HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the occupancy separations. This was evidenced by penetrations in one two-hour separation between the main hospital and an ambulatory surgery center. This affected one of six floors at the main hospital and could result in the faster spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the two-hour fire rated wall between the Outpatient Surgery and the Hospital was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL -

1. On 5/15/14, at 10:14 a.m., there were three approximately 14 inch by 12 inch rectangular cut-outs in the gypsum wall board in the two-hour fire rated wall between the Outpatient Surgery building and the Main Hospital. The cut-outs were filled with a fiber-like insulation material.

Based on observation and interview, the facility failed to ensure that doors in smoke barriers were self-closing or automatic closing in accordance with NFPA 101. This was evidenced by doors in a one-hour fire rated barrier that were obstructed from closing. This affected one of six floors in the main hospital and could result in the faster spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the smoke barrier separations were observed.

BUILDING 01 MAIN HOSPITAL

THIRD FLOOR -

1. On 5/14/14, at 9:32 a.m., the double doors leading into the 3 East Department from the elevator lobby were observed. These doors were located in a one-hour fire separation according to Administrative Staff 1 and floor plans provided by Engineering Staff 1. During activation of the fire alarm system, the doors began to close but would reopen when people walked by or through the doors. The doors did not fully close during fire alarm activation.
During an interview at 9:33 a.m., Engineering Staff 2 stated that the doors were equipped with a sensor that stopped the door from closing when it detected movement in close proximity. He stated that the sensor was not deactivated upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This affected one of six floors at the main hospital and could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with the Engineer Staff 1 from 5/13/14 to 5/15/14, the smoke barrier door was observed.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR -

1. On 5/14/14, at 9:59 a.m., the smoke barrier double doors by Room 293 were held open with electronic automatic-closing devices. The left door closed but failed to latch upon activation of the fire alarm system.

Based on observation, the facility failed to ensure that hazardous areas were protected by smoke-resisting partitions and self-closing doors. This was evidenced by one hazardous area door with a disarmed self-closing device and by hazardous areas without self-closing doors. This affected one of six floors of the main hospital and two of five outpatient clinics. This could result in the faster spread of smoke and fire and increase the risk of injury to patients, visitors, and staff in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
6.2.1.2 Hazard of contents shall be determined by the authority having jurisdiction on the basis of the character of the contents and the processes or operations conducted in the building or structure.

19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:

(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft ( 4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with the Engineering Staff 3 from 5/13/14 to 5/15/14, the hazardous areas were observed.

BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -

1. On 5/14/14, at 10:14 a.m., the arms of the self-closing device on the door to the electrical room, near the Helipad, were disconnected and the door failed to self-close as a result.


BUILDING 03 MERCY MATERNITY CLINIC -

2. On 5/14/14, at 4:40 p.m., the Janitor Closet was used to store paper products, hand sanitizer (63% ethyl alcohol) containers, and other combustible supplies. The door to the Janitor Closet was not equipped with a self-closing device.


BUILDING 06 HARTNELL AVE CLINIC

ONCOLOGY SUITE -

3. On 5/15/14, at 1:40 p.m., the door into the Chemical Hood Room was not equipped with a self-closing device. The door opened into the pharmacy office and a patient care suite.

BUILDING 05 PRE-OPERATIVE CLINIC

2. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Pre-op Clinic.

BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC

3. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Mercy Woundcare Hyperbaric Clinic.

Based on record review and interview, the facility failed to maintain its battery-powered emergency lights. This was evidenced by no records of monthly and annual testing of these lights. This affected patients, staff, and visitors at three of five offsite clinics. This could result in a delay in evacuation due to limited visibility in the event of an emergency .

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

19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

39.2.8 Illumination of Means of Egress. Means of egress
shall be illuminated in accordance with Section 7.8.
39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review and interview with Engineering Staff 1 from 5/13/14 to 5/15/14, the emergency lighting records were requested.

BUILDING 03 MERCY MATERNITY CLINIC

1. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Mercy Maternity Clinic.

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Based on record review and interview, the facility failed to maintain its emergency exit signs. This was evidenced by incomplete testing and inspection records for exit signs at the main hospital. This affected patients, staff, and visitors on six of six floors at the main hospital. This could result in a delay in evacuation in the event of an emergency due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the exit sign inspection records were reviewed. The facility was equipped with hard-wired exit lights, some with and some without battery-powered illumination sources.

BUILDING 01 MAIN HOSPITAL -

1. On 5/13/14, at 11:10 a.m., the records showed that inspections of all the exit signs, with or without battery-powered back-up power, were done in March 2013, September 2013, and May 2014. There were no records of monthly tests of the exit signs.
During an interview with Engineering Staff 1 at 11:12 a.m., he stated that the hospital policy was to inspect the exit signs every six months.

Based on record review and interview, the facility failed to ensure that fire drills were held quarterly on each shift at unexpected times under varying conditions. This was evidenced by four of four night shift fire drills that were conducted at the same time every quarter, by fire drills with missing supporting documents, and by a missing fire drill document for an offsite location. This affected the main hospital and one of five offsite locations. This could result in a delay in staff response in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available 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 shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with facility staff from 5/13/14 to 5/15/14, the fire drill records were requested.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 9:44 a.m., the four most recent quarterly night shift fire drills were reviewed. The records indicated that the night shift drills held on 2/26/14, 12/31/13, 8/9/13, and 6/28/14 were conducted at 6:00 a.m. Four of four night shift drills were conducted at the same time.

2. On 5/13/14, at 9:46 a.m., the facility fire drill records consisted of a cover page for each drill indicating the time and date it was conducted. Attached to the cover sheets were corresponding "Observation Records" that evaluated the performance of staff in each department and had the signatures of the staff members who participated. The facility provided only cover sheets for the drills conducted on 8/9/13 at 6 a.m., 9/4/13 at 4:00 p.m., and 11/26/13 at 3:00 p.m. There were no Observation Records provided with these drills showing an evaluation of the drills and who had participated.
During an interview at 9:47 a.m., Engineering Staff 1 stated that the facility was in the process of changing the safety officer and this could have resulted in the incomplete fire drill records.
On 5/15/14, Engineering Staff 1 stated that Observation Records for the above mentioned fire drills could not be found.


BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC
3. On 5/13/14, at 2:21 p.m., there were no records indicating that a fire drill was conducted during the third quarter (July to September) of 2013.

Based on observation and interview, the facility failed to ensure that fire alarm system components were installed per code. This was evidenced by one of one pull station in the Hartnell Avenue Clinic that was installed in a locked utility room on the outside of the building. This affected the Hartnell Avenue Clinic which measured at approximately 11884 square feet. This could result in delay in notification due to the inaccessible pull box and possible harm to patients and staff, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.5 For fire alarm systems using automatic fire detection or water flow detection devices, not less than one manual fire alarm box shall be provided to initiate a fire alarm signal. This manual fire alarm box shall be located where required by the authority having jurisdiction.

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


Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the fire alarm system was observed.

BUILDING 06 HARTNELL AVENUE CLINIC

1. On 5/14/14, at 3:55 p.m., the facility's fire alarm system was equipped with one pull station that was located in a locked utility room. The utility room was located outside on the east side of the building. The facility failed to ensure that the pull station was installed so that it was readily accessible and visible.

During an interview on 5/14/14, at 4:02 p.m., Clinical Staff 1 stated that the pull station was located down the hallway from her desk. Additional interviews with the clinic staff were conducted and more than 50% of the staff, at the time of survey, were unable to locate the pull station. The building had been occupied for at least four months.

During an interview on 5/15/14, at 1:26 p.m., the Director of Outpatients Oncology stated it was a possibility that during and after treatments patients would not be able to rescue themselves in the event of an emergency.

Based on observation, the facility failed to maintain its fire alarm system. This was evidenced by batteries in the fire alarm panel and fire alarm panel components that were past due for replacement. This affected one of five offsite buildings and had the potential for fire alarm system failure.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
Table 7-3.2 Testing Frequencies
Item 6(d)(1) states that sealed-lead acid batteries are to be replaced every 4 years.

Findings:

During facility tour with Engineering Staff 3 from 5/13/14 to 5/15/14, the fire alarm system at Building 02 was observed.

BUILDING 02 MERCY FAMILY HEALTH CENTER -

1. On 5/14/14, at 2:40 p.m., the batteries in the fire alarm panel had a posted installation date of 9/2009, and the batteries in the dialer unit had a posted dated of 9/2009. These sealed-lead acid batteries were due to be replaced by September 2013.

BUILDING 05 PRE-OPERATIVE CLINIC

3. On 5/14/14, at 1:10 p.m., the facility failed to provide documents to show that sensitivity testing was conducted for five of five smoke detectors at this clinic.

On 5/15/14, at 3:20 p.m., Engineering Staff 1 confirmed that there were no records of sensitivity testing for these smoke detectors.

Based on record review and interview, the facility failed to ensure that the smoke detectors were maintained in reliable operating conditions. This was evidenced by an absence of records for sensitivity testing of hard-wired smoke detectors at two offsite clinics and an absence of records for testing of the single-station smoke detectors at one offsite location. This affected three of five offsite clinics and could result in a delay in notification to staff and patients, in the event of a fire.
NFPA 101, Life Safety Code 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment system , condition, arrangement, level of protection or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 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.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully
retested, device abandoned in place)

Findings:
During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the smoke detector maintenance records were requested.
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BUILDING 03 MERCY MATERNITY CLINIC -
This clinic was equipped throughout with single station smoke detectors.
1. On 5/15/14 at 3:20 p.m., there were no records of weekly testing of the smoke detectors as recommended by the manufacturer's guidelines and there were no records of when the batteries in the detectors had been changed.
Engineering Staff 1 confirmed there were no documents of weekly testing and the frequency of battery replacement for these smoke detectors.

BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC
2. On 5/15/14, at 10:20 a.m., Engineering Staff 3 failed to provide records of smoke detector sensitivity testing at this clinic.
During an interview at 3:20 p.m., Engineering Staff 1 confirmed that no smoke detector sensitivity testing had been conducted.

Based on observation and interview, the facility failed to ensure that sprinkler system valves were supervised. This was evidenced by two Post Indicating Valves (PIV) that were not supervised by tamper switches. This affected 6 of 6 floors at the main hospital and could result in a delay in extinguishing a fire in the event the valves are closed.
NFPA 101, Life Safety Code, 2000 Edition.
9.7.2 Supervision.
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
NFPA 72, National Fire Alarm Code, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.
Findings:
During a facility tour with Engineering Staff 1 from 5/13/14 to 5/15/14, the sprinkler system control valves were observed.
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BUILDING 01 MAIN HOSPITAL
1. On 5/14/14, at 12:02 p.m., the PIV located outside the front entrance of McAuley Hall (Administrative Building) was not equipped with supervisory switches. The PIV was locked in the open position, but it was not supervised by a system that would activate at least a local alarm if the valve was closed.
2. On 5/14/14, at 12:05 p.m., the PIV located outside the East Wing of the Main Hospital building was not equipped with a tamper alarm. The PIV was locked in the open position, but it was not supervised by a system that would activate at least a local alarm if the valve was closed.
During an interview at 12:05 p.m., Engineering Staff 1 stated that the system was old and he was granted justification not to install the PIVs with tamper switch by the Department. During survey and at the time of Exit Conference on 5/15/14, Engineering Staff 1 failed to produce documents that showed that the facility was given justifications for not installing the PIVs with tamper alarms.

Based on observation, record review, and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by incomplete testing records, by no repair records for sprinkler systems that failed vendor inspections, by missing escutcheon rings and sprinkler cover caps, by sprinkler heads that were not free of foreign materials, and by not maintaining the minimum required clearance below the sprinkler deflectors. Sprinkler heads were listed to respond to a calculated ceiling temperature. Escutcheon and cover fittings were part of the listed sprinkler assembly and a missing escutcheon fitting could allow heat and smoke to affect other areas in the building. This affected six of six floors in the main hospital and three of three sprinklered offsite buildings. This could result in a delay in extinguishing a fire.


NFPA 101, Life Safety Code, 2000 Edition
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

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

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


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.3.4 Minimum Distance Between Sprinklers. A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated the section for each type or style of sprinkler.

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1:Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.1 The provision of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of water flow at the alarm initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the sprinkler system was observed.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 10:44 a.m., records indicated that annual testing of the sprinkler system was conducted by a vendor on 3/8/14. There were Inspection, Testing, and Maintenance forms for each of the 15 risers at the facility. The Deficiencies and Comments sections from the forms indicated that Risers 2, 3, 13, 14, and 15 required repairs and that these risers failed inspection.
On 5/15/14, at 11:10 a.m., staff provided documentation indicating that Risers 13, 14, and 15 passed the inspection.

There were no records indicating that the deficiencies were repaired for Risers 2 and 3.

During an interview at 11:21 a.m., on 5/15/14, Engineering Staff 1 stated that the deficiencies listed by the vendor during the annual testing for Risers 2 and 3 had not yet been repaired.

2. On 5/13/14, at 1:54 p.m., records indicated that the five-year testing of the sprinkler system was conducted by a vendor on 3/8/11. There were Inspection, Testing, and Maintenance forms for each of the 15 risers at the facility. The Deficiencies and Comments sections from the forms indicated that Risers 1, 3, 6, 8, 10, 11 and 15 required repairs and that these risers failed inspection.
On 5/15/14, at 11:03 a.m., staff provided documentation indicating that all risers passed the five-year inspection except for Risers 3 and 6.

There were no records indicating that the deficiencies were repaired for Risers 3 and 6.

3. On 5/13/14, at 2:35 p.m., the testing records of the backflow prevention assemblies were requested. The vendor that conducted the annual test indicated that the backflow prevention device was "tested by others."
During an interview on 5/15/14 at 1:43 p.m., Engineering Staff 1 stated that the backflow prevention testing was not conducted, and that the facility hired a vendor to conduct the testing today (5/15/14).

The facility failed to conduct annual tests on the backflow prevention devices.

LOWER LEVEL 2 -

4. On 5/13/14, at 4:04 p.m., the concealed pendant sprinkler head in the telephone room (Door 2534) was missing a cover.


LOWER LEVEL -

5. On 5/14/14, at 4:49 p.m., the concealed pendant sprinkler head in the south corner of Auditorium B was missing a cover.


29566

FOURTH FLOOR -

6. On 5/13/14, at 3:40 p.m., in the Rapid Development Unit, supply items stored on the top of the clean supply shelves obstructed the dispersion patterns of two sprinkler heads. The supply items were positioned approximately 12 inches below the sprinkler deflectors.
THIRD FLOOR -


7. On 5/14/14, at 9:30 a.m., the Inspector's Test Valve (ITV) in the Mechanical Room was tested during fire alarm system testing. The fire alarm system notification devices activated 105 seconds after the ITV was opened. The ITV failed to activate within 90 seconds as required.

FIRST FLOOR -

8. On 5/14/14, at 10:58 a.m., access to a main sprinkler riser in the East Utility Room was blocked by six patient walkers and other items stored against the riser.

LOWER LEVEL -

9. On 5/15/14, at 9:10 a.m., dispersion patterns of two of six sprinkler heads in the kitchen pantry were obstructed by boxes of supplies on the top shelves. The boxes of supplies were stored less than 18 inches below the sprinkler deflector.

10. On 5/15/14, at 9:12 a.m., a sprinkler fusible link and deflector in the kitchen pantry were laden with debris.

11. On 5/15/14, at 9:17 a.m., two of two sprinkler heads in the walk-in freezer had a build up of debris on the bulbs and deflectors.

BUILDING 02 MERCY FAMILY HEALTH CENTER -

12. On 5/15/14, at 11:25 a.m., the annual sprinkler inspection and test dated 3/24/14 stated that the sprinkler system failed the annual test because there were two sprinkler heads within six feet of each other. The facility failed to provide documentation indicating that the repairs were made and if the system passed inspection.
During an interview with Engineering Staff 1 at 11:30 a.m., he stated that the corrections were not done.


BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

13. On 5/13/14, at 1:40 p.m., there were no records provided for a five year sprinkler system inspection and testing.
During an interview at 2:12 p.m., Engineering Staff 1 confirmed that there were no records of a five year sprinkler system inspection and testing.


BUILDING 06 ONCOLOGY SUITE

14. On 5/14/14, at 3:54 p.m., in the storage room, there were boxes of supplies on the top shelf blocking the dispersion pattern of one sprinkler head. The boxes of supplies were positioned less than 18 inches below the sprinkler deflector.

15. On 5/15/14, at 2:11 p.m., there were no records of a 5-year inspection and annual inspection conducted for the Hartnell Ave Clinic's sprinkler system.

During an interview with Engineering Staff 1, he stated that the sprinkler system testing was not done before or after the opening of the Oncology Suite.

During an interview on 5/14/14, at 4:12 p.m., the Director of Outpatient Services in Suite A (Oncology) stated that the renovation of Hartnell Avenue Clinic started in the summer of 2013 and was open to the public approximately four months ago.

Based on observation, the facility failed to maintain its fire extinguishers. This was evidenced by one fire extinguisher that was found unsecured on the floor and by one fire extinguisher that was mounted more than five feet above the ground. This affected two of six floors in the main hospital and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the fire extinguishers were observed.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR -

1. On 5/14/14, at 11:25 a.m., the fire extinguisher in Operating Room 9 was mounted so that the top of the extinguisher measured at approximately 6 feet 4 inches from the ground.

LOWER LEVEL -

2. On 5/15/14, at 8:56 a.m., there was a fire extinguisher unsecured on the floor of the Main Server/Data Room.

Based on record review, the facility failed to maintain its fire dampers. This was evidenced by the failure to provide documentation of repairs of deficiencies noted by a vendor during an inspection. This affected six of six floors at the main hospital and could result in the spread of smoke and fire through the HVAC system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.
3-4.7 Maintenance. At least every 4 years, fusible links(where applicable shall be removed; all dampers shall be operated to verify that they close fully; the latch if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

BUILDING 01 MAIN HOSPITAL

During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the dampers inspection and testing records were requested.

1. On 5/13/14, at 1:10 p.m., records showed that 87 dampers were tested on 7/15/10 by a vendor. Per the legend on the vendor's report, "B= bad," and 49 dampers were marked with the letter B. The facility provided quotes from the vendor on repairs to be made and handwritten notes on the inspection record of repairs made. They failed to provide supporting documents of repairs such as location of the dampers repaired, date the repairs were made, and initials or signature of the person(s) who made the repairs. Repairs of the dampers that failed the vendor inspection in 2010 could not be confirmed by the documentation provided.

Based on observation, the facility failed to maintain its cooking equipment as evidenced by grease-laden deposits on the sprinkler pipes in the hood. This affected one of six floors in the main hospital and could result in the increased risk of a grease fire.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1

Type or Volume of Cooking Frequency

Systems serving high-volume cooking operations such as
24-hour cooking, charbroiling or wok cooking. Quarterly
Findings:

During a tour of the facility with the Engineer Staff 3 from 5/13/14 to 5/15/14, the patient services kitchen stove was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL -

1. On 5/15/14, at 9:24 a.m., inside the stove exhaust hood, there was a build up of grease and debris on the sprinkler pipes and fusible links in the hood behind the hood filters.

Based on observation, the facility failed to maintain its medical gas storage locations. This was evidenced by oxygen cylinders stored less than five feet away from an electrical fixture electrical circuit panel of the Heli-pad, by oxygen cylinders that were not secured, and by oxygen cylinders that were less than five feet away from combustible materials. This affected two of six floors in the main hospital and could potentially cause a hazard.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

8-3.1.1 Cylinders and containers shall comply with 4-3.1.1.1(a).
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Findings:
During a facility tour with staff from 5/13/14 to 5/15/14, the medical gas cylinders were observed.
BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -
1. On 5/14/14, at 10:13 a.m., there were six oxygen E-cylinders, loosely held together with one chain, in the helipad electrical room. The cylinders were not secured.
2. On 5/14/14, at 10:14 a.m., there were eight oxygen E-cylinders and one nitrogen cylinder stored less than five feet away from the main electrical circuit panel of the helipad electrical room.


29665


BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -

3. On 5/14/14, at 3:26 p.m., there were four oxygen cylinders unsecured on the floor of the storage room outside the ambulance entrance of the Emergency Department.

LOWER LEVEL -

4. On 5/15/14, at 9:49 a.m., there were 18 oxygen H-cylinders stored less than one foot away from cardboard boxes in the med gas storage area outside Endoscopy. The medical gas storage area was directly adjacent to a Storage Supply/Staging Area that contained more than one hundred cardboard boxes of supplies. The facility did not maintain a minimum five foot clearance away from combustibles.

Based on observation, the facility failed to maintain its piped-in medical gas system. This was evidenced by one shut-off valve that was obstructed and was missing a cover. This was also evidenced by incomplete documentation of repairs of deficiencies noted during a vendor's inspection of the system. This affected six of six floors in the main hospital and could cause a potentially hazardous situation and increased risk of a 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.
(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.

4-3.4.1.1 General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, installation, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.

4-3.5.2.3 Patient Gas Systems-Level 1.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning and records of the test shall be maintained until the next test.

4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.


Findings:

During record review and a facility tour with Engineering Staff 1 and Engineering Staff 3 from 5/13/14 to 5/15/14, the piped-in medical gas system was observed and maintenance records were reviewed.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 9:40 a.m., the piped-in medical gas inspection report dated 12/12/13 listed the following deficiencies:

"a. HR Exam Room 4 outage leakage.
b. Emergency Trauma 2 wall vacuum system needed extended barrel 7 rough in assemble.
c. Room 231 vacuum system reduced flow/no flow.
d. Manifold Room Ventilation- CSOR ventilation from medical gas closet turned off needs to be checked by HVAC technician.
e. First floor east Radiology: N2O system -gauge accuracy -C and status -C
f. Third floor west Surgical ICU/CSOR: vacuum system gauge accuracy-C and status -C."

Per the vendor's legend printed on the report, C stands for "Compliance Action Required."

During an interview with Engineering Staff 1 at 9:30 a.m., he stated that the repairs were done in 2/14.

On 5/15/14, Engineering Staff produced both estimates and final work done records from vendor.
The records provided failed to identified repairs for the Manifold Room Ventilation, 1st floor Radiology East, and 3rd floor Surgical ICU/CSOR West.

The vender report dated 2/26/14:
"a.Vacuum inlet in Trauma 2 rough in is located too deep in wall for finish assy barrel to make a proper seal.
b.Outlet of ER exam Room 4 not repaired and 19 of 20 outlets repaired per report of 2/26/14
c. Room 231 not repaired due to other corrective action needed per e-mail report from vender on 5/13/14."

On 5/15/14, at 4: 14 p.m., the facility failed to provide complete documentation of repairs made on the discrepancies noted in the inspection report of 12/12/13.

2. On 5/15/14, at 9:02 a.m., in the kitchen pantry, the oxygen piped-in system shut-off valve was blocked by a rack with a soda fountain and soda containers.
The cover for the shut-off valve in the wall was displaced leaving the valve unprotected.

Based on record review and interview, the facility failed to maintain its anesthetizing locations. This was evidenced by relative humidity (RH) levels that fell below 20% at several anesthetizing locations without documentation of timely corrective actions. This was also evidenced by one room with incomplete humidity logs. The facility has elected to use a categorical waiver (S&C 13-25 as mentioned in the K000 tag) that allows facilities to maintain RH levels between 20% and 60% in accordance with NFPA 99, 2012 Edition. This affected two of six floors at the main hospital and could result in an increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

On April 19, 2013, the Center for Medicare & Medicaid Services (CMS) released a memorandum, Ref: S&C-13-25-LSC, regarding the requirements for maintaining relative humidity in anesthetizing locations.

Sections of the memorandum state:

B. Categorical Waiver for RH Levels in Anesthetizing Locations
The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent.

In light of NFPA's recent adoption of the ASHRAE Standard 170, as well as in response to industry feedback that the minimum 35 percent RH level is unduly burdensome, we are issuing via this memorandum a categorical waiver to permit hospitals and Critical Access Hospitals (CAHs) with new and existing ventilation systems supplying anesthetizing locations, as defined by the 1999 edition of NFPA 99, to operate with a RH level of ¿20 percent.

C. Waiver Does Not Apply If:
More stringent RH levels are required under State or local laws and regulations; or
The reduction of RH would negatively affect ventilation system performance.

D. Facilities Option to Elect to Use the Waiver
Facilities that elect to use the categorical waiver must document their decision to do so. If a hospital or CAH conforms to the above requirements, they will not need to apply in advance to CMS, nor will they need to wait until being cited for a deficiency in order to apply to use this waiver. At the entrance conference for any survey assessing LSC compliance, a facility that has elected to use this waiver must notify the survey team of this fact, as well as the fact that it meets the minimum RH standard of ¿20 percent. The facility must provide documentation of its prior election to apply the waiver option. The absence of such evidence provided at the start of a survey means that the facility may be issued a citation if not in conformance with the 2000 LSC edition. It is not acceptable for a healthcare facility to first notify surveyors of waiver election after a citation related to RH has been issued, except as part of a plan of correction in response to the citation.

E. Ongoing Requirements
Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital's or CAH's ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.

Findings:

During record review with staff from 5/13/14 to 5/15/14, the facility's policy on maintaining relative humidity at anesthetizing locations and the corresponding humidity logs were requested. A central monitoring system called TempTrak was used to monitor and log the RH levels at the hospital's anesthetizing locations. Logs of the RH levels at these areas were requested on 5/13/14 and were provided at noon on 5/15/14.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR SURGERY -

On 5/15/14, at 12:04 p.m., a graph of daily RH readings from the past six months was provided for each operating room on the second floor, ORs 1 through 9. The specific dates and times the RH fell out of range were recorded on a report called the TempTrak Sensor Alarm/Note Report. Per the TempTrak graphs for each room, the "Alarm Min" set for ORs 1 through 9 was 19% RH and the "Alarm Max" was set at 61%. During an interview, Engineering Staff 2 stated that the TempTrak system was set to alarm if the RH in the ORs fell out of the 20 to 60% range.


OPERATING ROOM 1 (OR1) -

Based on the TempTrak Sensor for OR 1, the RH fell below 20% during the following days:

1. On 3/17/14, at 6:30 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until on 3/20/14 at 6:21 a.m.

2. On 3/21/14, at 11:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until on 3/23/14 at 4:45 a.m.


OPERATING ROOM 2 (OR2) -

Based on the TempTrak Sensor for OR 2, the RH fell below 20% during the following days:

3. On 12/9/13, at 11:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until on 12/12/13 at 7:17 a.m.

4. On 1/5/14, at 7:30 a.m., the RH in the room was recorded as 9%, and the alarm was not cleared by engineering until 1/6/14 at 5:36 a.m.

5. On 1/6/14, at 8:00 a.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

6. On 2/1/14, at 4:30 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

7. On 3/18/14, at 9:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.

8. On 4/18/14, at 4:30 p.m., the RH in the room was recorded as 17 %, and the alarm was not cleared by engineering until 4/25/14 at 5:14 a.m.


OPERATING ROOM 4 (OR4) -

Based on the TempTrak Sensor for OR 4, the RH fell below 20% during the following days:

9. On 3/18/14, at 2:00 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.


OPERATING ROOM 8 (OR8) -

Based on the TempTrak Sensor for OR 8, the RH fell below 20% during the following days:

10. On 12/3/13, at 6:00 p.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 12/5/13 at 6:48 p.m.

11. On 12/9/13, at 11:30 a.m., the RH in the room was recorded as 14%, and the alarm was not cleared by engineering until 12/12/13 at 7:17 a.m.

12. On 12/30/13, at 7:30 a.m., the RH in the room was recorded as 16%, and the alarm was not cleared by engineering until 1/2/14 at 6:20 a.m.

13. On 1/6/14, at 6:00 a.m., the RH in the room was recorded as 16%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

14. On 1/31/14, at 10:00 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

15. On 3/18/14, at 9:30 a.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.


OPERATING ROOM 9 (OR9) -

Based on the TempTrak Sensor for OR 9, the RH fell below 20% during the following days:

16. On 1/6/14, at 6:00 a.m., the RH in the room was recorded as 14%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

17. On 2/1/14, at 6:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

THIRD FLOOR OBSTETRIC SURGERY -

OB OR 1 -

Based on the TempTrak Sensor for OB OR 1, the RH fell below 20% during the following days:

18. On 3/21/14, at 2:30 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/23/14 at 4:46 a.m.

OB OR 2 -

Based on the TempTrak Sensor for OB OR 2, the RH fell below 20% during the following days:

19. On 3/17/14, at 2:30 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.

20. On 4/18/14, at 5:30 p.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 4/25/14 at 5:14 a.m.


THIRD FLOOR CARDIAC SURGERY -

21. On 5/15/14, at 2:40 p.m., the TempTrak Sensor History graph was provided for the Cardiac Surgery OR. The graph showed the RH levels in the room over the past six months. The legend of the graph showed that "Alarm Min" for this room was set at 0%, not at 19% like the other anesthetizing locations.
During an interview at 2:41 p.m., Engineering Staff 2 stated that the TempTrak system would not alarm when the RH fell below 20% in this room as long as the Alarm Min was set at 0%.

The graph indicated that RH levels fell below 20% in December 2013, January 2014, February 2014, and March 2014. The exact dates could not be determined because the TempTrak Sensor Alarm Report did not record humidity levels below 0% for this room.

Based on observation, the facility failed to ensure that openings in smoke barrier walls were sealed in accordance with NFPA 101. This affected three of six floors of the main hospital and could result in the spread of smoke and fire from one smoke compartment to another.

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

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the smoke barrier walls were inspected.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL 2 -

1. On 5/13/14, at 3:42 p.m., there was an approximately two inch unsealed conduit passing through the smoke barrier wall next to Elevator 1.
During an interview at 3:43 p.m., Engineering Staff 5 stated that the caulking that originally sealed the conduit had fallen out and he found the original caulking material above a ceiling tile in the attic space.

SECOND FLOOR -

2. On 5/14/14, at 10:00 a.m., there was an approximately one inch unsealed conduit passing through the smoke barrier wall next to Room 272 (2 West).





29566


LOWER LEVEL -

3. On 5/15/14, at 9:40 a.m., the soda machine in the cafeteria used hoses running from the machine to the ceiling back down to the floor in the cafeteria kitchen then to the kitchen pantry. The hoses ran through a conduit that measured approximately three inches at the floor entrance and the ceiling entrance. The conduit was sealed with non-fire rated foam at the floor entrance.

Based on observation, the facility failed to maintain its electrical wiring. This was evidenced by the use of extension cords and surge protectors in lieu of permanent wiring. This affected five of six floors in the main hospital and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the electrical wiring was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL 2 -

1. On 5/13/14, at 3:50 p.m., a coffee pot, microwave, refrigerator, and toaster were plugged into a six-plug surge protector in the Cancer Registry Office.


2. On 5/13/14, at 4:21 p.m., there was six-plug surge protector plugged into another six-plug surge protector in the former Linear Accelerator Room 2 (Door 2516).


THIRD FLOOR -

3. On 5/14/14, at 1:47 p.m., there was a medications refrigerator plugged into an extension cord at the 3 South Main Nurses Station.

FIRST FLOOR -

4. On 5/14/14, at 2:45 p.m., the procedure table in Radiology Room 5 (Speech Therapy Room) was plugged into a four-plug surge protector that was mounted on the wall behind the table.

5. On 5/14/14, at 2:47 p.m., there was a three-plug 40-foot extension cord anchored to the ceiling of the Nuclear Medicine Treatment Room. The extension cord was plugged into a duplex outlet in the ceiling.

LOWER LEVEL -

6. On 5/15/14, at 9:36 a.m., there was a six-plug surge protector plugged into a six-plug surge protector in the Point Care Testing Office.

7. On 5/15/14, at 10:30 a.m., there was a three-plug 30-foot extension cord anchored to the ceiling of the storage room (Door 1155) next to Sterile Processing. The extension cord was plugged into a duplex outlet in the ceiling.



29566

FOURTH FLOOR -

8. On 5/13/14, at 4:01 p.m., there were a microwave, a refrigerator, and a coffee maker plugged into a single multi-plug surge protector in the Trauma Services Office.

Based on observation, the facility failed to maintain the integrity of the occupancy separations. This was evidenced by penetrations in one two-hour separation between the main hospital and an ambulatory surgery center. This affected one of six floors at the main hospital and could result in the faster spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the two-hour fire rated wall between the Outpatient Surgery and the Hospital was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL -

1. On 5/15/14, at 10:14 a.m., there were three approximately 14 inch by 12 inch rectangular cut-outs in the gypsum wall board in the two-hour fire rated wall between the Outpatient Surgery building and the Main Hospital. The cut-outs were filled with a fiber-like insulation material.

Based on observation and interview, the facility failed to ensure that doors in smoke barriers were self-closing or automatic closing in accordance with NFPA 101. This was evidenced by doors in a one-hour fire rated barrier that were obstructed from closing. This affected one of six floors in the main hospital and could result in the faster spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the smoke barrier separations were observed.

BUILDING 01 MAIN HOSPITAL

THIRD FLOOR -

1. On 5/14/14, at 9:32 a.m., the double doors leading into the 3 East Department from the elevator lobby were observed. These doors were located in a one-hour fire separation according to Administrative Staff 1 and floor plans provided by Engineering Staff 1. During activation of the fire alarm system, the doors began to close but would reopen when people walked by or through the doors. The doors did not fully close during fire alarm activation.
During an interview at 9:33 a.m., Engineering Staff 2 stated that the doors were equipped with a sensor that stopped the door from closing when it detected movement in close proximity. He stated that the sensor was not deactivated upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This affected one of six floors at the main hospital and could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with the Engineer Staff 1 from 5/13/14 to 5/15/14, the smoke barrier door was observed.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR -

1. On 5/14/14, at 9:59 a.m., the smoke barrier double doors by Room 293 were held open with electronic automatic-closing devices. The left door closed but failed to latch upon activation of the fire alarm system.

Based on observation, the facility failed to ensure that hazardous areas were protected by smoke-resisting partitions and self-closing doors. This was evidenced by one hazardous area door with a disarmed self-closing device and by hazardous areas without self-closing doors. This affected one of six floors of the main hospital and two of five outpatient clinics. This could result in the faster spread of smoke and fire and increase the risk of injury to patients, visitors, and staff in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
6.2.1.2 Hazard of contents shall be determined by the authority having jurisdiction on the basis of the character of the contents and the processes or operations conducted in the building or structure.

19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:

(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft ( 4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with the Engineering Staff 3 from 5/13/14 to 5/15/14, the hazardous areas were observed.

BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -

1. On 5/14/14, at 10:14 a.m., the arms of the self-closing device on the door to the electrical room, near the Helipad, were disconnected and the door failed to self-close as a result.


BUILDING 03 MERCY MATERNITY CLINIC -

2. On 5/14/14, at 4:40 p.m., the Janitor Closet was used to store paper products, hand sanitizer (63% ethyl alcohol) containers, and other combustible supplies. The door to the Janitor Closet was not equipped with a self-closing device.


BUILDING 06 HARTNELL AVE CLINIC

ONCOLOGY SUITE -

3. On 5/15/14, at 1:40 p.m., the door into the Chemical Hood Room was not equipped with a self-closing device. The door opened into the pharmacy office and a patient care suite.

BUILDING 05 PRE-OPERATIVE CLINIC

2. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Pre-op Clinic.

BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC

3. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Mercy Woundcare Hyperbaric Clinic.

Based on record review and interview, the facility failed to maintain its battery-powered emergency lights. This was evidenced by no records of monthly and annual testing of these lights. This affected patients, staff, and visitors at three of five offsite clinics. This could result in a delay in evacuation due to limited visibility in the event of an emergency .

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

19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

39.2.8 Illumination of Means of Egress. Means of egress
shall be illuminated in accordance with Section 7.8.
39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review and interview with Engineering Staff 1 from 5/13/14 to 5/15/14, the emergency lighting records were requested.

BUILDING 03 MERCY MATERNITY CLINIC

1. On 5/15/14, at 1:05 p.m., there were no records of monthly 30-second testing and annual 90-minute testing of the battery-powered emergency lights at this clinic.
During an interview with Engineering Staff 1 at 1:07 p.m., he confirmed that the facility failed to conduct and document the monthly and annual testing of the emergency lighting at the Mercy Maternity Clinic.

.

Based on record review and interview, the facility failed to maintain its emergency exit signs. This was evidenced by incomplete testing and inspection records for exit signs at the main hospital. This affected patients, staff, and visitors on six of six floors at the main hospital. This could result in a delay in evacuation in the event of an emergency due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the exit sign inspection records were reviewed. The facility was equipped with hard-wired exit lights, some with and some without battery-powered illumination sources.

BUILDING 01 MAIN HOSPITAL -

1. On 5/13/14, at 11:10 a.m., the records showed that inspections of all the exit signs, with or without battery-powered back-up power, were done in March 2013, September 2013, and May 2014. There were no records of monthly tests of the exit signs.
During an interview with Engineering Staff 1 at 11:12 a.m., he stated that the hospital policy was to inspect the exit signs every six months.

Based on record review and interview, the facility failed to ensure that fire drills were held quarterly on each shift at unexpected times under varying conditions. This was evidenced by four of four night shift fire drills that were conducted at the same time every quarter, by fire drills with missing supporting documents, and by a missing fire drill document for an offsite location. This affected the main hospital and one of five offsite locations. This could result in a delay in staff response in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available 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 shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with facility staff from 5/13/14 to 5/15/14, the fire drill records were requested.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 9:44 a.m., the four most recent quarterly night shift fire drills were reviewed. The records indicated that the night shift drills held on 2/26/14, 12/31/13, 8/9/13, and 6/28/14 were conducted at 6:00 a.m. Four of four night shift drills were conducted at the same time.

2. On 5/13/14, at 9:46 a.m., the facility fire drill records consisted of a cover page for each drill indicating the time and date it was conducted. Attached to the cover sheets were corresponding "Observation Records" that evaluated the performance of staff in each department and had the signatures of the staff members who participated. The facility provided only cover sheets for the drills conducted on 8/9/13 at 6 a.m., 9/4/13 at 4:00 p.m., and 11/26/13 at 3:00 p.m. There were no Observation Records provided with these drills showing an evaluation of the drills and who had participated.
During an interview at 9:47 a.m., Engineering Staff 1 stated that the facility was in the process of changing the safety officer and this could have resulted in the incomplete fire drill records.
On 5/15/14, Engineering Staff 1 stated that Observation Records for the above mentioned fire drills could not be found.


BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC
3. On 5/13/14, at 2:21 p.m., there were no records indicating that a fire drill was conducted during the third quarter (July to September) of 2013.

Based on observation and interview, the facility failed to ensure that fire alarm system components were installed per code. This was evidenced by one of one pull station in the Hartnell Avenue Clinic that was installed in a locked utility room on the outside of the building. This affected the Hartnell Avenue Clinic which measured at approximately 11884 square feet. This could result in delay in notification due to the inaccessible pull box and possible harm to patients and staff, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.5 For fire alarm systems using automatic fire detection or water flow detection devices, not less than one manual fire alarm box shall be provided to initiate a fire alarm signal. This manual fire alarm box shall be located where required by the authority having jurisdiction.

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


Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the fire alarm system was observed.

BUILDING 06 HARTNELL AVENUE CLINIC

1. On 5/14/14, at 3:55 p.m., the facility's fire alarm system was equipped with one pull station that was located in a locked utility room. The utility room was located outside on the east side of the building. The facility failed to ensure that the pull station was installed so that it was readily accessible and visible.

During an interview on 5/14/14, at 4:02 p.m., Clinical Staff 1 stated that the pull station was located down the hallway from her desk. Additional interviews with the clinic staff were conducted and more than 50% of the staff, at the time of survey, were unable to locate the pull station. The building had been occupied for at least four months.

During an interview on 5/15/14, at 1:26 p.m., the Director of Outpatients Oncology stated it was a possibility that during and after treatments patients would not be able to rescue themselves in the event of an emergency.

Based on observation, the facility failed to maintain its fire alarm system. This was evidenced by batteries in the fire alarm panel and fire alarm panel components that were past due for replacement. This affected one of five offsite buildings and had the potential for fire alarm system failure.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
Table 7-3.2 Testing Frequencies
Item 6(d)(1) states that sealed-lead acid batteries are to be replaced every 4 years.

Findings:

During facility tour with Engineering Staff 3 from 5/13/14 to 5/15/14, the fire alarm system at Building 02 was observed.

BUILDING 02 MERCY FAMILY HEALTH CENTER -

1. On 5/14/14, at 2:40 p.m., the batteries in the fire alarm panel had a posted installation date of 9/2009, and the batteries in the dialer unit had a posted dated of 9/2009. These sealed-lead acid batteries were due to be replaced by September 2013.

BUILDING 05 PRE-OPERATIVE CLINIC

3. On 5/14/14, at 1:10 p.m., the facility failed to provide documents to show that sensitivity testing was conducted for five of five smoke detectors at this clinic.

On 5/15/14, at 3:20 p.m., Engineering Staff 1 confirmed that there were no records of sensitivity testing for these smoke detectors.

Based on record review and interview, the facility failed to ensure that the smoke detectors were maintained in reliable operating conditions. This was evidenced by an absence of records for sensitivity testing of hard-wired smoke detectors at two offsite clinics and an absence of records for testing of the single-station smoke detectors at one offsite location. This affected three of five offsite clinics and could result in a delay in notification to staff and patients, in the event of a fire.
NFPA 101, Life Safety Code 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment system , condition, arrangement, level of protection or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 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.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully
retested, device abandoned in place)

Findings:
During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the smoke detector maintenance records were requested.
.
BUILDING 03 MERCY MATERNITY CLINIC -
This clinic was equipped throughout with single station smoke detectors.
1. On 5/15/14 at 3:20 p.m., there were no records of weekly testing of the smoke detectors as recommended by the manufacturer's guidelines and there were no records of when the batteries in the detectors had been changed.
Engineering Staff 1 confirmed there were no documents of weekly testing and the frequency of battery replacement for these smoke detectors.

BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC
2. On 5/15/14, at 10:20 a.m., Engineering Staff 3 failed to provide records of smoke detector sensitivity testing at this clinic.
During an interview at 3:20 p.m., Engineering Staff 1 confirmed that no smoke detector sensitivity testing had been conducted.

Based on observation and interview, the facility failed to ensure that sprinkler system valves were supervised. This was evidenced by two Post Indicating Valves (PIV) that were not supervised by tamper switches. This affected 6 of 6 floors at the main hospital and could result in a delay in extinguishing a fire in the event the valves are closed.
NFPA 101, Life Safety Code, 2000 Edition.
9.7.2 Supervision.
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
NFPA 72, National Fire Alarm Code, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.
Findings:
During a facility tour with Engineering Staff 1 from 5/13/14 to 5/15/14, the sprinkler system control valves were observed.
.
BUILDING 01 MAIN HOSPITAL
1. On 5/14/14, at 12:02 p.m., the PIV located outside the front entrance of McAuley Hall (Administrative Building) was not equipped with supervisory switches. The PIV was locked in the open position, but it was not supervised by a system that would activate at least a local alarm if the valve was closed.
2. On 5/14/14, at 12:05 p.m., the PIV located outside the East Wing of the Main Hospital building was not equipped with a tamper alarm. The PIV was locked in the open position, but it was not supervised by a system that would activate at least a local alarm if the valve was closed.
During an interview at 12:05 p.m., Engineering Staff 1 stated that the system was old and he was granted justification not to install the PIVs with tamper switch by the Department. During survey and at the time of Exit Conference on 5/15/14, Engineering Staff 1 failed to produce documents that showed that the facility was given justifications for not installing the PIVs with tamper alarms.

Based on observation, record review, and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by incomplete testing records, by no repair records for sprinkler systems that failed vendor inspections, by missing escutcheon rings and sprinkler cover caps, by sprinkler heads that were not free of foreign materials, and by not maintaining the minimum required clearance below the sprinkler deflectors. Sprinkler heads were listed to respond to a calculated ceiling temperature. Escutcheon and cover fittings were part of the listed sprinkler assembly and a missing escutcheon fitting could allow heat and smoke to affect other areas in the building. This affected six of six floors in the main hospital and three of three sprinklered offsite buildings. This could result in a delay in extinguishing a fire.


NFPA 101, Life Safety Code, 2000 Edition
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

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

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


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.3.4 Minimum Distance Between Sprinklers. A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated the section for each type or style of sprinkler.

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1:Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.1 The provision of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of water flow at the alarm initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the sprinkler system was observed.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 10:44 a.m., records indicated that annual testing of the sprinkler system was conducted by a vendor on 3/8/14. There were Inspection, Testing, and Maintenance forms for each of the 15 risers at the facility. The Deficiencies and Comments sections from the forms indicated that Risers 2, 3, 13, 14, and 15 required repairs and that these risers failed inspection.
On 5/15/14, at 11:10 a.m., staff provided documentation indicating that Risers 13, 14, and 15 passed the inspection.

There were no records indicating that the deficiencies were repaired for Risers 2 and 3.

During an interview at 11:21 a.m., on 5/15/14, Engineering Staff 1 stated that the deficiencies listed by the vendor during the annual testing for Risers 2 and 3 had not yet been repaired.

2. On 5/13/14, at 1:54 p.m., records indicated that the five-year testing of the sprinkler system was conducted by a vendor on 3/8/11. There were Inspection, Testing, and Maintenance forms for each of the 15 risers at the facility. The Deficiencies and Comments sections from the forms indicated that Risers 1, 3, 6, 8, 10, 11 and 15 required repairs and that these risers failed inspection.
On 5/15/14, at 11:03 a.m., staff provided documentation indicating that all risers passed the five-year inspection except for Risers 3 and 6.

There were no records indicating that the deficiencies were repaired for Risers 3 and 6.

3. On 5/13/14, at 2:35 p.m., the testing records of the backflow prevention assemblies were requested. The vendor that conducted the annual test indicated that the backflow prevention device was "tested by others."
During an interview on 5/15/14 at 1:43 p.m., Engineering Staff 1 stated that the backflow prevention testing was not conducted, and that the facility hired a vendor to conduct the testing today (5/15/14).

The facility failed to conduct annual tests on the backflow prevention devices.

LOWER LEVEL 2 -

4. On 5/13/14, at 4:04 p.m., the concealed pendant sprinkler head in the telephone room (Door 2534) was missing a cover.


LOWER LEVEL -

5. On 5/14/14, at 4:49 p.m., the concealed pendant sprinkler head in the south corner of Auditorium B was missing a cover.


29566

FOURTH FLOOR -

6. On 5/13/14, at 3:40 p.m., in the Rapid Development Unit, supply items stored on the top of the clean supply shelves obstructed the dispersion patterns of two sprinkler heads. The supply items were positioned approximately 12 inches below the sprinkler deflectors.
THIRD FLOOR -


7. On 5/14/14, at 9:30 a.m., the Inspector's Test Valve (ITV) in the Mechanical Room was tested during fire alarm system testing. The fire alarm system notification devices activated 105 seconds after the ITV was opened. The ITV failed to activate within 90 seconds as required.

FIRST FLOOR -

8. On 5/14/14, at 10:58 a.m., access to a main sprinkler riser in the East Utility Room was blocked by six patient walkers and other items stored against the riser.

LOWER LEVEL -

9. On 5/15/14, at 9:10 a.m., dispersion patterns of two of six sprinkler heads in the kitchen pantry were obstructed by boxes of supplies on the top shelves. The boxes of supplies were stored less than 18 inches below the sprinkler deflector.

10. On 5/15/14, at 9:12 a.m., a sprinkler fusible link and deflector in the kitchen pantry were laden with debris.

11. On 5/15/14, at 9:17 a.m., two of two sprinkler heads in the walk-in freezer had a build up of debris on the bulbs and deflectors.

BUILDING 02 MERCY FAMILY HEALTH CENTER -

12. On 5/15/14, at 11:25 a.m., the annual sprinkler inspection and test dated 3/24/14 stated that the sprinkler system failed the annual test because there were two sprinkler heads within six feet of each other. The facility failed to provide documentation indicating that the repairs were made and if the system passed inspection.
During an interview with Engineering Staff 1 at 11:30 a.m., he stated that the corrections were not done.


BUILDING 04 MERCY WOUNDCARE HYPERBARIC CLINIC

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

13. On 5/13/14, at 1:40 p.m., there were no records provided for a five year sprinkler system inspection and testing.
During an interview at 2:12 p.m., Engineering Staff 1 confirmed that there were no records of a five year sprinkler system inspection and testing.


BUILDING 06 ONCOLOGY SUITE

14. On 5/14/14, at 3:54 p.m., in the storage room, there were boxes of supplies on the top shelf blocking the dispersion pattern of one sprinkler head. The boxes of supplies were positioned less than 18 inches below the sprinkler deflector.

15. On 5/15/14, at 2:11 p.m., there were no records of a 5-year inspection and annual inspection conducted for the Hartnell Ave Clinic's sprinkler system.

During an interview with Engineering Staff 1, he stated that the sprinkler system testing was not done before or after the opening of the Oncology Suite.

During an interview on 5/14/14, at 4:12 p.m., the Director of Outpatient Services in Suite A (Oncology) stated that the renovation of Hartnell Avenue Clinic started in the summer of 2013 and was open to the public approximately four months ago.

Based on observation, the facility failed to maintain its fire extinguishers. This was evidenced by one fire extinguisher that was found unsecured on the floor and by one fire extinguisher that was mounted more than five feet above the ground. This affected two of six floors in the main hospital and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the fire extinguishers were observed.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR -

1. On 5/14/14, at 11:25 a.m., the fire extinguisher in Operating Room 9 was mounted so that the top of the extinguisher measured at approximately 6 feet 4 inches from the ground.

LOWER LEVEL -

2. On 5/15/14, at 8:56 a.m., there was a fire extinguisher unsecured on the floor of the Main Server/Data Room.

Based on record review, the facility failed to maintain its fire dampers. This was evidenced by the failure to provide documentation of repairs of deficiencies noted by a vendor during an inspection. This affected six of six floors at the main hospital and could result in the spread of smoke and fire through the HVAC system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.
3-4.7 Maintenance. At least every 4 years, fusible links(where applicable shall be removed; all dampers shall be operated to verify that they close fully; the latch if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

BUILDING 01 MAIN HOSPITAL

During record review with Engineering Staff 1 from 5/13/14 to 5/15/14, the dampers inspection and testing records were requested.

1. On 5/13/14, at 1:10 p.m., records showed that 87 dampers were tested on 7/15/10 by a vendor. Per the legend on the vendor's report, "B= bad," and 49 dampers were marked with the letter B. The facility provided quotes from the vendor on repairs to be made and handwritten notes on the inspection record of repairs made. They failed to provide supporting documents of repairs such as location of the dampers repaired, date the repairs were made, and initials or signature of the person(s) who made the repairs. Repairs of the dampers that failed the vendor inspection in 2010 could not be confirmed by the documentation provided.

Based on observation, the facility failed to maintain its cooking equipment as evidenced by grease-laden deposits on the sprinkler pipes in the hood. This affected one of six floors in the main hospital and could result in the increased risk of a grease fire.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1

Type or Volume of Cooking Frequency

Systems serving high-volume cooking operations such as
24-hour cooking, charbroiling or wok cooking. Quarterly
Findings:

During a tour of the facility with the Engineer Staff 3 from 5/13/14 to 5/15/14, the patient services kitchen stove was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL -

1. On 5/15/14, at 9:24 a.m., inside the stove exhaust hood, there was a build up of grease and debris on the sprinkler pipes and fusible links in the hood behind the hood filters.

Based on observation, the facility failed to maintain its medical gas storage locations. This was evidenced by oxygen cylinders stored less than five feet away from an electrical fixture electrical circuit panel of the Heli-pad, by oxygen cylinders that were not secured, and by oxygen cylinders that were less than five feet away from combustible materials. This affected two of six floors in the main hospital and could potentially cause a hazard.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

8-3.1.1 Cylinders and containers shall comply with 4-3.1.1.1(a).
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Findings:
During a facility tour with staff from 5/13/14 to 5/15/14, the medical gas cylinders were observed.
BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -
1. On 5/14/14, at 10:13 a.m., there were six oxygen E-cylinders, loosely held together with one chain, in the helipad electrical room. The cylinders were not secured.
2. On 5/14/14, at 10:14 a.m., there were eight oxygen E-cylinders and one nitrogen cylinder stored less than five feet away from the main electrical circuit panel of the helipad electrical room.


29665


BUILDING 01 MAIN HOSPITAL

FIRST FLOOR -

3. On 5/14/14, at 3:26 p.m., there were four oxygen cylinders unsecured on the floor of the storage room outside the ambulance entrance of the Emergency Department.

LOWER LEVEL -

4. On 5/15/14, at 9:49 a.m., there were 18 oxygen H-cylinders stored less than one foot away from cardboard boxes in the med gas storage area outside Endoscopy. The medical gas storage area was directly adjacent to a Storage Supply/Staging Area that contained more than one hundred cardboard boxes of supplies. The facility did not maintain a minimum five foot clearance away from combustibles.

Based on observation, the facility failed to maintain its piped-in medical gas system. This was evidenced by one shut-off valve that was obstructed and was missing a cover. This was also evidenced by incomplete documentation of repairs of deficiencies noted during a vendor's inspection of the system. This affected six of six floors in the main hospital and could cause a potentially hazardous situation and increased risk of a 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.
(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.

4-3.4.1.1 General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, installation, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.

4-3.5.2.3 Patient Gas Systems-Level 1.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning and records of the test shall be maintained until the next test.

4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.


Findings:

During record review and a facility tour with Engineering Staff 1 and Engineering Staff 3 from 5/13/14 to 5/15/14, the piped-in medical gas system was observed and maintenance records were reviewed.

BUILDING 01 MAIN HOSPITAL

1. On 5/13/14, at 9:40 a.m., the piped-in medical gas inspection report dated 12/12/13 listed the following deficiencies:

"a. HR Exam Room 4 outage leakage.
b. Emergency Trauma 2 wall vacuum system needed extended barrel 7 rough in assemble.
c. Room 231 vacuum system reduced flow/no flow.
d. Manifold Room Ventilation- CSOR ventilation from medical gas closet turned off needs to be checked by HVAC technician.
e. First floor east Radiology: N2O system -gauge accuracy -C and status -C
f. Third floor west Surgical ICU/CSOR: vacuum system gauge accuracy-C and status -C."

Per the vendor's legend printed on the report, C stands for "Compliance Action Required."

During an interview with Engineering Staff 1 at 9:30 a.m., he stated that the repairs were done in 2/14.

On 5/15/14, Engineering Staff produced both estimates and final work done records from vendor.
The records provided failed to identified repairs for the Manifold Room Ventilation, 1st floor Radiology East, and 3rd floor Surgical ICU/CSOR West.

The vender report dated 2/26/14:
"a.Vacuum inlet in Trauma 2 rough in is located too deep in wall for finish assy barrel to make a proper seal.
b.Outlet of ER exam Room 4 not repaired and 19 of 20 outlets repaired per report of 2/26/14
c. Room 231 not repaired due to other corrective action needed per e-mail report from vender on 5/13/14."

On 5/15/14, at 4: 14 p.m., the facility failed to provide complete documentation of repairs made on the discrepancies noted in the inspection report of 12/12/13.

2. On 5/15/14, at 9:02 a.m., in the kitchen pantry, the oxygen piped-in system shut-off valve was blocked by a rack with a soda fountain and soda containers.
The cover for the shut-off valve in the wall was displaced leaving the valve unprotected.

Based on record review and interview, the facility failed to maintain its anesthetizing locations. This was evidenced by relative humidity (RH) levels that fell below 20% at several anesthetizing locations without documentation of timely corrective actions. This was also evidenced by one room with incomplete humidity logs. The facility has elected to use a categorical waiver (S&C 13-25 as mentioned in the K000 tag) that allows facilities to maintain RH levels between 20% and 60% in accordance with NFPA 99, 2012 Edition. This affected two of six floors at the main hospital and could result in an increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

On April 19, 2013, the Center for Medicare & Medicaid Services (CMS) released a memorandum, Ref: S&C-13-25-LSC, regarding the requirements for maintaining relative humidity in anesthetizing locations.

Sections of the memorandum state:

B. Categorical Waiver for RH Levels in Anesthetizing Locations
The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent.

In light of NFPA's recent adoption of the ASHRAE Standard 170, as well as in response to industry feedback that the minimum 35 percent RH level is unduly burdensome, we are issuing via this memorandum a categorical waiver to permit hospitals and Critical Access Hospitals (CAHs) with new and existing ventilation systems supplying anesthetizing locations, as defined by the 1999 edition of NFPA 99, to operate with a RH level of ¿20 percent.

C. Waiver Does Not Apply If:
More stringent RH levels are required under State or local laws and regulations; or
The reduction of RH would negatively affect ventilation system performance.

D. Facilities Option to Elect to Use the Waiver
Facilities that elect to use the categorical waiver must document their decision to do so. If a hospital or CAH conforms to the above requirements, they will not need to apply in advance to CMS, nor will they need to wait until being cited for a deficiency in order to apply to use this waiver. At the entrance conference for any survey assessing LSC compliance, a facility that has elected to use this waiver must notify the survey team of this fact, as well as the fact that it meets the minimum RH standard of ¿20 percent. The facility must provide documentation of its prior election to apply the waiver option. The absence of such evidence provided at the start of a survey means that the facility may be issued a citation if not in conformance with the 2000 LSC edition. It is not acceptable for a healthcare facility to first notify surveyors of waiver election after a citation related to RH has been issued, except as part of a plan of correction in response to the citation.

E. Ongoing Requirements
Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital's or CAH's ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.

Findings:

During record review with staff from 5/13/14 to 5/15/14, the facility's policy on maintaining relative humidity at anesthetizing locations and the corresponding humidity logs were requested. A central monitoring system called TempTrak was used to monitor and log the RH levels at the hospital's anesthetizing locations. Logs of the RH levels at these areas were requested on 5/13/14 and were provided at noon on 5/15/14.

BUILDING 01 MAIN HOSPITAL

SECOND FLOOR SURGERY -

On 5/15/14, at 12:04 p.m., a graph of daily RH readings from the past six months was provided for each operating room on the second floor, ORs 1 through 9. The specific dates and times the RH fell out of range were recorded on a report called the TempTrak Sensor Alarm/Note Report. Per the TempTrak graphs for each room, the "Alarm Min" set for ORs 1 through 9 was 19% RH and the "Alarm Max" was set at 61%. During an interview, Engineering Staff 2 stated that the TempTrak system was set to alarm if the RH in the ORs fell out of the 20 to 60% range.


OPERATING ROOM 1 (OR1) -

Based on the TempTrak Sensor for OR 1, the RH fell below 20% during the following days:

1. On 3/17/14, at 6:30 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until on 3/20/14 at 6:21 a.m.

2. On 3/21/14, at 11:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until on 3/23/14 at 4:45 a.m.


OPERATING ROOM 2 (OR2) -

Based on the TempTrak Sensor for OR 2, the RH fell below 20% during the following days:

3. On 12/9/13, at 11:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until on 12/12/13 at 7:17 a.m.

4. On 1/5/14, at 7:30 a.m., the RH in the room was recorded as 9%, and the alarm was not cleared by engineering until 1/6/14 at 5:36 a.m.

5. On 1/6/14, at 8:00 a.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

6. On 2/1/14, at 4:30 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

7. On 3/18/14, at 9:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.

8. On 4/18/14, at 4:30 p.m., the RH in the room was recorded as 17 %, and the alarm was not cleared by engineering until 4/25/14 at 5:14 a.m.


OPERATING ROOM 4 (OR4) -

Based on the TempTrak Sensor for OR 4, the RH fell below 20% during the following days:

9. On 3/18/14, at 2:00 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.


OPERATING ROOM 8 (OR8) -

Based on the TempTrak Sensor for OR 8, the RH fell below 20% during the following days:

10. On 12/3/13, at 6:00 p.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 12/5/13 at 6:48 p.m.

11. On 12/9/13, at 11:30 a.m., the RH in the room was recorded as 14%, and the alarm was not cleared by engineering until 12/12/13 at 7:17 a.m.

12. On 12/30/13, at 7:30 a.m., the RH in the room was recorded as 16%, and the alarm was not cleared by engineering until 1/2/14 at 6:20 a.m.

13. On 1/6/14, at 6:00 a.m., the RH in the room was recorded as 16%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

14. On 1/31/14, at 10:00 p.m., the RH in the room was recorded as 17%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

15. On 3/18/14, at 9:30 a.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.


OPERATING ROOM 9 (OR9) -

Based on the TempTrak Sensor for OR 9, the RH fell below 20% during the following days:

16. On 1/6/14, at 6:00 a.m., the RH in the room was recorded as 14%, and the alarm was not cleared by engineering until 1/9/14 at 7:07 a.m.

17. On 2/1/14, at 6:30 a.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 2/6/14 at 6:56 a.m.

THIRD FLOOR OBSTETRIC SURGERY -

OB OR 1 -

Based on the TempTrak Sensor for OB OR 1, the RH fell below 20% during the following days:

18. On 3/21/14, at 2:30 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/23/14 at 4:46 a.m.

OB OR 2 -

Based on the TempTrak Sensor for OB OR 2, the RH fell below 20% during the following days:

19. On 3/17/14, at 2:30 p.m., the RH in the room was recorded as 18%, and the alarm was not cleared by engineering until 3/20/14 at 6:21 a.m.

20. On 4/18/14, at 5:30 p.m., the RH in the room was recorded as 19%, and the alarm was not cleared by engineering until 4/25/14 at 5:14 a.m.


THIRD FLOOR CARDIAC SURGERY -

21. On 5/15/14, at 2:40 p.m., the TempTrak Sensor History graph was provided for the Cardiac Surgery OR. The graph showed the RH levels in the room over the past six months. The legend of the graph showed that "Alarm Min" for this room was set at 0%, not at 19% like the other anesthetizing locations.
During an interview at 2:41 p.m., Engineering Staff 2 stated that the TempTrak system would not alarm when the RH fell below 20% in this room as long as the Alarm Min was set at 0%.

The graph indicated that RH levels fell below 20% in December 2013, January 2014, February 2014, and March 2014. The exact dates could not be determined because the TempTrak Sensor Alarm Report did not record humidity levels below 0% for this room.

Based on observation, the facility failed to ensure that openings in smoke barrier walls were sealed in accordance with NFPA 101. This affected three of six floors of the main hospital and could result in the spread of smoke and fire from one smoke compartment to another.

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

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the smoke barrier walls were inspected.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL 2 -

1. On 5/13/14, at 3:42 p.m., there was an approximately two inch unsealed conduit passing through the smoke barrier wall next to Elevator 1.
During an interview at 3:43 p.m., Engineering Staff 5 stated that the caulking that originally sealed the conduit had fallen out and he found the original caulking material above a ceiling tile in the attic space.

SECOND FLOOR -

2. On 5/14/14, at 10:00 a.m., there was an approximately one inch unsealed conduit passing through the smoke barrier wall next to Room 272 (2 West).





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LOWER LEVEL -

3. On 5/15/14, at 9:40 a.m., the soda machine in the cafeteria used hoses running from the machine to the ceiling back down to the floor in the cafeteria kitchen then to the kitchen pantry. The hoses ran through a conduit that measured approximately three inches at the floor entrance and the ceiling entrance. The conduit was sealed with non-fire rated foam at the floor entrance.

Based on observation, the facility failed to maintain its electrical wiring. This was evidenced by the use of extension cords and surge protectors in lieu of permanent wiring. This affected five of six floors in the main hospital and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 5/13/14 to 5/15/14, the electrical wiring was observed.

BUILDING 01 MAIN HOSPITAL

LOWER LEVEL 2 -

1. On 5/13/14, at 3:50 p.m., a coffee pot, microwave, refrigerator, and toaster were plugged into a six-plug surge protector in the Cancer Registry Office.


2. On 5/13/14, at 4:21 p.m., there was six-plug surge protector plugged into another six-plug surge protector in the former Linear Accelerator Room 2 (Door 2516).


THIRD FLOOR -

3. On 5/14/14, at 1:47 p.m., there was a medications refrigerator plugged into an extension cord at the 3 South Main Nurses Station.

FIRST FLOOR -

4. On 5/14/14, at 2:45 p.m., the procedure table in Radiology Room 5 (Speech Therapy Room) was plugged into a four-plug surge protector that was mounted on the wall behind the table.

5. On 5/14/14, at 2:47 p.m., there was a three-plug 40-foot extension cord anchored to the ceiling of the Nuclear Medicine Treatment Room. The extension cord was plugged into a duplex outlet in the ceiling.

LOWER LEVEL -

6. On 5/15/14, at 9:36 a.m., there was a six-plug surge protector plugged into a six-plug surge protector in the Point Care Testing Office.

7. On 5/15/14, at 10:30 a.m., there was a three-plug 30-foot extension cord anchored to the ceiling of the storage room (Door 1155) next to Sterile Processing. The extension cord was plugged into a duplex outlet in the ceiling.



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FOURTH FLOOR -

8. On 5/13/14, at 4:01 p.m., there were a microwave, a refrigerator, and a coffee maker plugged into a single multi-plug surge protector in the Trauma Services Office.