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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 8 floors at the Tower building and 3 of 3 floors at the Pavilion building. This could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, on 10/22/12 and 10/23/12, the walls and ceilings were observed in the Tower and the Pavilion Building.

Tower building
1. On 10/22/12, at 2:35 p.m., there were four approximately 1/4 inch to 1/2 inch penetrations in the EVS closet, Room 1064, on the GL 1st floor.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 3 floors at the Dominican building and could result in the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, on 10/23/12, the walls and ceilings were observed in the Dominican building.

1. At 10:43 a.m., there were two approximately 1/4 inch penetrations in the left wall, in the janitor's closet next to physical therapy, on the 1st floor.
2. At 10:46 a.m., there was an approximately 1/4 inch penetration around a ceiling sprinkler, in the consultation room next to the elevator, on the 1st floor.
3. At 10:49 a.m., a sprinkler was not flush against the ceiling and exposed an approximately 1/8 inch penetration, in Medical Dressing Room 1, on the 1st floor.
4. At 10:50 a.m., a sprinkler was not flush against the ceiling and exposed an approximately 1/8 inch penetration, in Medical Dressing Room 4, on the 1st floor.

Pavilion building - 10/23/12

2. At 8:34 a.m., there was an approximately 1/8 inch circular penetration in the ceiling, around a sprinkler deflector plate, in the EVS closet, Room 322, on the 3rd floor.
3. At 8:40 a.m., there was an approximately 1/8 inch penetration around a 3/4 inch conduit pipe in the right wall of Electrical Room 304, on the 3rd floor.
4. At 8:41 a.m., there was an approximately 1/8 inch penetration around a MC cable in the left wall, two approximately 1/8 inch penetrations in the left wall, and an approximately 1/8 inch penetration around a red wire, in the left wall, in Mechanical Room 315, on the 3rd floor.
5. At 8:50 a.m., there were three approximately 1/4 inch penetrations in the back wall, in Mechanical Room 2167, on the 2nd floor.
6. At 8:52 a.m., there was an approximately 1/2 inch penetration in the front wall, by a spare pipe, in Data Room 202, on the 2nd floor.
7. At 9:04 a.m., 3 of 6 sprinklers were not flush against the ceiling, and there was a missing escutcheon ring, in the central sterile area, Room 236, on the 2nd floor. This exposed approximately 1/8 inch penetrations in the ceiling around the sprinklers.
8. At 9:15 a.m., there was an approximately 1/4 inch penetration around a copper pipe, in the back wall in Electrical Room 119, on the 1st floor. There was an approximately 1 by 3 inch penetration in the wall near a brace in the back wall.

Based on observation, the facility failed to ensure the corridors were able to resist the passage of smoke. This was evidenced by penetrations in one corridor wall. This affected 1 of 8 floors at the Tower building, and could result in the passage of smoke from one smoke compartment to another.

Findings:

During a tour of the facility with staff, the corridor walls were observed in the Tower building.
On 10/22/12 at 3:14 p.m., there was an approximately 1/2 inch penetration in the left wall of the OR 1221 corridor, on the GL first floor.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch or were obstructed from closing. This affected 1 of 3 floors at the Dominican building and could result in the spread of smoke or fire.

Findings:

During a tour of the facility with staff, on 10/23/12, the corridor doors were observed in the Dominican building.

1. At 10:35 a.m., the self-closing door was obstructed by a chair, in Physical Therapy Room 5, on the 1st floor.
2. At 10:40 a.m., the self-closing door was held open by a kick stop, in Physical Therapy Room 2, on the 1st floor.
3. At 10:48 a.m., in the Endoscopy/Infusion area, the door to the Mechanical Room did not latch when closed.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch or were obstructed from closing. This affected 3 of 8 floors at the Tower building. This could result in the inability to contain a fire, and the spread of smoke and fire.

Findings:

During a tour of the facility with staff, on 10/22/12, the corridor doors were observed in the Tower building.

1. At 10:45 a.m., the door to the NICU was obstructed by a step stool, on the 2nd floor.
2. At 2:36 p.m., the self-closing door in Room 1020, Exam 17, was obstructed by a trash bin, on the GL 1st floor.
3. At 2:38 p.m., the self-closing door in Room 1024, Exam 21, was obstructed by a chair, on the GL 1st floor.
4. At 3:37 p.m., the self-closing door in storage room 0325 was obstructed by a chair, on the Garden floor inside Physical Therapy 0324.

Based on observation and testing, the facility failed to maintain their barrier doors. This was evidenced by a stairwell door that failed to latch and by fire doors that failed to release and close. This affected 1 of 8 floors at the Tower building and could lead to the spread of smoke and fire moving up or down the stairwell and through the open doors.

Findings:

During observation and testing with staff, the doors were observed in the Tower building.

1. On 10/22/12 at 10:09 a.m., the self-closing stairwell door failed to latch upon release, on the 5th floor in Stairwell 1-5035.
2. On 10/25/12 at 9:40 a.m., fire door DHW6 was held open by an approved magnetic device. When the fire alarm was activated, the right leaf fire door failed to release, on the 5th floor.
3. On 10/25/12 at 9:43 a.m., fire door DHW8 was held open by an approved magnetic device. When the fire alarm was activated, the right leaf fire door failed to release, on the 5th floor.
4. On 10/25/12 at 9:43 a.m., on the 5th floor, the right leaf of the fire doors, by Room 5008 and the Pantry Room, did not latch after activation of the fire alarm system. The door was tested three times.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by exit sign directional arrows that failed to direct the correct direction to an exit. This affected 2 of 8 floors at the Tower building, and the Garden floor in the Pavilion. This could result in a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with staff, the exit signs were observed in the Tower and Pavilion buildings, on 10/22/12.

1. At 3 p.m., an exit sign arrow was directing to the left on the GL 1st floor by Cardiac Cath Lab 1207. The arrow pointed to a window instead of to the exit.
2. At 3:01 p.m., an exit sign arrow was directing to the right, to a wall instead to an exit. The sign was located on the GL 1st floor by OR 3.
3. At 3:05 p.m., an exit sign arrow was directing to the left that lead to a wall instead to an exit, on the GL 1st floor by Electrical 1B room 1127 corridor.
4. At 3:06 p.m., an exit sign arrow was directing to the right, towards a wall instead of to an exit. The sign was located on the GL 1st floor by EVS Closet 1133.
5. At 3:07 a.m., an exit sign arrow was directing to the left towards a wall instead of to an exit. The sign was located on the GL 1st floor by Sterile Storage Room 1210.

Pavilion building
6. At 3:39 p.m., an exit sign arrow was directing to the right, on the Garden floor by the physical therapy 0324 corridor. Going right led to a wall instead of to an exit.

Based on observation, the facility failed to maintain one smoke barrier wall, as evidenced by a penetration in one area. This deficient practice could lead to the passage of smoke or fire in the event of a fire and affected 1 of 3 floors at the Pavilion building.

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed in the Pavilion Building.

On 10/23/12 at 8:38 a.m., there was an approximately one inch penetration in the smoke barrier wall, on the second floor, by Equipment Storage Room 224.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by a door to a hazardous area that was not equipped with a self-closing device. This affected 1 of 8 floors at the Tower building, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

NFPA 101, 1999 Edition
Table 18.3.2.1 Hazardous Area Protection
Hazardous Area Description Separation/Protection

Storage rooms larger than 50 ft2 (4.6 m2),
but not exceeding 100 ft2 (9.3 m2) storing combustible material.

Findings:

During a tour of the facility with staff, the hazardous areas were observed in the Tower building.

On 10/22/12 at 3:25 p.m., the kitchen dry storage room, on the Garden floor, contained approximately a dozen cardboard boxes. The room was over 150 square feet in size. The door was not equipped with a self-closing device.

Based on observation and interview, the facility failed to provide battery powered emergency lighting units in anesthetizing locations. This was evidenced by no battery powered emergency lighting units in their procedure rooms. This affected 1 of 3 floors at the Dominican building and could result in limited visibility in the event of a power failure.

NFPA 99 Health Care Facilities 1999 edition
3-3.2.1.2, All Patient Care Areas. (5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101. 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with staff, the procedure rooms were observed
in the Endoscopy/Infusion area, in the Dominican building.

On 10/23/12 at 10:58 a.m., there were no battery powered emergency lighting units in the four endoscopy procedure rooms. In the event of a power outage there would be no immediate lighting until the generator started.

The DN (discharge nurse) was interviewed at that time. The DN indicated if a loss of power occurred, all procedures would stop. The staff would obtain flashlights at the Nursing Station to use.

Based on interview, the facility failed to ensure that all staff members were familiar with the emergency plan procedures. This was evidenced by 6 of 27 staff members at the Tower building, who were not familiar with the fire safety procedures in the event of a fire. This could result in a delay in staff response in the event of a fire.

NFPA 101, 2000 Edition
18.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
18.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During an interview with staff, on 10/25/12, staff were interviewed regarding the emergency and fire safety plans.

Tower building
1. At 9:20 a.m., a Housekeeping Temp was interviewed regarding what action to take in the event of a fire. The Housekeeping Temp stated that she just started working at the facility and did not know the procedures.

2. At 1:00 p.m., a Doctor in the Emergency Department was interviewed regarding what action to take in the event of a fire. The doctor did not know the procedures.

3. At 1:30 p.m., two Volunteers and the Manager, in the Gift Shop, were interviewed regarding what action to take in the event of a fire. One volunteer stated she just started six weeks ago and did not know the procedures. The other volunteer and manager did not know the procedures.

4. At 2:15 p.m., a warehouse clerk in the bulk storage area was interviewed regarding what action to take in the event of a fire. The warehouse clerk could not find the nearest manual fire alarm box. The clerk went into the Central Processing Area (0190) and the Mail Room looking for the manual fire alarm box.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 1 of 4 missing fire drills. This could lead to a delay in staff response in the event of an emergency.

Findings:

During document review and interview with staff, the fire drill records were reviewed in the Pavilion building.

At 11 a.m., 1 of 4 fire drill records was missing for the fourth quarter, NOC shift in 2011. During an interview, engineering staff stated that fire drills were conducted once a year at the Pavilion.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 3 of 4 fire drills missing during the past 12 month period. This affected 39 of 39 patients at the Dominican building, and could lead to staff not understanding the evacuation procedures in the event of an emergency.

Findings:

During document review with staff, on 10/24/12, the fire drill records were reviewed.

At 11 a.m., 3 of 4 fire drill records were missing for the previous 12 month period. There were no fire drills conducted for the 2nd and 3rd quarters of 2012 and for the fourth quarter of 2011.
During an interview Staff stated that fire drills were conducted once a year at the Dominican Campus.

Based on observation, testing, and interview, the facility failed to maintain the fire alarm system and devices. This was evidenced by chimes that were not audible, by a delay in alarm activation when testing pull stations, by obstructed pull station access, and by trouble signals at the fire alarm panels. This affected 8 of 8 floors at the Tower building, and could result in a malfunction leading to a delay in notification in the event of a fire.

NFPA 101, Life Safety Code 1999
18.9.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

NFPA 72, National Fire Alarm Code 1999 Edition.
1-5.4.2.2. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

NFPA 70, National Electrical Code 1999 Edition
110-26. Spaces about electrical equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosure housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During observation, and fire alarm testing with staff, the fire alarm system and devices were observed.

Tower building
1. On 10/22/12 at 10 a.m., remote alarm panels on all 8 floors indicated trouble, supervisory, and monitor trouble flashing. The reading on the annunciator screen indicated, "001 Supervisory Act, Power Plant RM P028, Refrigerant Warning, 800."

During an interview the Facilities Director stated there is a sensor for each chiller. If there is a refrigerant leak, the alarm will go off and in this case, there is no leak. The vendor had calibrated the system but it still shows a trouble signal. The trouble signal does not affect the fire alarm system.
2. On 10/22/12 at 10:05 a.m., a file rack NS7066, was placed in front of the annunciator panel obstructing access to it, on the 7th floor Nurse Station 1.
3. On 10/22/12 at 10:13 a.m., a clipboard NS5067 was placed in front of the annunciator panel obstructing access to it, at the 6th floor Nurse Station 1.
4. On 10/22/12 at 10:15 a.m., a printer machine NS5059 was placed in front of the annunciator panel obstructing access to it, on the 6th floor Nurse Station 3.
5. On 10/25/12 at 1:55 p.m., a printer machine 10.180.14.150 was placed in front of the annunciator panel obstructing access to it, on the ground level of PACU.
6. On 10/25/12 at 8:48 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor near Room 7034.
7. On 10/25/12 at 8:50 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor across from Room 7002.
8. On 10/25/12 at 8:58 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor by Room 7013.
9. On 10/25/12 at 9:27 a.m., the strobe/chime combo failed to emit an audible sound, on the 6th floor by Room 6004.
10. On 10/25/12 at 9:28 a.m., the strobe/chime combo failed to emit an audible sound, on the 6th floor by Room 6034.
11. On 10/25/12 at 9:34 a.m., the strobe/chime combos failed to emit an audible sound, on the 5th floor by Room 5034.
12. On 10/25/12 at 9:35 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5002.
13. On 10/25/12 at 9:36 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5004.
14. On 10/25/12 at 9:37 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5013.
15. On 10/25/12 at 9:43 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5023.
16. On 10/25/12 at 9:44 a.m., there was a 17.7 seconds delay from activating the pull station to sounding a alarm, on the 5th floor by Room 5023.
17. On 10/25/12 at 9:49 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4034.
18. On 10/25/12 at 9:50 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4002.
19. On 10/25/12 at 9:52 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4004.
20. On 10/25/12 at 9:53 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4013.
21. On 10/25/12 at 10:25 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3023.
22. On 10/25/12 at 10:26 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3037.
23. On 10/25/12 at 10:27 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3020.
24. On 10/25/12 at 10:28 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3015.
25. On 10/25/12 at 10:29 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3008.
26. On 10/25/12 at 10:30 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3003.
27. On 10/25/12 at 10:31 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3028.
28. On 10/25/12 at 10:34 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2033.
29. On 10/25/12 at 10:40 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2017.
30. On 10/25/12 at 10:41 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2068.


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31. On 10/25/12 at 8:50 a.m., the chime/strobe notification device, by Nurses Station 7066, did not emit an audible sound, on the 7th floor.
32. On 10/25/12 at 8:52 a.m., the chime/strobe notification device, by Room 7014, did not emit an audible sound, on the 7th floor.
33. On 10/25/12 at 8:53 a.m., the chime/strobe notification device, by Room 7023, did not emit an audible sound, on the 7th floor.
34. On 10/25/12 at 9:27 a.m., the chime/strobe notification device, by Room 6013, did not emit an audible sound, on the 6th floor.
35. On 10/25/12 at 9:28 a.m., the chime/strobe notification device, by Room 6023, did not emit an audible sound, on the 6th floor.
36. On 10/25/12 at 9:41 a.m., the chime/strobe notification device, by Room 5023, did not emit an audible sound, on the 5th floor.
37. On 10/25/12 at 9:42 a.m., the chime/strobe notification device, by Room 5014, did not emit an audible sound, on the 5th floor.
38. On 10/25/12 at 9:52 a.m., the chime/strobe notification device, by Room 4023, did not emit an audible sound, on the 4th floor.
39. On 10/25/12 at 10:26 a.m., the chime/strobe notification device, by Isolation Room 3001, did not emit an audible sound, on the 3rd floor.
40. On 10/25/12 at 10:32 a.m., the chime/strobe notification device, by Room 3011, did not emit an audible sound, on the 3rd floor.
41. On 10/25/12 at 10:40 a.m., the chime/strobe notification device, by Room 2024, did not emit an audible sound, on the 2nd floor.
42. On 10/25/12 at 10:41 a.m., the chime/strobe notification device, by Rooms 2022 and 2023, did not emit an audible sound, on the 2nd floor.
43. On 10/25/12 at 10:42 a.m., the chime/strobe notification device, above the medical gas valves labeled RVB-201, did not emit an audible sound, on the 2nd floor.

Based on observation, the facility failed to maintain the fire alarm system and devices. This was evidenced by a pull station that was obstructed. This affected 1 of 3 floors at the Dominican building, and could result in a delay in activation of the fire alarm system, in the event of a fire.

NFPA 101, 2000 edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Findings:

During a tour of the facility with staff, the pull stations were observed in the Dominican building.

On 10/23/12 at 10:53 a.m., a manual fire alarm box was obstructed by a printer, on a Shred-it box, at the Nursing Station in the Endo/Infusion area.

Based on document review and interview, the facility failed to maintain their smoke detectors. This was evidenced by no current records for the bi-annual smoke detector sensitivity test. This affected 39 of 39 patients in the Dominican building, and could result in increased potential for smoke detector malfunction leading to the spread of fire or smoke.

NFPA 72 National Fire Alarm Code 1999 Edition, 7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked); the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Findings:

During document review and interview with staff, the records for smoke sensitivity were requested.

On 10/24/12 at 2 p.m., the maintenance records did not contain documents for current smoke detector sensitivity testing. There were no reports for sensitivity testing that included a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the test. The date of the last smoke sensitivity test was unknown as there were no records for a previous test.

During an interview, the FD stated the Dominican building smoke sensitivity was extended to 5 years. He indicated he would fax the report to the district office by 10/29/12. On 10/30/12, at 11:50 a.m., there was no fax received for the smoke sensitivity testing in the Dominican building.

Based on observation, the facility failed to maintain their sprinklers. This was evidenced by sprinklers with displaced escutcheon rings and by debris on one sprinkler deflector. This affected 1 floor in the Tower building and 2 of 3 floors at the Pavilion building. This could result in spread of smoke or a delay in activation of the sprinkler system in the event of a fire.

NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paints, 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.

Findings:

During a tour of the facility with staff, from 10/23/12 through 10/25/12, the sprinklers were observed. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads.

Tower building
1. On 10/25/12 at 1:43 p.m., a sprinkler in the Imaging tech work 1120 had debris on the sprinkler deflector head, on the GL 1st floor.

Based on observation, the facility failed to maintain their sprinklers. This was evidenced by sprinklers with missing escutcheon rings or rings that were not flush with the ceiling. This affected 1 of 3 floors at the Dominican building, and could result in the spread of smoke around the sprinkler heads, in the event of a fire.

NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paints, 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.

Findings:

During a tour of the facility with staff, the sprinklers were observed in the Dominican building.

1. On 10/23/12 at 10:55 a.m., a sprinkler was missing an escutcheon ring, exposing the sprinkler pipe in the ceiling, in the outpatient coding area on the 1st floor.
2. On 10/23/12 at 11:01 a.m., an escutcheon ring was loose and not flush with the ceiling in the Endoscopy/Infusion area in Procedure Room 3.

Pavilion building - 10/23/12
2. At 8:33 a.m., a sprinkler in the EVS closet, Room 322, had debris on the sprinkle deflector.
3. At 8:55 a.m., a sprinkler escutcheon ring fell down and was hanging on the deflector head, in the Pathology lab 234 area, on the 2nd floor.

Based on observation, the facility failed to protect the cooking facilities in accordance with NFPA 96. This was evidenced by the failure to post a warning sign by the portable fire extinguisher in the kitchen. This affected 1 of 8 floors at the Tower building, and had the potential to delay extinguishing a cooking fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition
7-2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.
7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Findings:

During a tour of the kitchen area, with staff, the portable fire extinguishers were observed in the Tower building.
On 10/22/12 at 3:30 p.m., there was no sign in the kitchen areas to let staff know to activate the fire extinguishing system prior to using the portable K class fire extinguishers, in the event of a fire, on the Garden floor.

Based on observation, the facility failed to maintain the medical gas system. This was evidenced by a shut off valve that was blocked and by no humidity logs for the last 12 months. This affected 1 of 3 floors at the Pavilion building, and could result in a delay to shut off medical gases in the event of an emergency or increase the risk of fire.

NFPA 99, Health Care Facilities 1999 Edition
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Findings:

During a tour of the facility with staff, the shut off valves were observed and humidity logs were requested.

Pavilion building
1. On 10/23/12 at 9 a.m., the shut off valve by Operating Room 2 was blocked by an omnicell cart that was stored in front of the gas shut-off valve, on the 2nd floor.


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2. On 10/24/12 at 2:13 p.m., the humidity logs for the Surgery Center were requested. No logs were provided.

During an interview, Engineering Staff stated that the facility just started logging the humidity in September 2012.

Based on document review and interview, the facility failed to maintain their relative humidity. This was evidenced by humidity levels that were not logged daily in anesthetizing locations. This affected 1 of 3 floors at the Dominican building, and could result in the potential risk of fire.

Findings:

During document review and interview with staff, the humidity log were requested at the Dominican Campus.
On 10/24/12 at 2:14 p.m. during document review, the humidity logs for the Endoscopy/Infusion area were not provided.

During an interview, Engineering Staff stated that the facility just started logging the humidity in September 2012. There were no records indicating that the facility monitored the humidity in the procedure rooms prior to September.

Based on document review and interview, the facility failed to maintain their emergency diesel generators. This was evidenced by no records for a current annual load bank test. This affected all patients at the Dominican building, and could result in a malfunction of the emergency generator.

NFPA 110, 1999
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review with staff, the emergency diesel generator records were requested.

Dominican building - 10/24/12
At 10:53 a.m., the generator binder EC020507 indicated the last annual load bank test was conducted in August of 2011. Records indicated that diesel generator 100REOZJ-100KW was last done on 8/24/2011, and diesel generator E5Z88-R2-300KW was last done on 8/25/2011.

During an interview, the facilities director stated the facility conducted their annual load bank test in 8/2011, but it is usually scheduled in November for the Dominican building.

Based on observation, the facility failed to maintain their emergency diesel generators. This was evidenced by no battery back-up task illumination at the generator set location. This affected all patients at the Pavilion building, and could result in a delay in repairs if the generator malfunctioned during a power outage.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3.1 The level 1 or level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility with staff, the emergency diesel generator was observed in the Pavilion Building.

On 10/23/12 at 9:40 a.m., there was no battery-powered task illumination in the emergency generator area. The emergency generator was housed in an enclosed area.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidence by an obstructed electrical panel and one missing cover plate. This affected 1 of 8 floors at the Tower building and 1 of 3 floors at the Pavilion building. This could result in a delay to access the electrical panel in the event of an emergency.

NFPA 70 National Electrical Code, 1999 Edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater.
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with staff, the electrical equipment and utilities were observed.

Tower building
1. On 10/22/12 at 10:11 a.m., an 8 foot ladder was placed within a few inches of Electrical panel EC5C Fed from DB ECFA, on the 5th floor Room 5037.

Pavilion building
2. On 10/22/12 at 8:37 a.m., a metal junction box was missing a cover plate, on the 1st floor Room 304.

Based on observation, the facility failed to maintain the installation of the alcohol based hand rub dispensers (ABHRs). This was evidenced by ABHRs mounted over or adjacent to an ignition source. This affected 2 of 8 floors at the Tower building and 1 of 3 floors at the Pavilion building. This could result in an increased potential for the alcohol based hand rub to ignite a fire.

Findings:

During a tour of the facility with staff, the alcohol based hand rub dispensers were observed through out the facility.

Tower building - 10/22/12
1. At 10 a.m., an ABHR dispenser was installed 3 inches to the left from a light switch, on the 2nd floor near Room 2029 Labor/Postpartum.
2. At 2:58 p.m., an ABHR dispenser was installed 3 inches above a light switch, on the GL first floor by Pathology 1255.

Pavilion building - 10/23/12
3. At 9:32 a.m., in the Radiology Department Echo Room, an ABHR dispenser was mounted within 4 inches of a light switch.
4. At 9:35 a.m., in the Radiology Department EEG 150 Room, an ABHR dispenser was mounted within 5 inches above an electrical outlet.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 8 floors at the Tower building and 3 of 3 floors at the Pavilion building. This could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, on 10/22/12 and 10/23/12, the walls and ceilings were observed in the Tower and the Pavilion Building.

Tower building
1. On 10/22/12, at 2:35 p.m., there were four approximately 1/4 inch to 1/2 inch penetrations in the EVS closet, Room 1064, on the GL 1st floor.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 3 floors at the Dominican building and could result in the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, on 10/23/12, the walls and ceilings were observed in the Dominican building.

1. At 10:43 a.m., there were two approximately 1/4 inch penetrations in the left wall, in the janitor's closet next to physical therapy, on the 1st floor.
2. At 10:46 a.m., there was an approximately 1/4 inch penetration around a ceiling sprinkler, in the consultation room next to the elevator, on the 1st floor.
3. At 10:49 a.m., a sprinkler was not flush against the ceiling and exposed an approximately 1/8 inch penetration, in Medical Dressing Room 1, on the 1st floor.
4. At 10:50 a.m., a sprinkler was not flush against the ceiling and exposed an approximately 1/8 inch penetration, in Medical Dressing Room 4, on the 1st floor.

Pavilion building - 10/23/12

2. At 8:34 a.m., there was an approximately 1/8 inch circular penetration in the ceiling, around a sprinkler deflector plate, in the EVS closet, Room 322, on the 3rd floor.
3. At 8:40 a.m., there was an approximately 1/8 inch penetration around a 3/4 inch conduit pipe in the right wall of Electrical Room 304, on the 3rd floor.
4. At 8:41 a.m., there was an approximately 1/8 inch penetration around a MC cable in the left wall, two approximately 1/8 inch penetrations in the left wall, and an approximately 1/8 inch penetration around a red wire, in the left wall, in Mechanical Room 315, on the 3rd floor.
5. At 8:50 a.m., there were three approximately 1/4 inch penetrations in the back wall, in Mechanical Room 2167, on the 2nd floor.
6. At 8:52 a.m., there was an approximately 1/2 inch penetration in the front wall, by a spare pipe, in Data Room 202, on the 2nd floor.
7. At 9:04 a.m., 3 of 6 sprinklers were not flush against the ceiling, and there was a missing escutcheon ring, in the central sterile area, Room 236, on the 2nd floor. This exposed approximately 1/8 inch penetrations in the ceiling around the sprinklers.
8. At 9:15 a.m., there was an approximately 1/4 inch penetration around a copper pipe, in the back wall in Electrical Room 119, on the 1st floor. There was an approximately 1 by 3 inch penetration in the wall near a brace in the back wall.

Based on observation, the facility failed to ensure the corridors were able to resist the passage of smoke. This was evidenced by penetrations in one corridor wall. This affected 1 of 8 floors at the Tower building, and could result in the passage of smoke from one smoke compartment to another.

Findings:

During a tour of the facility with staff, the corridor walls were observed in the Tower building.
On 10/22/12 at 3:14 p.m., there was an approximately 1/2 inch penetration in the left wall of the OR 1221 corridor, on the GL first floor.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch or were obstructed from closing. This affected 1 of 3 floors at the Dominican building and could result in the spread of smoke or fire.

Findings:

During a tour of the facility with staff, on 10/23/12, the corridor doors were observed in the Dominican building.

1. At 10:35 a.m., the self-closing door was obstructed by a chair, in Physical Therapy Room 5, on the 1st floor.
2. At 10:40 a.m., the self-closing door was held open by a kick stop, in Physical Therapy Room 2, on the 1st floor.
3. At 10:48 a.m., in the Endoscopy/Infusion area, the door to the Mechanical Room did not latch when closed.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch or were obstructed from closing. This affected 3 of 8 floors at the Tower building. This could result in the inability to contain a fire, and the spread of smoke and fire.

Findings:

During a tour of the facility with staff, on 10/22/12, the corridor doors were observed in the Tower building.

1. At 10:45 a.m., the door to the NICU was obstructed by a step stool, on the 2nd floor.
2. At 2:36 p.m., the self-closing door in Room 1020, Exam 17, was obstructed by a trash bin, on the GL 1st floor.
3. At 2:38 p.m., the self-closing door in Room 1024, Exam 21, was obstructed by a chair, on the GL 1st floor.
4. At 3:37 p.m., the self-closing door in storage room 0325 was obstructed by a chair, on the Garden floor inside Physical Therapy 0324.

Based on observation and testing, the facility failed to maintain their barrier doors. This was evidenced by a stairwell door that failed to latch and by fire doors that failed to release and close. This affected 1 of 8 floors at the Tower building and could lead to the spread of smoke and fire moving up or down the stairwell and through the open doors.

Findings:

During observation and testing with staff, the doors were observed in the Tower building.

1. On 10/22/12 at 10:09 a.m., the self-closing stairwell door failed to latch upon release, on the 5th floor in Stairwell 1-5035.
2. On 10/25/12 at 9:40 a.m., fire door DHW6 was held open by an approved magnetic device. When the fire alarm was activated, the right leaf fire door failed to release, on the 5th floor.
3. On 10/25/12 at 9:43 a.m., fire door DHW8 was held open by an approved magnetic device. When the fire alarm was activated, the right leaf fire door failed to release, on the 5th floor.
4. On 10/25/12 at 9:43 a.m., on the 5th floor, the right leaf of the fire doors, by Room 5008 and the Pantry Room, did not latch after activation of the fire alarm system. The door was tested three times.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by exit sign directional arrows that failed to direct the correct direction to an exit. This affected 2 of 8 floors at the Tower building, and the Garden floor in the Pavilion. This could result in a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with staff, the exit signs were observed in the Tower and Pavilion buildings, on 10/22/12.

1. At 3 p.m., an exit sign arrow was directing to the left on the GL 1st floor by Cardiac Cath Lab 1207. The arrow pointed to a window instead of to the exit.
2. At 3:01 p.m., an exit sign arrow was directing to the right, to a wall instead to an exit. The sign was located on the GL 1st floor by OR 3.
3. At 3:05 p.m., an exit sign arrow was directing to the left that lead to a wall instead to an exit, on the GL 1st floor by Electrical 1B room 1127 corridor.
4. At 3:06 p.m., an exit sign arrow was directing to the right, towards a wall instead of to an exit. The sign was located on the GL 1st floor by EVS Closet 1133.
5. At 3:07 a.m., an exit sign arrow was directing to the left towards a wall instead of to an exit. The sign was located on the GL 1st floor by Sterile Storage Room 1210.

Pavilion building
6. At 3:39 p.m., an exit sign arrow was directing to the right, on the Garden floor by the physical therapy 0324 corridor. Going right led to a wall instead of to an exit.

Based on observation, the facility failed to maintain one smoke barrier wall, as evidenced by a penetration in one area. This deficient practice could lead to the passage of smoke or fire in the event of a fire and affected 1 of 3 floors at the Pavilion building.

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed in the Pavilion Building.

On 10/23/12 at 8:38 a.m., there was an approximately one inch penetration in the smoke barrier wall, on the second floor, by Equipment Storage Room 224.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by a door to a hazardous area that was not equipped with a self-closing device. This affected 1 of 8 floors at the Tower building, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

NFPA 101, 1999 Edition
Table 18.3.2.1 Hazardous Area Protection
Hazardous Area Description Separation/Protection

Storage rooms larger than 50 ft2 (4.6 m2),
but not exceeding 100 ft2 (9.3 m2) storing combustible material.

Findings:

During a tour of the facility with staff, the hazardous areas were observed in the Tower building.

On 10/22/12 at 3:25 p.m., the kitchen dry storage room, on the Garden floor, contained approximately a dozen cardboard boxes. The room was over 150 square feet in size. The door was not equipped with a self-closing device.

Based on observation and interview, the facility failed to provide battery powered emergency lighting units in anesthetizing locations. This was evidenced by no battery powered emergency lighting units in their procedure rooms. This affected 1 of 3 floors at the Dominican building and could result in limited visibility in the event of a power failure.

NFPA 99 Health Care Facilities 1999 edition
3-3.2.1.2, All Patient Care Areas. (5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101. 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with staff, the procedure rooms were observed
in the Endoscopy/Infusion area, in the Dominican building.

On 10/23/12 at 10:58 a.m., there were no battery powered emergency lighting units in the four endoscopy procedure rooms. In the event of a power outage there would be no immediate lighting until the generator started.

The DN (discharge nurse) was interviewed at that time. The DN indicated if a loss of power occurred, all procedures would stop. The staff would obtain flashlights at the Nursing Station to use.

Based on interview, the facility failed to ensure that all staff members were familiar with the emergency plan procedures. This was evidenced by 6 of 27 staff members at the Tower building, who were not familiar with the fire safety procedures in the event of a fire. This could result in a delay in staff response in the event of a fire.

NFPA 101, 2000 Edition
18.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
18.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During an interview with staff, on 10/25/12, staff were interviewed regarding the emergency and fire safety plans.

Tower building
1. At 9:20 a.m., a Housekeeping Temp was interviewed regarding what action to take in the event of a fire. The Housekeeping Temp stated that she just started working at the facility and did not know the procedures.

2. At 1:00 p.m., a Doctor in the Emergency Department was interviewed regarding what action to take in the event of a fire. The doctor did not know the procedures.

3. At 1:30 p.m., two Volunteers and the Manager, in the Gift Shop, were interviewed regarding what action to take in the event of a fire. One volunteer stated she just started six weeks ago and did not know the procedures. The other volunteer and manager did not know the procedures.

4. At 2:15 p.m., a warehouse clerk in the bulk storage area was interviewed regarding what action to take in the event of a fire. The warehouse clerk could not find the nearest manual fire alarm box. The clerk went into the Central Processing Area (0190) and the Mail Room looking for the manual fire alarm box.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 1 of 4 missing fire drills. This could lead to a delay in staff response in the event of an emergency.

Findings:

During document review and interview with staff, the fire drill records were reviewed in the Pavilion building.

At 11 a.m., 1 of 4 fire drill records was missing for the fourth quarter, NOC shift in 2011. During an interview, engineering staff stated that fire drills were conducted once a year at the Pavilion.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 3 of 4 fire drills missing during the past 12 month period. This affected 39 of 39 patients at the Dominican building, and could lead to staff not understanding the evacuation procedures in the event of an emergency.

Findings:

During document review with staff, on 10/24/12, the fire drill records were reviewed.

At 11 a.m., 3 of 4 fire drill records were missing for the previous 12 month period. There were no fire drills conducted for the 2nd and 3rd quarters of 2012 and for the fourth quarter of 2011.
During an interview Staff stated that fire drills were conducted once a year at the Dominican Campus.

Based on observation, testing, and interview, the facility failed to maintain the fire alarm system and devices. This was evidenced by chimes that were not audible, by a delay in alarm activation when testing pull stations, by obstructed pull station access, and by trouble signals at the fire alarm panels. This affected 8 of 8 floors at the Tower building, and could result in a malfunction leading to a delay in notification in the event of a fire.

NFPA 101, Life Safety Code 1999
18.9.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

NFPA 72, National Fire Alarm Code 1999 Edition.
1-5.4.2.2. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

NFPA 70, National Electrical Code 1999 Edition
110-26. Spaces about electrical equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosure housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During observation, and fire alarm testing with staff, the fire alarm system and devices were observed.

Tower building
1. On 10/22/12 at 10 a.m., remote alarm panels on all 8 floors indicated trouble, supervisory, and monitor trouble flashing. The reading on the annunciator screen indicated, "001 Supervisory Act, Power Plant RM P028, Refrigerant Warning, 800."

During an interview the Facilities Director stated there is a sensor for each chiller. If there is a refrigerant leak, the alarm will go off and in this case, there is no leak. The vendor had calibrated the system but it still shows a trouble signal. The trouble signal does not affect the fire alarm system.
2. On 10/22/12 at 10:05 a.m., a file rack NS7066, was placed in front of the annunciator panel obstructing access to it, on the 7th floor Nurse Station 1.
3. On 10/22/12 at 10:13 a.m., a clipboard NS5067 was placed in front of the annunciator panel obstructing access to it, at the 6th floor Nurse Station 1.
4. On 10/22/12 at 10:15 a.m., a printer machine NS5059 was placed in front of the annunciator panel obstructing access to it, on the 6th floor Nurse Station 3.
5. On 10/25/12 at 1:55 p.m., a printer machine 10.180.14.150 was placed in front of the annunciator panel obstructing access to it, on the ground level of PACU.
6. On 10/25/12 at 8:48 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor near Room 7034.
7. On 10/25/12 at 8:50 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor across from Room 7002.
8. On 10/25/12 at 8:58 a.m., the strobe/chime combo failed to emit an audible sound, on the 7th floor by Room 7013.
9. On 10/25/12 at 9:27 a.m., the strobe/chime combo failed to emit an audible sound, on the 6th floor by Room 6004.
10. On 10/25/12 at 9:28 a.m., the strobe/chime combo failed to emit an audible sound, on the 6th floor by Room 6034.
11. On 10/25/12 at 9:34 a.m., the strobe/chime combos failed to emit an audible sound, on the 5th floor by Room 5034.
12. On 10/25/12 at 9:35 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5002.
13. On 10/25/12 at 9:36 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5004.
14. On 10/25/12 at 9:37 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5013.
15. On 10/25/12 at 9:43 a.m., the strobe/chime combo failed to emit an audible sound, on the 5th floor by Room 5023.
16. On 10/25/12 at 9:44 a.m., there was a 17.7 seconds delay from activating the pull station to sounding a alarm, on the 5th floor by Room 5023.
17. On 10/25/12 at 9:49 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4034.
18. On 10/25/12 at 9:50 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4002.
19. On 10/25/12 at 9:52 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4004.
20. On 10/25/12 at 9:53 a.m., the strobe/chime combo failed to emit an audible sound, on the 4th floor by Room 4013.
21. On 10/25/12 at 10:25 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3023.
22. On 10/25/12 at 10:26 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3037.
23. On 10/25/12 at 10:27 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3020.
24. On 10/25/12 at 10:28 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3015.
25. On 10/25/12 at 10:29 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3008.
26. On 10/25/12 at 10:30 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3003.
27. On 10/25/12 at 10:31 a.m., the strobe/chime combo failed to emit an audible sound, on the 3rd floor by Room 3028.
28. On 10/25/12 at 10:34 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2033.
29. On 10/25/12 at 10:40 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2017.
30. On 10/25/12 at 10:41 a.m., the strobe/chime combo failed to emit an audible sound, on the 2nd floor by Room 2068.


30514

31. On 10/25/12 at 8:50 a.m., the chime/strobe notification device, by Nurses Station 7066, did not emit an audible sound, on the 7th floor.
32. On 10/25/12 at 8:52 a.m., the chime/strobe notification device, by Room 7014, did not emit an audible sound, on the 7th floor.
33. On 10/25/12 at 8:53 a.m., the chime/strobe notification device, by Room 7023, did not emit an audible sound, on the 7th floor.
34. On 10/25/12 at 9:27 a.m., the chime/strobe notification device, by Room 6013, did not emit an audible sound, on the 6th floor.
35. On 10/25/12 at 9:28 a.m., the chime/strobe notification device, by Room 6023, did not emit an audible sound, on the 6th floor.
36. On 10/25/12 at 9:41 a.m., the chime/strobe notification device, by Room 5023, did not emit an audible sound, on the 5th floor.
37. On 10/25/12 at 9:42 a.m., the chime/strobe notification device, by Room 5014, did not emit an audible sound, on the 5th floor.
38. On 10/25/12 at 9:52 a.m., the chime/strobe notification device, by Room 4023, did not emit an audible sound, on the 4th floor.
39. On 10/25/12 at 10:26 a.m., the chime/strobe notification device, by Isolation Room 3001, did not emit an audible sound, on the 3rd floor.
40. On 10/25/12 at 10:32 a.m., the chime/strobe notification device, by Room 3011, did not emit an audible sound, on the 3rd floor.
41. On 10/25/12 at 10:40 a.m., the chime/strobe notification device, by Room 2024, did not emit an audible sound, on the 2nd floor.
42. On 10/25/12 at 10:41 a.m., the chime/strobe notification device, by Rooms 2022 and 2023, did not emit an audible sound, on the 2nd floor.
43. On 10/25/12 at 10:42 a.m., the chime/strobe notification device, above the medical gas valves labeled RVB-201, did not emit an audible sound, on the 2nd floor.

Based on observation, the facility failed to maintain the fire alarm system and devices. This was evidenced by a pull station that was obstructed. This affected 1 of 3 floors at the Dominican building, and could result in a delay in activation of the fire alarm system, in the event of a fire.

NFPA 101, 2000 edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Findings:

During a tour of the facility with staff, the pull stations were observed in the Dominican building.

On 10/23/12 at 10:53 a.m., a manual fire alarm box was obstructed by a printer, on a Shred-it box, at the Nursing Station in the Endo/Infusion area.

Based on document review and interview, the facility failed to maintain their smoke detectors. This was evidenced by no current records for the bi-annual smoke detector sensitivity test. This affected 39 of 39 patients in the Dominican building, and could result in increased potential for smoke detector malfunction leading to the spread of fire or smoke.

NFPA 72 National Fire Alarm Code 1999 Edition, 7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked); the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Findings:

During document review and interview with staff, the records for smoke sensitivity were requested.

On 10/24/12 at 2 p.m., the maintenance records did not contain documents for current smoke detector sensitivity testing. There were no reports for sensitivity testing that included a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the test. The date of the last smoke sensitivity test was unknown as there were no records for a previous test.

During an interview, the FD stated the Dominican building smoke sensitivity was extended to 5 years. He indicated he would fax the report to the district office by 10/29/12. On 10/30/12, at 11:50 a.m., there was no fax received for the smoke sensitivity testing in the Dominican building.

Based on observation, the facility failed to maintain their sprinklers. This was evidenced by sprinklers with displaced escutcheon rings and by debris on one sprinkler deflector. This affected 1 floor in the Tower building and 2 of 3 floors at the Pavilion building. This could result in spread of smoke or a delay in activation of the sprinkler system in the event of a fire.

NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paints, 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.

Findings:

During a tour of the facility with staff, from 10/23/12 through 10/25/12, the sprinklers were observed. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads.

Tower building
1. On 10/25/12 at 1:43 p.m., a sprinkler in the Imaging tech work 1120 had debris on the sprinkler deflector head, on the GL 1st floor.

Based on observation, the facility failed to maintain their sprinklers. This was evidenced by sprinklers with missing escutcheon rings or rings that were not flush with the ceiling. This affected 1 of 3 floors at the Dominican building, and could result in the spread of smoke around the sprinkler heads, in the event of a fire.

NFPA 25 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paints, 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.

Findings:

During a tour of the facility with staff, the sprinklers were observed in the Dominican building.

1. On 10/23/12 at 10:55 a.m., a sprinkler was missing an escutcheon ring, exposing the sprinkler pipe in the ceiling, in the outpatient coding area on the 1st floor.
2. On 10/23/12 at 11:01 a.m., an escutcheon ring was loose and not flush with the ceiling in the Endoscopy/Infusion area in Procedure Room 3.

Pavilion building - 10/23/12
2. At 8:33 a.m., a sprinkler in the EVS closet, Room 322, had debris on the sprinkle deflector.
3. At 8:55 a.m., a sprinkler escutcheon ring fell down and was hanging on the deflector head, in the Pathology lab 234 area, on the 2nd floor.

Based on observation, the facility failed to protect the cooking facilities in accordance with NFPA 96. This was evidenced by the failure to post a warning sign by the portable fire extinguisher in the kitchen. This affected 1 of 8 floors at the Tower building, and had the potential to delay extinguishing a cooking fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition
7-2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.
7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Findings:

During a tour of the kitchen area, with staff, the portable fire extinguishers were observed in the Tower building.
On 10/22/12 at 3:30 p.m., there was no sign in the kitchen areas to let staff know to activate the fire extinguishing system prior to using the portable K class fire extinguishers, in the event of a fire, on the Garden floor.

Based on observation, the facility failed to maintain the medical gas system. This was evidenced by a shut off valve that was blocked and by no humidity logs for the last 12 months. This affected 1 of 3 floors at the Pavilion building, and could result in a delay to shut off medical gases in the event of an emergency or increase the risk of fire.

NFPA 99, Health Care Facilities 1999 Edition
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Findings:

During a tour of the facility with staff, the shut off valves were observed and humidity logs were requested.

Pavilion building
1. On 10/23/12 at 9 a.m., the shut off valve by Operating Room 2 was blocked by an omnicell cart that was stored in front of the gas shut-off valve, on the 2nd floor.


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2. On 10/24/12 at 2:13 p.m., the humidity logs for the Surgery Center were requested. No logs were provided.

During an interview, Engineering Staff stated that the facility just started logging the humidity in September 2012.

Based on document review and interview, the facility failed to maintain their relative humidity. This was evidenced by humidity levels that were not logged daily in anesthetizing locations. This affected 1 of 3 floors at the Dominican building, and could result in the potential risk of fire.

Findings:

During document review and interview with staff, the humidity log were requested at the Dominican Campus.
On 10/24/12 at 2:14 p.m. during document review, the humidity logs for the Endoscopy/Infusion area were not provided.

During an interview, Engineering Staff stated that the facility just started logging the humidity in September 2012. There were no records indicating that the facility monitored the humidity in the procedure rooms prior to September.

Based on document review and interview, the facility failed to maintain their emergency diesel generators. This was evidenced by no records for a current annual load bank test. This affected all patients at the Dominican building, and could result in a malfunction of the emergency generator.

NFPA 110, 1999
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review with staff, the emergency diesel generator records were requested.

Dominican building - 10/24/12
At 10:53 a.m., the generator binder EC020507 indicated the last annual load bank test was conducted in August of 2011. Records indicated that diesel generator 100REOZJ-100KW was last done on 8/24/2011, and diesel generator E5Z88-R2-300KW was last done on 8/25/2011.

During an interview, the facilities director stated the facility conducted their annual load bank test in 8/2011, but it is usually scheduled in November for the Dominican building.

Based on observation, the facility failed to maintain their emergency diesel generators. This was evidenced by no battery back-up task illumination at the generator set location. This affected all patients at the Pavilion building, and could result in a delay in repairs if the generator malfunctioned during a power outage.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3.1 The level 1 or level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility with staff, the emergency diesel generator was observed in the Pavilion Building.

On 10/23/12 at 9:40 a.m., there was no battery-powered task illumination in the emergency generator area. The emergency generator was housed in an enclosed area.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidence by an obstructed electrical panel and one missing cover plate. This affected 1 of 8 floors at the Tower building and 1 of 3 floors at the Pavilion building. This could result in a delay to access the electrical panel in the event of an emergency.

NFPA 70 National Electrical Code, 1999 Edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater.
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with staff, the electrical equipment and utilities were observed.

Tower building
1. On 10/22/12 at 10:11 a.m., an 8 foot ladder was placed within a few inches of Electrical panel EC5C Fed from DB ECFA, on the 5th floor Room 5037.

Pavilion building
2. On 10/22/12 at 8:37 a.m., a metal junction box was missing a cover plate, on the 1st floor Room 304.