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Based on observation, the facility failed to keep exits clear of stored materials. Storage in exit access ways could impede the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.

Findings include:

On July 25-26, 2011 while on tour of the facility with facility staff, the horizontal exits connecting the hospital to the medical office building were observed to contain beds, carts furniture and other hospital equipment.

On July 25, 2011 at 2:40 PM while on tour of the facility with facility staff in the east end stair tower at the intermediate floor landings, "Paraslyde" evacuation sleds were observed hanging on the walls.

On July 26, 2011 at 9:50 AM while on tour of the facility with facility staff, at the medical office building horizontal exit connector a nurse stated that the computers on wheels (COWS) and filing cabinets at this area was the "cow corral." Four COWS and filing cabinets were observed in front of the horizontal exit doors.

"An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit..." NFPA 101(2000), 7.1.3.2.3 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof." NFPA 101(2000), 7.1.10.2.1; Horizontal exits per NFPA 101(2000) 7.2.4 and 19.2.2.5

Based on observations and records review, the facility failed to maintain their fire alarm system in accordance with NFPA 72.

Findings:

On July 26, 2011 at 2:00 PM while on tour of the facility with facility staff, the fire alarm panel was observed to have a supervisory trouble signal. The signal indicated an initiating device (smoke detector) in the lab. The device could not be located in the lab because none of the devices had identifiers. Staff then made an unsuccessful attempt to clear the trouble code.

Fire alarm panel, initiation and detection devices are required to insure reliable performance of the system. Failure of the system or its components could result in the delayed notification of the occupants and fire and rescue personnel. NFPA 72 (1999) 7-3.1, 7-3.2

Based on observation with facility staff, the facility failed to provide electronic supervised monitoring of sprinkler control valves devices in accordance with NFPA 72 and NFPA 25.
Findings include:
On July 26, 2011 at 2:30 PM while on tour of the facility with facility staff, the sprinkler water supply at the fire pump room was located. Staff was asked to close the OS & Y main sprinkler control valve to perform a supervisory test of the valve tamper switch. At two revolutions of the valve wheel the alarm panel was observed and no supervisory signal had been received at the panel. A second valve was tested in the same manner and no signal was sent to the fire alarm panel. A remote monitor in the facilities operations office failed to indicate a supervisory trouble signal. NFPA 72(1999) 2-9.1.1

Based on a review of the facility records, and observations made during tour of the facility, it was determined that automatic sprinkler system was not installed in accordance with NFPA 13, or maintained and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:

On July 25, 2011 at 1:12 PM while on tour of the facility with facility staff, it was observed that a pendant type sprinkler head in the penthouse had been installed in the upright position. The use of this head in the upright position would not provide the spray pattern intended for an upright type head. This situation could cause failure or delayed activation of the head under the presence of heat thus delaying or preventing control of a fire.

NFPA 25 (2002 Edition) Inspection, Testing and Maintenance of Water-Based Fire Protection Systems: 5.2.1.1.1.: "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage; and shall be installed in the proper orientation."

Based on observations during tour of the facility, and record review, it was determined that the facility failed to install or maintain the required portable fire extinguishers in accordance with NFPA 101 (2000) Life Safety Code and NFPA 10 (1999) Standard for Portable Fire Extinguishers. Non-compliance with standards for fire extinguishers could delay or deny extinguishment of fires in the incipient stage.

Findings include:

On July 25-26, 2011, fire extinguishers in the following areas were found to have expired "Verification of Service"collars; the second floor electric equipment room and the first floor elevator equipment room.

"Every six years, stored pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures" and "each extinguisher that has undergone maintenance...shall have a verification of service collar around the neck of the container. The collar shall contain a single circular piece of uninterrupted material that will not permit the collar to move over the neck of the container..." NFPA 10 (1999) 6.3.3; 6.3.4.2

Based on observation the facility failed to maintain storage of compressed gasses in accordance with NFPA 99, Standard for Health Care Facilities.
Findings include:
On July 25, 2011 at 1:35 PM while on tour of the facility with facility staff in the Emergency Department across from the nurses station, (17) e-sized oxygen tanks were observed.
On July 26, 2011 at 9:12 AM while on tour of the facility with facility staff on the fourth floor clean utility room oxygen cylinders were observed stored. The door to the room was not locked and the room was not identified as containing oxidizing gasses.
On July 26, 2011 at 9:45 AM while on tour of the facility with facility staff on the third floor clean utility room oxygen cylinders were observed stored. The room was not identified as containing oxidizing gasses.
"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." NFPA 99 (2005) 9.4.2.1; "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1)A minimum distance of 6.1 m (20 ft), (2)A minimum distance of 1.5 m (5 ft) 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, (3)An enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour. NFPA 99 (2005) 9.4.2.3 Rooms used for storing oxygen cylinders shall be identified with a sign to include the following wording as a minimum; " CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING " NFPA 99 (2005) 9.4.4.2

Based on observation, the facility failed to maintain battery back-up emergency lighting in a generator transfer switch room.

Findings include:

On July 25, 2011 while on tour of the facility with facility staff on the first floor, a transfer switch room for the generator an elevator equipment was observed. The room did not have battery back-up emergency lighting. Emergency lighting is required in the event of a simultaneous failure of the public utility and the emergency generator. NFPA 99 (2005) 4.4.2.2.2.2 (5)

Based on observation, the facility failed to keep exits clear of stored materials. Storage in exit access ways could impede the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.

Findings include:

On July 25-26, 2011 while on tour of the facility with facility staff, the horizontal exits connecting the hospital to the medical office building were observed to contain beds, carts furniture and other hospital equipment.

On July 25, 2011 at 2:40 PM while on tour of the facility with facility staff in the east end stair tower at the intermediate floor landings, "Paraslyde" evacuation sleds were observed hanging on the walls.

On July 26, 2011 at 9:50 AM while on tour of the facility with facility staff, at the medical office building horizontal exit connector a nurse stated that the computers on wheels (COWS) and filing cabinets at this area was the "cow corral." Four COWS and filing cabinets were observed in front of the horizontal exit doors.

"An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit..." NFPA 101(2000), 7.1.3.2.3 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof." NFPA 101(2000), 7.1.10.2.1; Horizontal exits per NFPA 101(2000) 7.2.4 and 19.2.2.5

Based on observations and records review, the facility failed to maintain their fire alarm system in accordance with NFPA 72.

Findings:

On July 26, 2011 at 2:00 PM while on tour of the facility with facility staff, the fire alarm panel was observed to have a supervisory trouble signal. The signal indicated an initiating device (smoke detector) in the lab. The device could not be located in the lab because none of the devices had identifiers. Staff then made an unsuccessful attempt to clear the trouble code.

Fire alarm panel, initiation and detection devices are required to insure reliable performance of the system. Failure of the system or its components could result in the delayed notification of the occupants and fire and rescue personnel. NFPA 72 (1999) 7-3.1, 7-3.2

Based on observation with facility staff, the facility failed to provide electronic supervised monitoring of sprinkler control valves devices in accordance with NFPA 72 and NFPA 25.
Findings include:
On July 26, 2011 at 2:30 PM while on tour of the facility with facility staff, the sprinkler water supply at the fire pump room was located. Staff was asked to close the OS & Y main sprinkler control valve to perform a supervisory test of the valve tamper switch. At two revolutions of the valve wheel the alarm panel was observed and no supervisory signal had been received at the panel. A second valve was tested in the same manner and no signal was sent to the fire alarm panel. A remote monitor in the facilities operations office failed to indicate a supervisory trouble signal. NFPA 72(1999) 2-9.1.1

Based on a review of the facility records, and observations made during tour of the facility, it was determined that automatic sprinkler system was not installed in accordance with NFPA 13, or maintained and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:

On July 25, 2011 at 1:12 PM while on tour of the facility with facility staff, it was observed that a pendant type sprinkler head in the penthouse had been installed in the upright position. The use of this head in the upright position would not provide the spray pattern intended for an upright type head. This situation could cause failure or delayed activation of the head under the presence of heat thus delaying or preventing control of a fire.

NFPA 25 (2002 Edition) Inspection, Testing and Maintenance of Water-Based Fire Protection Systems: 5.2.1.1.1.: "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage; and shall be installed in the proper orientation."

Based on observations during tour of the facility, and record review, it was determined that the facility failed to install or maintain the required portable fire extinguishers in accordance with NFPA 101 (2000) Life Safety Code and NFPA 10 (1999) Standard for Portable Fire Extinguishers. Non-compliance with standards for fire extinguishers could delay or deny extinguishment of fires in the incipient stage.

Findings include:

On July 25-26, 2011, fire extinguishers in the following areas were found to have expired "Verification of Service"collars; the second floor electric equipment room and the first floor elevator equipment room.

"Every six years, stored pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures" and "each extinguisher that has undergone maintenance...shall have a verification of service collar around the neck of the container. The collar shall contain a single circular piece of uninterrupted material that will not permit the collar to move over the neck of the container..." NFPA 10 (1999) 6.3.3; 6.3.4.2

Based on observation the facility failed to maintain storage of compressed gasses in accordance with NFPA 99, Standard for Health Care Facilities.
Findings include:
On July 25, 2011 at 1:35 PM while on tour of the facility with facility staff in the Emergency Department across from the nurses station, (17) e-sized oxygen tanks were observed.
On July 26, 2011 at 9:12 AM while on tour of the facility with facility staff on the fourth floor clean utility room oxygen cylinders were observed stored. The door to the room was not locked and the room was not identified as containing oxidizing gasses.
On July 26, 2011 at 9:45 AM while on tour of the facility with facility staff on the third floor clean utility room oxygen cylinders were observed stored. The room was not identified as containing oxidizing gasses.
"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." NFPA 99 (2005) 9.4.2.1; "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1)A minimum distance of 6.1 m (20 ft), (2)A minimum distance of 1.5 m (5 ft) 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, (3)An enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour. NFPA 99 (2005) 9.4.2.3 Rooms used for storing oxygen cylinders shall be identified with a sign to include the following wording as a minimum; " CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING " NFPA 99 (2005) 9.4.4.2

Based on observation, the facility failed to maintain battery back-up emergency lighting in a generator transfer switch room.

Findings include:

On July 25, 2011 while on tour of the facility with facility staff on the first floor, a transfer switch room for the generator an elevator equipment was observed. The room did not have battery back-up emergency lighting. Emergency lighting is required in the event of a simultaneous failure of the public utility and the emergency generator. NFPA 99 (2005) 4.4.2.2.2.2 (5)