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Based on observation and interview, the facility failed to maintain their building construction as evidenced by unsealed penetrations in two walls. This could potentially allow the migration of smoke and cause harm to patients.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, the construction was observed.

Building 1 Douglas Hospital February 21, 2012:
At 9:41 a.m., there was an approximate 2 foot by 18 inch air conditioning duct with an approximate 1/4 inch unsealed penetration around the edges of the duct and the wall in Room 7802. Staff Manager 1 acknowledged the finding and said that he will look into why it is that way.

At 9:53 a.m., there was an approximate 2 foot by 18 inch air conditioning duct with an approximate ½ inch unsealed penetration around the edges of the duct and the wall in Room 7803 (Electrical Room). Staff Manager 1 acknowledged the finding.


February 22, 2012
At 1:59 p.m., the Inspector of Record (IOR) stated during an interview " the ducts need to be sealed. That was part of the construction project for the Douglas building. "

Based on observation and interview, the facility failed to maintain the corridor doors as evidenced by doors that were obstructed from closing, doors that failed to release from the magnetic holding devices, and doors that failed to positive latch. This would allow the migration of smoke and or fire and cause potential harm to patients and staff. This affected 5 of 12 buildings.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, Fire Marshall, Safety Officer, Engineer 2, Compliance Officer, and Assistant Director on February 21, 2012, through February 24, 2012, the corridor doors were observed and tested.

Building 1A University Hospital Tower February 22, 2012:

At 8:27 a.m., the corridor door to Shower room 3313 was observed to be partially open and obstructed from fully closing by plastic bags filled with trash. The room is used for storing trash and soiled linen and the door is equipped with a self-closure device. The plastic trash bags were arranged so that the door was no longer obstructed and the door latched upon self- closure.

At 8:35 a.m., the corridor door to Patient room 3241 was obstructed from closure by a trash can. Engineer 2 removed the trash can and the door latched.

At 8:38 a.m., the corridor door to Patient room 3243 was obstructed from closure by a trash can. Engineer 2 removed the trash can and the door latched.

At 8:45 a.m., the corridor door to Shower room 3313, was again observed to be partially open, a gray soiled linen bin was impeding the door from fully closing. The plastic trash bags and the soiled linen bin were arranged so that the gray soiled linen bin was no longer impeding the corridor door from self-closure. This was acknowledged by the Safety Officer, Compliance Officer and Assistant Director.

At 9:00 a.m., the corridor door to Patient room 2229, failed to latch upon closure.

At 9:30 a.m., the Construction door located on the first floor link near the Elevator Lobby failed to latch when manually closed. The door hit the side of the door frame and could not be closed. This was acknowledged by the Safety Officer, Compliance Officer and Assistant Director.



26387

Building 1 Douglas Hospital February 21, 2012:

At 3:11 p.m., there was a door to Room 1264 (identified as Equipment Room) that was obstructed from closing with a tan colored rubber wedge under the bottom portion of the door. Engineer 1 removed the rubber wedge upon discovery.

Building 1 Douglas Hospital February 22, 2012:

At 12:25 p.m., there was a North Leaf door equipped with a self-closure device (identified as 5800B) that failed to positive latch when tested. The Fire Marshall acknowledged the finding.

Building 3 Neuropsychiatric Center February 23, 2012:

At 10:38 a.m., there was a door Room 359 (North) that was obstructed from closure with a ping pong table in front of the door path. The Fire Marshall acknowledged the finding and moved the ping pong table.

At 1:23 p.m., there was a door to Dining Room 1 North that failed to latch when tested. Engineer 1 stated " the door coordinator is off sequence, causing one door to close before the other. " The Fire Marshall acknowledged the finding.

Building 23 Chao Family Comprehensive Cancer Center February 23, 2012:

At 4:00 p.m., there was a door to Room 112 (identified as the waiting Room) that was obstructed from closure with a chair placed in front of the door.

At 4:02 p.m., RN 1 was interviewed and stated " the door is propped open with a chair daily because patients complain that the room is too warm. "

Building 22B Nikken Center February 24, 2012:

At 9:10 a.m., the corridor door to Room 116A, was obstructed from closure with a step stool in front of the door. During an interview, at 9:12 a.m., Staff 1 stated " the door is propped open every day because the medical equipment heats up and I must leave the door open to vent out the hot air. "

Based on observation and interview, the facility failed to maintain the stairway enclosure doors as evidenced by a door that failed to latch. This would allow the migration of smoke and or fire and cause potential harm to patients and staff during a fire emergency evacuation. This affected 1 of 12 buildings.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, the stairway doors were observed.

Building 1 Douglas Hospital February 21, 2012:
At 1:32 p.m., there was a stairway door that was identified as 3891.1 near Room 3892-1 that failed to latch. The latching mechanism was stuck open. The State Fire Marshall acknowledged the finding.

Based on observation and interview, the facility failed to maintain doors on magnetic holding devices to release and latch upon activation of the fire alarm system devices as evidenced by doors that failed to release in 1 of 7 floors in Building 1 (Douglas Hospital) and 1 of 4 floors in the Chao Family Cancer Center. This failure could result in the migration of smoke and fire, in the event of a fire causing potential harm to patients.

Findings:

During the testing of the fire alarm system with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, through February 24, 2012, the doors were observed.

Building 1 Douglas Hospital February 22, 2012:
From 8:39 a.m. to 9:54a.m., during the testing of the fire alarm devices on the 7th floor the following doors failed to release from their magnetic hold-open devices in the following locations:
1. Doors Near Room 7622
2. Door 7400A
3. Doors Near Room 7100C3
4. Doors Near Room 76001A
5. Door 7400A-2
6. Door near Room 7611

At 9:50 a.m., Staff Manager 1 and Fire Marshall were interviewed and Staff Manager 1 stated " It is a programming error and I will call Simplex". The facility initiated a fire watch.

At 5:10 p.m., on February 22, 2012, fire alarm activation devices on the 7th floor were re-tested and all of the smoke barrier doors released and closed upon activation of the fire alarm system. The facility ceased the fire watch.


Building 23 Chao Family Comprehensive Cancer Center February 23, 2012:

At 4:35 p.m., the corridor door to Room 148, failed to release from the magnetic holding device when tested. Engineer 1 acknowledged the finding.

Based on observation, the facility failed to display exits signs in all egress paths as evidenced by no Exit sign displayed in 1 of 12 Buildings. This could delay egress and cause potential harm to patients and staff in the event of a fire emergency.

Findings:

During a tour of the facility with Engineer 1 and State Fire Marshall on February 23-24, 2012, the egress paths and exit signs were observed.

Building Gottschalk Medical Plaza February 24, 2012:

At 10:24 a.m., there was no exit sign in the egress path from Room 2222 on the second floor. The Fire Marshall acknowledged the finding.

Based on observation, the facility failed to maintain their smoke barrier walls as evidenced by a penetration in a smoke barrier wall. This affected 1 of 7 floors in Building 1. This could result in the spread of smoke and fire, in the event of a fire and cause potential harm to patients.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 tour of the facility with the Fire Marshall, Engineer 1, and Staff Manager 1 on February 21, 2012, the smoke barrier walls were observed.

Building 1 Douglas Hospital February 21, 2012:
At 11:08 a.m., there was an approximately 3/4 inch unsealed penetration with a ¼ inch antenna wire coming through the hole at the separation suite identified as 7200A. Engineer 1 acknowledged the finding and described the wire as an antenna wire.

Based on observation and interview, the facility failed to maintain their smoke barriers as evidenced by smoke barrier doors that failed to latch upon activation of the fire alarm system as evidenced by doors that failed to latch upon release from the magnetic holding devices. This affected 3 of 12 buildings and could result in the migration of smoke and fire, in the event of a fire causing potential harm to patients.

Findings:

During fire alarm testing with Engineer 1, Staff Manager 1 and Fire Marshall on February 22, 2012, through February 24, 2012, the smoke barrier doors were tested and observed and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 10:55 a.m., there was a Right Leaf smoke barrier door that was identified as 6200A (West Door), which failed to positive latch when tested. Engineer 1 acknowledged the finding.

At 12:42 p.m., there was an east smoke barrier door identified as 5400ES that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 12:43 p.m., there was a south smoke barrier door identified as 5400D that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 12:54 p.m., there was a west smoke barrier door identified as 7400C-3 that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 1:23 p.m., there was an east smoke barrier door near Room 4429 and identified as 4400F.1 that failed to latch when tested. The Fire Marshall acknowledged the finding.

Building 1A University Hospital Tower February 23, 2012:

At 10:41 a.m., there was a won smoke barrier door that failed to close when tested near Nursing Station 3 South (338). The Fire Marshall acknowledged the finding.

Building 22C Diagnostic Services Center February 23, 2012:

At 4:23 p.m., there was smoke barrier door near Room 119 and identified as door number FSDZ2C010119 that failed to latch when tested. The Fire Marshall acknowledged the finding and stated "the electronic latching mechanism was not latching."

Based on observation, and interview, the facility failed to maintain the integrity of the fire alarm system. This was evidenced by the failure of audible and visual devices, and by failure to maintain alarm activation devices for immediate access. This would delay notification and could result in the potential failure of the fire alarm system to notify occupants of a fire or other emergency in the facility and affected 3 of 12 buildings.

NFPA 72, National Fire Alarm Code (1999 Edition)
1-5.4.2 Alarm Signals.
1-5.4.2.1* Coded Alarm Signals. A coded alarm signal shall consist of not less than three complete rounds of the number transmitted. Each round shall consist of not less than three impulses.
1-5.4.2.2* Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

2-8.2 Location and Spacing.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturers recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Findings:

During a tour of the facility with the Fire Marshall, Engineer 1, and Staff Manager 1 on February 21, through February 24, 2012, the fire alarm system components were observed, tested, and staff personnel were interviewed.

Building 1 Douglas Hospital February 21, 2012:

At 2:52 p.m., on the first floor Infusion Center there was a fire alarm activation device (pull station) that was impeded from view and access near Station 13 and 14. There was a chair in front of the alarm activation device (pull station). Engineer 1 removed the chair upon discovery.

Building 3 Neuropsychiatric Center February 23, 2012:

At 12:39 p.m., at the 2 South Nursing Station was a key activated fire alarm device located behind three sheets of paper that were taped in front of the device and impeded the device from access and view. Engineer 1 removed the paper and acknowledged the finding.

Building 29 Pavilion III February 23, 2012:

At 3:08 p.m., there was a strobe/chime fire alarm annunciator on the Southwest corridor wall, outside of GYN-ONC that failed to annunciate an audible alarm and the strobe failed to flash. The Fire Marshall acknowledged the finding.

Based on observation, the facility failed to maintain their smoke detectors. This was evidenced by the failure 27 of 119 multi sensor smoke detectors that failed to activate an audible alarm, and 2 smoke detectors that failed to activate an audible alarm. This would delay the notification of a fire in the facility and allow for smoke and or fire to travel through the building and cause harm to patients and staff. This affected 2 of 12 buildings.

NFPA 101 Life Safety Code (2000 Edition)
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all
of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with the Fire Marshall and Engineer 1 on February 22 through February 24, 2012, the smoke detectors were tested and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 1:50 p.m., there was a smoke detector (Identification number N5-M1-152) at Nursing Station 32A (3rd Floor) that was approximately 70% covered with foreign material (grayish matter) and failed to activate an audible fire alarm when tested with canned smoke. Four attempts were made with canned smoke without activating an audible alarm. Engineer 1 acknowledged the finding.

Building 1A University Hospital Tower February 22, 2012:

At 2:19 p.m., there were 27 (a person to monitor an asof 119 multi sensor devices in the Emergency Patient Rooms and Nursing Station that failed to annunciate an audible alarm when tested. The devices sent a signal to the fire alarm control panel. The Fire Marshall and Engineer 1 acknowledged the finding and initiated a Fire Watch.

February 23, 2012:
At 8:36 a.m., the 27 multi sensor devices in the Emergency Patient Rooms and Nursing Station were reprogrammed and retested. All 27 devices activated an audible alarm and sent a signal to the fire alarm control panel. The facility ceased the fire watch at 6:00 p.m.

Building 30A Pavilion 2 February 23, 2012:

At 1:45 p.m., there was 1 of 1 smoke detector in Building 30A that failed to activate an audible fire alarm when tested. Five attempts were made with canned smoke without sounding an audible alarm. Engineer 1 acknowledged the finding.

Based on observation, and interview, the facility failed to maintain their sprinkler system water flow valves as evidenced by a valve that failed to activate an audible alarm when tested. This affected 1 of 12 buildings (Building 1) and could potentially allow for the sprinkler system to activate in the event of a fire and fail to notify staff in the immediate area resulting in potential harm to patients.

NFPA 72, National Fire Alarm Code (1999 Edition)
1-5.4.2 Alarm Signals.
1-5.4.2.2* Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
1-5.4.3.2.2 Visible and audible supervisory signals and visible indication of their restoration to normal shall be indicated within 90 seconds at the following locations:
(1) Control unit (central equipment) for local fire alarm systems
(2) Building fire command center for emergency voice/alarm communications systems
(3) Supervising station location for systems installed in compliance with Chapter 5

Findings:

During fire alarm testing with Engineer 1 and Fire Marshall on February 22, 2012, the sprinkler flow valves were tested and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 3:20 p.m., there was a sprinkler flow valve identified as valve 0101-02 outside of Room 1294-1 that failed to activate an audible alarm when tested. Engineer 1 and The Fire Marshall acknowledged the finding.

At 3:23 p.m., during an interview, the Fire Marshall stated "we will contact the fire alarm company and initiate a fire watch for the first floor (a person looking for smoke and or fire) until the valve is repaired."

At 5:10 p.m., the sprinkler flow valve identified as valve 0101-02 outside of Room 1294-1 was retested and activated an audible fire alarm. The facility ceased their fire watch.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems as evidenced by sprinklers that were covered with foreign materials. The failure to maintain the sprinkler heads could result in a malfunction during a fire and cause potential harm to patients. This affected 1 of 12 buildings.

NFPA 25 Inspection, Testing, and Maintenance of Water Base Fire Protection (1998 Edition)
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1 and Fire Marshall on February 24, 2012, the sprinkler system was examined.

Building Gottschalk Medical Plaza Multi-Specialty Suite February 24, 2012:
At 10:08 a.m., there were 2 of 2 sprinklers in Exam Room 6 that were approximately 100% covered with foreign material (grayish matter). Engineer 1 acknowledged the finding.

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10 as evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected 1 of 12 buildings and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire and potential harm to patients.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with Engineer 1 and Fire Marshall on February 21, 2012, the portable fire extinguishers were observed.

Building 1 Douglas Hospital February 21, 2012:

At 2:19 p.m., there was a fire extinguisher in Staff Receiving, Rapid Response Chemistry that was impeded from immediate access with a wooden cabinet and a trash can that was placed in front of the extinguisher. Engineer 1 moved the items upon discovery and the Fire Marshall acknowledged the finding.

Based on observation, the facility failed to ensure its oxygen cylinders were secure in accordance with NFPA 99, as evidenced by unsecured oxygen cylinders in 1 of 7 floors in Building 1 and 1 of 4 floors in Building 23. This could result in potential harm to patients in the event a cylinder should become damage or dislocated.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a tour of the facility with the Safety Officer, Compliance Officer, Assistant Director and Engineering Staff 2, on February 21, 2012 through February 24, 2012, the oxygen storage was observed.

Building 1 Douglas Hospital on February 21, 2012:

At 9:56 a.m., there were two unsecured ' E ' oxygen cylinders in Equipment Room 6444-2.

BUILDING 23 Chao Family comprehensive Cancer Center on February 23,2012:

At 1:22 p.m., there was one unsecured ' E ' oxygen cylinder in the Surgery Suite Soiled Linen Room 358.

Based on observation, the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70, as evidenced by failing to prevent multi-plug power strip from being plugged into a multi-plug power strip, a refrigerator plugged into a power strip and not directly into an electrical receptacle, by the use of an extension cord and two 6 outlet wall adapters with out any overcurrent protection in 3 of 12 buildings. This could potentially increase the risk of an electrical fire and could result in potential harm to patients.

NFPA 70, National Electrical Code (1999) Edition, Chapter 2 Article 240 Wiring and Protection
Section 240-4. Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

NFPA 70, National Electrical Code (1999) Edition, Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with the Safety Officer, Compliance Officer, Assistant Director and Engineer Staff 2, on February 21, 2012 through February 24, 2012, the electrical equipment and wring was observed.

Building 1 Douglas Hospital on February 21, 2012:

At 10:58 a.m., there was a multi-plug power strip plugged into a multi-plug power strip under the desk in Office 4457.

Building 23 Chao Family comprehensive Cancer Center on February 23, 2012:

At 1:02 p.m., there was a multi-plug power strip plugged into another multi-plug power strip and a refrigerator plugged into one of the power strips outside of Room 329.

At 1:14 p.m., in the Out Patient Surgical Services Recovery area there was a 6 outlet wall adapter in use, the adapter had no over current protection.

BUILDING 25B Pavilion IV on February 23, 2012:

At 3:35 p.m., the Senior Health Center had a copy machine and a paper shredder plugged into a six outlet wall adapter that had no overcurrent protection.

BUILDING 35 Gottschalk Medical Plaza on February 24, 2012:

At 10:24 a.m., in the Multi - Specialty Suite there was an extension cord in use that had no overcurrent protection in Exam Room 1311.

Based on observation and interview, the facility failed to maintain their building construction as evidenced by unsealed penetrations in two walls. This could potentially allow the migration of smoke and cause harm to patients.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, the construction was observed.

Building 1 Douglas Hospital February 21, 2012:
At 9:41 a.m., there was an approximate 2 foot by 18 inch air conditioning duct with an approximate 1/4 inch unsealed penetration around the edges of the duct and the wall in Room 7802. Staff Manager 1 acknowledged the finding and said that he will look into why it is that way.

At 9:53 a.m., there was an approximate 2 foot by 18 inch air conditioning duct with an approximate ½ inch unsealed penetration around the edges of the duct and the wall in Room 7803 (Electrical Room). Staff Manager 1 acknowledged the finding.


February 22, 2012
At 1:59 p.m., the Inspector of Record (IOR) stated during an interview " the ducts need to be sealed. That was part of the construction project for the Douglas building. "

Based on observation and interview, the facility failed to maintain the corridor doors as evidenced by doors that were obstructed from closing, doors that failed to release from the magnetic holding devices, and doors that failed to positive latch. This would allow the migration of smoke and or fire and cause potential harm to patients and staff. This affected 5 of 12 buildings.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, Fire Marshall, Safety Officer, Engineer 2, Compliance Officer, and Assistant Director on February 21, 2012, through February 24, 2012, the corridor doors were observed and tested.

Building 1A University Hospital Tower February 22, 2012:

At 8:27 a.m., the corridor door to Shower room 3313 was observed to be partially open and obstructed from fully closing by plastic bags filled with trash. The room is used for storing trash and soiled linen and the door is equipped with a self-closure device. The plastic trash bags were arranged so that the door was no longer obstructed and the door latched upon self- closure.

At 8:35 a.m., the corridor door to Patient room 3241 was obstructed from closure by a trash can. Engineer 2 removed the trash can and the door latched.

At 8:38 a.m., the corridor door to Patient room 3243 was obstructed from closure by a trash can. Engineer 2 removed the trash can and the door latched.

At 8:45 a.m., the corridor door to Shower room 3313, was again observed to be partially open, a gray soiled linen bin was impeding the door from fully closing. The plastic trash bags and the soiled linen bin were arranged so that the gray soiled linen bin was no longer impeding the corridor door from self-closure. This was acknowledged by the Safety Officer, Compliance Officer and Assistant Director.

At 9:00 a.m., the corridor door to Patient room 2229, failed to latch upon closure.

At 9:30 a.m., the Construction door located on the first floor link near the Elevator Lobby failed to latch when manually closed. The door hit the side of the door frame and could not be closed. This was acknowledged by the Safety Officer, Compliance Officer and Assistant Director.



26387

Building 1 Douglas Hospital February 21, 2012:

At 3:11 p.m., there was a door to Room 1264 (identified as Equipment Room) that was obstructed from closing with a tan colored rubber wedge under the bottom portion of the door. Engineer 1 removed the rubber wedge upon discovery.

Building 1 Douglas Hospital February 22, 2012:

At 12:25 p.m., there was a North Leaf door equipped with a self-closure device (identified as 5800B) that failed to positive latch when tested. The Fire Marshall acknowledged the finding.

Building 3 Neuropsychiatric Center February 23, 2012:

At 10:38 a.m., there was a door Room 359 (North) that was obstructed from closure with a ping pong table in front of the door path. The Fire Marshall acknowledged the finding and moved the ping pong table.

At 1:23 p.m., there was a door to Dining Room 1 North that failed to latch when tested. Engineer 1 stated " the door coordinator is off sequence, causing one door to close before the other. " The Fire Marshall acknowledged the finding.

Building 23 Chao Family Comprehensive Cancer Center February 23, 2012:

At 4:00 p.m., there was a door to Room 112 (identified as the waiting Room) that was obstructed from closure with a chair placed in front of the door.

At 4:02 p.m., RN 1 was interviewed and stated " the door is propped open with a chair daily because patients complain that the room is too warm. "

Building 22B Nikken Center February 24, 2012:

At 9:10 a.m., the corridor door to Room 116A, was obstructed from closure with a step stool in front of the door. During an interview, at 9:12 a.m., Staff 1 stated " the door is propped open every day because the medical equipment heats up and I must leave the door open to vent out the hot air. "

Based on observation and interview, the facility failed to maintain the stairway enclosure doors as evidenced by a door that failed to latch. This would allow the migration of smoke and or fire and cause potential harm to patients and staff during a fire emergency evacuation. This affected 1 of 12 buildings.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, the stairway doors were observed.

Building 1 Douglas Hospital February 21, 2012:
At 1:32 p.m., there was a stairway door that was identified as 3891.1 near Room 3892-1 that failed to latch. The latching mechanism was stuck open. The State Fire Marshall acknowledged the finding.

Based on observation and interview, the facility failed to maintain doors on magnetic holding devices to release and latch upon activation of the fire alarm system devices as evidenced by doors that failed to release in 1 of 7 floors in Building 1 (Douglas Hospital) and 1 of 4 floors in the Chao Family Cancer Center. This failure could result in the migration of smoke and fire, in the event of a fire causing potential harm to patients.

Findings:

During the testing of the fire alarm system with Engineer 1, Staff Manager 1, and Fire Marshall on February 21, 2012, through February 24, 2012, the doors were observed.

Building 1 Douglas Hospital February 22, 2012:
From 8:39 a.m. to 9:54a.m., during the testing of the fire alarm devices on the 7th floor the following doors failed to release from their magnetic hold-open devices in the following locations:
1. Doors Near Room 7622
2. Door 7400A
3. Doors Near Room 7100C3
4. Doors Near Room 76001A
5. Door 7400A-2
6. Door near Room 7611

At 9:50 a.m., Staff Manager 1 and Fire Marshall were interviewed and Staff Manager 1 stated " It is a programming error and I will call Simplex". The facility initiated a fire watch.

At 5:10 p.m., on February 22, 2012, fire alarm activation devices on the 7th floor were re-tested and all of the smoke barrier doors released and closed upon activation of the fire alarm system. The facility ceased the fire watch.


Building 23 Chao Family Comprehensive Cancer Center February 23, 2012:

At 4:35 p.m., the corridor door to Room 148, failed to release from the magnetic holding device when tested. Engineer 1 acknowledged the finding.

Based on observation, the facility failed to display exits signs in all egress paths as evidenced by no Exit sign displayed in 1 of 12 Buildings. This could delay egress and cause potential harm to patients and staff in the event of a fire emergency.

Findings:

During a tour of the facility with Engineer 1 and State Fire Marshall on February 23-24, 2012, the egress paths and exit signs were observed.

Building Gottschalk Medical Plaza February 24, 2012:

At 10:24 a.m., there was no exit sign in the egress path from Room 2222 on the second floor. The Fire Marshall acknowledged the finding.

Based on observation, the facility failed to maintain their smoke barrier walls as evidenced by a penetration in a smoke barrier wall. This affected 1 of 7 floors in Building 1. This could result in the spread of smoke and fire, in the event of a fire and cause potential harm to patients.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 tour of the facility with the Fire Marshall, Engineer 1, and Staff Manager 1 on February 21, 2012, the smoke barrier walls were observed.

Building 1 Douglas Hospital February 21, 2012:
At 11:08 a.m., there was an approximately 3/4 inch unsealed penetration with a ¼ inch antenna wire coming through the hole at the separation suite identified as 7200A. Engineer 1 acknowledged the finding and described the wire as an antenna wire.

Based on observation and interview, the facility failed to maintain their smoke barriers as evidenced by smoke barrier doors that failed to latch upon activation of the fire alarm system as evidenced by doors that failed to latch upon release from the magnetic holding devices. This affected 3 of 12 buildings and could result in the migration of smoke and fire, in the event of a fire causing potential harm to patients.

Findings:

During fire alarm testing with Engineer 1, Staff Manager 1 and Fire Marshall on February 22, 2012, through February 24, 2012, the smoke barrier doors were tested and observed and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 10:55 a.m., there was a Right Leaf smoke barrier door that was identified as 6200A (West Door), which failed to positive latch when tested. Engineer 1 acknowledged the finding.

At 12:42 p.m., there was an east smoke barrier door identified as 5400ES that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 12:43 p.m., there was a south smoke barrier door identified as 5400D that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 12:54 p.m., there was a west smoke barrier door identified as 7400C-3 that failed to latch when tested. The Fire Marshall acknowledged the finding.

At 1:23 p.m., there was an east smoke barrier door near Room 4429 and identified as 4400F.1 that failed to latch when tested. The Fire Marshall acknowledged the finding.

Building 1A University Hospital Tower February 23, 2012:

At 10:41 a.m., there was a won smoke barrier door that failed to close when tested near Nursing Station 3 South (338). The Fire Marshall acknowledged the finding.

Building 22C Diagnostic Services Center February 23, 2012:

At 4:23 p.m., there was smoke barrier door near Room 119 and identified as door number FSDZ2C010119 that failed to latch when tested. The Fire Marshall acknowledged the finding and stated "the electronic latching mechanism was not latching."

Based on observation, and interview, the facility failed to maintain the integrity of the fire alarm system. This was evidenced by the failure of audible and visual devices, and by failure to maintain alarm activation devices for immediate access. This would delay notification and could result in the potential failure of the fire alarm system to notify occupants of a fire or other emergency in the facility and affected 3 of 12 buildings.

NFPA 72, National Fire Alarm Code (1999 Edition)
1-5.4.2 Alarm Signals.
1-5.4.2.1* Coded Alarm Signals. A coded alarm signal shall consist of not less than three complete rounds of the number transmitted. Each round shall consist of not less than three impulses.
1-5.4.2.2* Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

2-8.2 Location and Spacing.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturers recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Findings:

During a tour of the facility with the Fire Marshall, Engineer 1, and Staff Manager 1 on February 21, through February 24, 2012, the fire alarm system components were observed, tested, and staff personnel were interviewed.

Building 1 Douglas Hospital February 21, 2012:

At 2:52 p.m., on the first floor Infusion Center there was a fire alarm activation device (pull station) that was impeded from view and access near Station 13 and 14. There was a chair in front of the alarm activation device (pull station). Engineer 1 removed the chair upon discovery.

Building 3 Neuropsychiatric Center February 23, 2012:

At 12:39 p.m., at the 2 South Nursing Station was a key activated fire alarm device located behind three sheets of paper that were taped in front of the device and impeded the device from access and view. Engineer 1 removed the paper and acknowledged the finding.

Building 29 Pavilion III February 23, 2012:

At 3:08 p.m., there was a strobe/chime fire alarm annunciator on the Southwest corridor wall, outside of GYN-ONC that failed to annunciate an audible alarm and the strobe failed to flash. The Fire Marshall acknowledged the finding.

Based on observation, the facility failed to maintain their smoke detectors. This was evidenced by the failure 27 of 119 multi sensor smoke detectors that failed to activate an audible alarm, and 2 smoke detectors that failed to activate an audible alarm. This would delay the notification of a fire in the facility and allow for smoke and or fire to travel through the building and cause harm to patients and staff. This affected 2 of 12 buildings.

NFPA 101 Life Safety Code (2000 Edition)
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all
of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with the Fire Marshall and Engineer 1 on February 22 through February 24, 2012, the smoke detectors were tested and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 1:50 p.m., there was a smoke detector (Identification number N5-M1-152) at Nursing Station 32A (3rd Floor) that was approximately 70% covered with foreign material (grayish matter) and failed to activate an audible fire alarm when tested with canned smoke. Four attempts were made with canned smoke without activating an audible alarm. Engineer 1 acknowledged the finding.

Building 1A University Hospital Tower February 22, 2012:

At 2:19 p.m., there were 27 (a person to monitor an asof 119 multi sensor devices in the Emergency Patient Rooms and Nursing Station that failed to annunciate an audible alarm when tested. The devices sent a signal to the fire alarm control panel. The Fire Marshall and Engineer 1 acknowledged the finding and initiated a Fire Watch.

February 23, 2012:
At 8:36 a.m., the 27 multi sensor devices in the Emergency Patient Rooms and Nursing Station were reprogrammed and retested. All 27 devices activated an audible alarm and sent a signal to the fire alarm control panel. The facility ceased the fire watch at 6:00 p.m.

Building 30A Pavilion 2 February 23, 2012:

At 1:45 p.m., there was 1 of 1 smoke detector in Building 30A that failed to activate an audible fire alarm when tested. Five attempts were made with canned smoke without sounding an audible alarm. Engineer 1 acknowledged the finding.

Based on observation, and interview, the facility failed to maintain their sprinkler system water flow valves as evidenced by a valve that failed to activate an audible alarm when tested. This affected 1 of 12 buildings (Building 1) and could potentially allow for the sprinkler system to activate in the event of a fire and fail to notify staff in the immediate area resulting in potential harm to patients.

NFPA 72, National Fire Alarm Code (1999 Edition)
1-5.4.2 Alarm Signals.
1-5.4.2.2* Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device. Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
1-5.4.3.2.2 Visible and audible supervisory signals and visible indication of their restoration to normal shall be indicated within 90 seconds at the following locations:
(1) Control unit (central equipment) for local fire alarm systems
(2) Building fire command center for emergency voice/alarm communications systems
(3) Supervising station location for systems installed in compliance with Chapter 5

Findings:

During fire alarm testing with Engineer 1 and Fire Marshall on February 22, 2012, the sprinkler flow valves were tested and staff personnel were interviewed.

Building 1 Douglas Hospital February 22, 2012:

At 3:20 p.m., there was a sprinkler flow valve identified as valve 0101-02 outside of Room 1294-1 that failed to activate an audible alarm when tested. Engineer 1 and The Fire Marshall acknowledged the finding.

At 3:23 p.m., during an interview, the Fire Marshall stated "we will contact the fire alarm company and initiate a fire watch for the first floor (a person looking for smoke and or fire) until the valve is repaired."

At 5:10 p.m., the sprinkler flow valve identified as valve 0101-02 outside of Room 1294-1 was retested and activated an audible fire alarm. The facility ceased their fire watch.

Based on observation, the facility failed to ensure the automatic sprinkler system is maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems as evidenced by sprinklers that were covered with foreign materials. The failure to maintain the sprinkler heads could result in a malfunction during a fire and cause potential harm to patients. This affected 1 of 12 buildings.

NFPA 25 Inspection, Testing, and Maintenance of Water Base Fire Protection (1998 Edition)
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with Engineer 1, Staff Manager 1 and Fire Marshall on February 24, 2012, the sprinkler system was examined.

Building Gottschalk Medical Plaza Multi-Specialty Suite February 24, 2012:
At 10:08 a.m., there were 2 of 2 sprinklers in Exam Room 6 that were approximately 100% covered with foreign material (grayish matter). Engineer 1 acknowledged the finding.

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10 as evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected 1 of 12 buildings and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire and potential harm to patients.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with Engineer 1 and Fire Marshall on February 21, 2012, the portable fire extinguishers were observed.

Building 1 Douglas Hospital February 21, 2012:

At 2:19 p.m., there was a fire extinguisher in Staff Receiving, Rapid Response Chemistry that was impeded from immediate access with a wooden cabinet and a trash can that was placed in front of the extinguisher. Engineer 1 moved the items upon discovery and the Fire Marshall acknowledged the finding.

Based on observation, the facility failed to ensure its oxygen cylinders were secure in accordance with NFPA 99, as evidenced by unsecured oxygen cylinders in 1 of 7 floors in Building 1 and 1 of 4 floors in Building 23. This could result in potential harm to patients in the event a cylinder should become damage or dislocated.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a tour of the facility with the Safety Officer, Compliance Officer, Assistant Director and Engineering Staff 2, on February 21, 2012 through February 24, 2012, the oxygen storage was observed.

Building 1 Douglas Hospital on February 21, 2012:

At 9:56 a.m., there were two unsecured ' E ' oxygen cylinders in Equipment Room 6444-2.

BUILDING 23 Chao Family comprehensive Cancer Center on February 23,2012:

At 1:22 p.m., there was one unsecured ' E ' oxygen cylinder in the Surgery Suite Soiled Linen Room 358.

Based on observation, the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70, as evidenced by failing to prevent multi-plug power strip from being plugged into a multi-plug power strip, a refrigerator plugged into a power strip and not directly into an electrical receptacle, by the use of an extension cord and two 6 outlet wall adapters with out any overcurrent protection in 3 of 12 buildings. This could potentially increase the risk of an electrical fire and could result in potential harm to patients.

NFPA 70, National Electrical Code (1999) Edition, Chapter 2 Article 240 Wiring and Protection
Section 240-4. Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

NFPA 70, National Electrical Code (1999) Edition, Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with the Safety Officer, Compliance Officer, Assistant Director and Engineer Staff 2, on February 21, 2012 through February 24, 2012, the electrical equipment and wring was observed.

Building 1 Douglas Hospital on February 21, 2012:

At 10:58 a.m., there was a multi-plug power strip plugged into a multi-plug power strip under the desk in Office 4457.

Building 23 Chao Family comprehensive Cancer Center on February 23, 2012:

At 1:02 p.m., there was a multi-plug power strip plugged into another multi-plug power strip and a refrigerator plugged into one of the power strips outside of Room 329.

At 1:14 p.m., in the Out Patient Surgical Services Recovery area there was a 6 outlet wall adapter in use, the adapter had no over current protection.

BUILDING 25B Pavilion IV on February 23, 2012:

At 3:35 p.m., the Senior Health Center had a copy machine and a paper shredder plugged into a six outlet wall adapter that had no overcurrent protection.

BUILDING 35 Gottschalk Medical Plaza on February 24, 2012:

At 10:24 a.m., in the Multi - Specialty Suite there was an extension cord in use that had no overcurrent protection in Exam Room 1311.