an average of 1 ft-candle measured along the path of egress at floor level. 7.9.2.1

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

The emergency lighting system must be either continuously in operation or must be capable of repeated automatic operation without manual intervention. 7.9.2.5

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior exits were illuminated with a light fixture with a single high pressure sodium bulb without quick strike capabilities. The exterior exits and the exit paths throughout the building were not adequately illuminated. Several bulbs in the light fixtures of the emergency lighting system were also burnt-out.

c) Doors must be arranged to be opened readily from the egress side whenever the building is occupied. Locks must not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The west entrance door was equipped with a key lock and a lever latch.

2) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

3) Visual inspection frequencies and specific testing and maintenance frequencies for fire alarm systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated:

a) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

Evidence of sensitivity testing of the smoke detectors was not included in the fire alarm testing documentation.

b) The number, location of and test results the sprinkler flow switch and sprinkler tamper switches were not included in the fire alarm testing documentation.

4) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

a) Sprinkler record review determined the facility failed to conduct quarterly tests and maintenance of the sprinkler system.

b) Observation determined the sprinklers throughout the building would not provide adequate coverage. Sprinklers were located too far below the ceiling/roof assembly, obstructed by light fixtures and signage, and not provided in some areas. Missing suspended ceiling tile slows the activation of the sprinkler system. Missing ceiling tiles were found throughout the building.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly visual inspections and maintenance of the emergency generator electrical transfer switch.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

The facility failed to provide documentation of a preventive maintenance program that included quarterly inspections for the emergency generator electrical transfer switch.

Patients and hospital personnel in the area of oxygen administration should be advised of respiratory therapy hazards and regulations.
Visitors should be cautioned of these hazards through the prominent posting of signs.
Precautionary signs, readable from a distance of 5-ft, must be conspicuously displayed wherever supplemental oxygen is in use. They must be attached to adjacent doorways or to building walls or be supported by other appropriate means. A suggested text for precautionary signs for oxygen is CAUTION - OXYGEN IN USE - KEEP FLAMES AWAY - NO SMOKING - NO ELECTRICAL APPLIANCES.

In health care facilities where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with NO SMOKING language are not required. The nonsmoking policies shall be strictly enforced.

The facility failed to provide precautionary signs adjacent to patient room doorways where oxygen was in use or in rooms where cylinders were stored.

Observation determined:
1) Oxygen was in use in Patient Rooms on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors but precautionary signs were not posted adjacent to the door.
2) Oxygen cylinders were stored in Supply Rooms on the third (3rd), fourth (4th), fifth (5th), and sixth (6th) floors but precautionary signs were not posted adjacent to the door.

The facility failed to ensure the generator was inspected weekly, including battery electrolyte levels. 1999 edition, NFPA 110, 6-3.6.

Observation determined the batteries for the emergency generator were of the maintenance free design. Maintenance free batteries are specifically disallowed in NFPA 110, 1999 edition, chapter 3-5.4.5.