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Based on observations and staff interviews during the facility tour with the maintenance director, the facility failed to prohibit storage in the exit stairwell. Storing materials in the exit stairwell allows the possibility of the exit becoming blocked in the event of a fire hazard.

The findings include:

During the facility tour with the maintenance director on 5/6/2014 at 10:00 am, it was found that there was a large trash can stored in the exit stairwell of the laboratory. NFPA 7.1.3.2.3* "An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit." An interview conducted with the nursing staff at that time and she confirmed the violations.

Based on observations and interview with the maintenance director during facility tour, the facility failed to maintain proper maintenance of the sprinkler system. Mixed sprinkler heads of standard and quick response in the same compartment could result in a delayed or premature response of the sprinkler system. This could affect everyone in the facility in an emergency situation.

The findings include:

During the facility tour with the Maintenance Director on 5/7/2014 at 11:00 am, it was found that the sprinkler heads in the soiled utility room on the 2nd floor Neonatal Intensive Care Unit (NICU) were a mix of quick and standard response sprinkler heads. An interview was conducted with the Maintenance Director during the observation at approximately 11:00 am. The Maintenance Director confirmed the findings.
Per NFPA 25 (1998) 2-2.1.1 "Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage." and NFPA 13 (1999) 5-3.1.5.2 " When existing light hazard systems are converted to use quick-response, all sprinklers in a compartmented space shall be changed."

Based on observations and interview with the maintenance director; during the tour of the facility, it was determined that the facility failed to maintain the kitchen hood system which would allow grease-latent vapors to build up in the seams resulting in a potential fire above the hood suppression system and endangering building occupants.
Findings include:
During the facility tour with the Maintenance Director on 5/6/2014 at 9:00 am, the kitchen hood system was observed to have caulk falling out, and or missing from the seams. " Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight " NFPA 96 (2008) 5.1.4

Based on observation and interview with the maintenance director, the facility failed to maintain proper storage and signage for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.

The findings include:

During the facility tour with the maintenance director on 5/7/2014 at 11:41 am, it was observed that 1) oxygen cylinders were left unsecured on base of beds in corridor of the 2nd floor Central Processing Department (CDP), 2) an unsecured free standing bottle in the TriMedix office, 3) soiled utility room in Pediatrics had medical gas stored with no signage, 4) clean utility had an unsecured bottle of medical gas (Nitrix), and 5) Operating room storage on 3rd floor had medical gas stored in a room with non-rated doors and locking device. Per NFPA 99 5.1.3.1.9, and NFPA 99 5.1.3.3.2(4)(5)(7)

Based on observations and interview with the maintenance director during facility tour, the facility failed to properly store flammables. Flammables not stored correctly can increase the chance of a hazardous situation and severely increase fire spread and heat release of the fire.

The findings include:

During the facility tour with the director of maintenance on 5/6/2014 at 11:02 am, it was found that chafing dish fuel was stored in the office of the distribution center manager. The flammables in the office were not contained in a flammable cabinet.

During the facility tour with the director of maintenance on 5/6/2014 at 11:13 am, it was found that Environmental Services was storing alcohol based hand sanitizer in excess of 10 gallons in a smoke compartment.

Per NFPA 30 - Flammable and Combustible Liquids Code

Based on observations and interview with the Maintenance Director while on tour of the facility, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:

During the facility tour with Maintenance Director on 5/6/2014 at 8:00 am, it was found that there were electrical strips and extension cords in use in: 1) Pharmacy - extension cord with power strip with refrigerator, 2) Endoscope lounge - extension cord with power strip with a microwave oven, toaster, and coffee maker plugged in, 3) HIM Outpatient (IT offices) - had power strip plugged into another power strip, 4) Distribution Center - extension cord with power strip, and power strip plugged into another power strip, Administration Offices - Mission Integration office had power strip plugged into another power strip, President / CEO office had extension cord with power strip. This is not in accordance with NFPA 1.

NFPA 1 - 11.1.5
Extension cords shall not be used as a substitute for permanent wiring

Based on observations and staff interviews during the facility tour with the maintenance director, the facility failed to prohibit storage in the exit stairwell. Storing materials in the exit stairwell allows the possibility of the exit becoming blocked in the event of a fire hazard.

The findings include:

During the facility tour with the maintenance director on 5/6/2014 at 10:00 am, it was found that there was a large trash can stored in the exit stairwell of the laboratory. NFPA 7.1.3.2.3* "An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit." An interview conducted with the nursing staff at that time and she confirmed the violations.

Based on observations and interview with the maintenance director during facility tour, the facility failed to maintain proper maintenance of the sprinkler system. Mixed sprinkler heads of standard and quick response in the same compartment could result in a delayed or premature response of the sprinkler system. This could affect everyone in the facility in an emergency situation.

The findings include:

During the facility tour with the Maintenance Director on 5/7/2014 at 11:00 am, it was found that the sprinkler heads in the soiled utility room on the 2nd floor Neonatal Intensive Care Unit (NICU) were a mix of quick and standard response sprinkler heads. An interview was conducted with the Maintenance Director during the observation at approximately 11:00 am. The Maintenance Director confirmed the findings.
Per NFPA 25 (1998) 2-2.1.1 "Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage." and NFPA 13 (1999) 5-3.1.5.2 " When existing light hazard systems are converted to use quick-response, all sprinklers in a compartmented space shall be changed."

Based on observations and interview with the maintenance director; during the tour of the facility, it was determined that the facility failed to maintain the kitchen hood system which would allow grease-latent vapors to build up in the seams resulting in a potential fire above the hood suppression system and endangering building occupants.
Findings include:
During the facility tour with the Maintenance Director on 5/6/2014 at 9:00 am, the kitchen hood system was observed to have caulk falling out, and or missing from the seams. " Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight " NFPA 96 (2008) 5.1.4

Based on observation and interview with the maintenance director, the facility failed to maintain proper storage and signage for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.

The findings include:

During the facility tour with the maintenance director on 5/7/2014 at 11:41 am, it was observed that 1) oxygen cylinders were left unsecured on base of beds in corridor of the 2nd floor Central Processing Department (CDP), 2) an unsecured free standing bottle in the TriMedix office, 3) soiled utility room in Pediatrics had medical gas stored with no signage, 4) clean utility had an unsecured bottle of medical gas (Nitrix), and 5) Operating room storage on 3rd floor had medical gas stored in a room with non-rated doors and locking device. Per NFPA 99 5.1.3.1.9, and NFPA 99 5.1.3.3.2(4)(5)(7)

Based on observations and interview with the maintenance director during facility tour, the facility failed to properly store flammables. Flammables not stored correctly can increase the chance of a hazardous situation and severely increase fire spread and heat release of the fire.

The findings include:

During the facility tour with the director of maintenance on 5/6/2014 at 11:02 am, it was found that chafing dish fuel was stored in the office of the distribution center manager. The flammables in the office were not contained in a flammable cabinet.

During the facility tour with the director of maintenance on 5/6/2014 at 11:13 am, it was found that Environmental Services was storing alcohol based hand sanitizer in excess of 10 gallons in a smoke compartment.

Per NFPA 30 - Flammable and Combustible Liquids Code

Based on observations and interview with the Maintenance Director while on tour of the facility, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:

During the facility tour with Maintenance Director on 5/6/2014 at 8:00 am, it was found that there were electrical strips and extension cords in use in: 1) Pharmacy - extension cord with power strip with refrigerator, 2) Endoscope lounge - extension cord with power strip with a microwave oven, toaster, and coffee maker plugged in, 3) HIM Outpatient (IT offices) - had power strip plugged into another power strip, 4) Distribution Center - extension cord with power strip, and power strip plugged into another power strip, Administration Offices - Mission Integration office had power strip plugged into another power strip, President / CEO office had extension cord with power strip. This is not in accordance with NFPA 1.

NFPA 1 - 11.1.5
Extension cords shall not be used as a substitute for permanent wiring